SUMMARY:

• 9+ years of strong business analysis experience in Healthcare industry.
• Highly proficient in working with users and stakeholders to elicit, analyze, communicate and validate requirements using JAD and Brainstorming sessions.
• Identify Functional, Non - Functional, and Business Rules, and then subsequently model them. In depth knowledge of Use Case Analysis, designing of various documents including Business Requirement Document (BRD), Functional Specification Document (FSD),Requirement Traceability Matrix (RTM), and testing documents (Test Plan/Scripts).
• Demonstrated ability to work actively in distinct phases of Software Development Life Cycle (SDLC) using Rational Unified Process (RUP), Agile (SCRUM) and Waterfall methodologies.
• Played the role of a Scrum Master in conducting Scrum ceremonies-Sprint planningand maintain Scrum artifacts: product backlog, sprint backlog, and increment
• Proficient in using UML and creating detailed Use-Cases, Scenarios, Data Flow Diagrams, Sequence Diagrams, Collaboration diagrams, Class Diagrams.
• Strong analytical skills in breaking down complex business problems into simple components and creating valuable solutions based on clear requirements
• Proficient with Microsoft Project to manage schedules, deadlines and resources, collaborate with different teams and analyze project information.
• Involved in understanding of business processes, analyzing requirements, finalizing the business scenario and implementing EDI
• Experience in verifying EDI raw data of 837 transactions as per HIPAA based transactional 5010 formats.
• Extensive experience in Gap analysis of HIPAA 4010 to HIPAA 5010 conversion using the implementation guide and companion guide of EDI transactions (EDI 837, EDI 835, EDI 834, EDI 820).
• Good knowledge of ICD 9- CM, ICD 10-CM structures& differences.
• Sound experience in conducting I mpact Analysis caused due to migration to ICD 10 on the key business process and key application system like claim processing, payments, reporting in health insurance companies.

TECHNICAL SKILLS:

ProjectManagement Tools: JIRA, MS project, IBM Rational tools, Requisite Pro, Clear Case and Clear Quest

Visual Modeling: MS Visio, PowerPoint, UML

Programming Languages: SQL, Test Script Language, SQA Basic

Web Tools: HTML, XML, MS FrontPage, Macromedia Dreamweaver

Documents and Sheets: MS Office - Word, Excel

Databases: MySQL Server, Oracle, MS Access

Operating System: Windows, Unix

CRM /Cloud: Salesforce.com administration (ADM 201 Certified)

PROFESSIONAL EXPERIENCE:

Confidential, Michigan

Sr. Business Systems Analyst

Environment: UML, MS Word, Rational RequisitePro, Rational ClearQuest, Quality Center, SQL, FTP, Facets, Microsoft SharePoint.

Responsibilities:

• Studied the current system functionalities & behavior and documented “As-Is” process; later upon business requirements and identifying the application shortcomings developed “To-Be” processes.
• Carried out User Acceptance Testing and extensively used SQL to verify data integrity.
• Worked with Trizetto professional services team to resolve the issues identified at analysis state while building the Custom components for Claim life cycle.
• Acted as a Claims Analyst was responsible for researching, analyzing, documenting and updating the claims data with respect to the research and analysis in updating and integrating the findings of customer's claims data.
• Analyzed EDI Transactions such as claim 837 P/I/D - medical claims, 835 - Health Care Claim Payment/Advice, 270 - Eligibility, Coverage or Benefit inquiry, 271 - Eligibility, Coverage or Benefit response, 276 - Claim status request, 277 - claim status response, 820 - Payment Order/Remittance Advice, and 834 - Benefit Enrollment and Maintenance.
• Held presentations and participated in walkthroughs with the development team and the QA team to help them understand the requirements and formulate test plans and test scripts.
• Facilitated UAT scripts and execution
• Maintained Requirement Traceability Matrix (RTM) to check whether the requirements of the system were met accordingly and to produce RFPs.
• Performed claim validations and Pend/Denied claims analysis for the Health plans Medicaid programs.

Confidential, Sacramento, CA

Sr. Business/Quality Analyst

Responsibilities:

• Worked with client to gather Business/Technical Requirements for HIPAA 5010 and ICD 10 projects.
• Worked on gathering requirement for testing EDI 834 with business and technical team.
• Validated and tested the entire new enrollment through EDI 834.
• Responsible for designing future state processes for ICD 9-10 Crosswalk Table and drafted High Level Business Requirements for ICD 9-10 conversion mapping.
• Worked extensively on the Procedure and Diagnosis Pricing and worked on the Reimbursement processing.
• Tested ICD 10 codes integrated with HIPAA 5010(EDI 835 and EDI 837)
• Gained extensive experience in designing/modifying the CICS screens for various areas such as Enrollment, Billing, Provider Record and Reimbursement Status.
• Tested various screens for ICD 10 such as RSF-890, RSF 891 and numerous other Formulary screens.
• Tested number of reports affected by the ICD 10 Procedure and Diagnosis code changes. Also tested for ICD indicator on various reports and Mainframe screens.
• Maintained EDMS (Electronic Data Management Systems) for CARR reports for both Daily and Weekly batch cycles.
• Worked extensively on reports such as CP-O-012 and CP-O-014.
• Experience in implementation of ICD-9-CM codes and ICD-10-CM codes changes in the current claim processing system.
• Worked on Rational Quality Manager which includes Test Cases, Scripts and Scenarios for EDI 834 and 837.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
• Responsible for Medicaid Claims Resolution/Reimbursement for health plan using MMIS.
• Provided online support to users for various applications such as IPCS (Internet Professional Claims Submission using EDI 837).
• Filed Bugs in Quality center for EDI 837 and EDI 834 and analyzed them to resolve the issue.

Environment: HP Quality Center 10.0, Caliber RM, SAP, MS Office, Windows XP, Windows Vista, MS Visio, HP SharePoint, MS Project, MS Visio, SQL, SOA Infra, XML

Confidential, Minneapolis, MN

Business Analyst

Responsibilities:

• Involved in business analysis of Inbound and Outbound Transactions.
• Involved profoundly in the GAP Analysis of transition from HIPAA 4010A to 5010 (EDI 276 and 277) focusing on the effects of new 5010 compliance rules on current transactions.
• Tested HIPAA Transactions and Code Sets Standards such as 276/277 transactions.
• Performed Web Portal testing and Web Portal Post Implementation testing for 278, 270/271, 276/277, 837 I/P/D.
• Mapped ICD9 to ICD10 and tested 270/271, 837 I/P/D and 835R transactions to migrate to 5010.
• Analyzed and identified gaps/issues in claims, encounters and remittance advice process flow.
• Created Use Case Diagrams and Test Cases for federal employee program.
• Rendered X12 Syntax Integrated Testing, Balancing Testing, Code Testing, Specialty Testing and Trading Partner Specific Testing when environment is upgraded.
• Performed regression testing to verify resolution of defects.
• Clarified QA team issues and reviewed test plans and test scripts developed by QA team to ensure coverage.

Environment: MS Project, MS Visio, MS Word, MS Excel, MS PowerPoint, Rational Requisite Pro, Rational Rose, Rational Clear Case, Oracle, SQL, Toad, Java, Windows XP, HP Quality

Confidential, Santa Rose, CA

BA/EDI Analyst

Responsibilities:

• Conducted JAD sessions, which focused on the definition of Business Requirements, security access groups and third-party insurance companies associated with claims business process (EDI 837 and EDI 835).
• Documented Technical specifications and business documents for EDI 837, 820 and 835.
• Worked with IT teams regarding EDI transaction such as X12 837/835 codes for claims processing.
• Conducted Gap Analysis to analyze the client’s applications programs to determine the impact of the HIPAA final rule on EDI Transaction Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance.
• Involved working with HIPPA-EDI 837 and 835 ANSI X12 Transaction Code sets.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team.
• Actively analyzed current business processes (Claims, Recipient eligibility and enrollment etc.) and worked with management to improve and implement enterprise solutions to ensure compliance.
• Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.
• Wrote multiple Test-Cases (unit, compliance, integration) for multiple transactions including 837, 835, 276, 277, 270 271 transactions.

Environment: HTML, Windows 2000, Rational Requisite Pro, RUP, MS Visio, MS Excel, MS Word, MS Office, UML, SQL, HIPAA, MS Access, Quality Center, UML, HIPAA

Confidential, Albany, NY

Business Analyst

Responsibilities:

• Gathered requirements from stakeholders through personal interviews, questionnaires and surveys.
• Interviewed Subject Matter Experts (SME), asking detailed questions and carefully recording the requirements in a format that can be reviewed and understood by both business people and technical people.
• Prepared Business Requirement Documents (BRD) based on the gathered requirements.
• Assisted QA in Test Cases and Test plans for the department director that was used to review and evaluate results of a testing cycle.
• Performed GAP analysis to identify holes in the requirements.
• Documenting the entire test plan, including test strategies and test cases.
• Used Rational Rose to prepare Use Case views for a clear understanding of the vision document and stakeholders’ requests.
• Performed the UAT with the clients and documented to clarifications.

Environment: MS Word, Visio, UML, RUP, SQL, Java