Professional Summary
Business Analyst Consultant with 7 years of diverse experience in Business Modeling, Document Processing,EDI, Mapping,HIPAA regulatory changes and Application Integration in healthcare domain. I am experienced in gathering business requirements,JAD Sessions, Gap Analysis, UML techniques and diagrams using IBM Rational Requisite Pro, ClearCase, ClearQuest & Rational Rose/ MS Visio to create Business Documentation,Claims Processing & Testing and Claims Adjudication for Medicare and Medicaid,Data Mapping / Modeling, and Medical Billing and specialized in ANSI 4010 / 5010 or ICD 9/10 implementation. I am a self-starter with motivation and capable to work independently.
Specific Expertise

• Experience with Business Analysis, Project Management, Rational Unified Process Methodologies, SDLC Methodologies and Modeling Techniques, Software Validation and Process Re-engineering
• Experienced in GAP Analysis of HIPAA 4010 to 5010 withparticular attention toqualifier, length and required field and situational rules.
• Led the team of Business Analysts for creation of Business and Functional Requirements for the creation of Electronic Health Records (EHR).
• Gained extensive experience with HL7 for various interfaces.
• Worked on the screenshot and prototype development for the various online screens meant for the EHR project.
• Worked on the modification of database models for health record consolidation.
• Reporting experience with business intelligence tools such as Cognos products, Crystal reports.
• Verified and documented HIPAA regulator changes found when moving from 4010 to 5010.
• Performed gap analysis and data mapping for HIPAA X12 4010A1 to 5010 migration.
• Expertise in verifying and understanding EDI raw data, both in 4010 and 5010 format.
• Strong understanding of ICD 9 and ICD-10 structures and formats.
• Expertise in Interviews, Joint Application Development Sessions (JAD), Focus sessions for requirements gathering, analysis and design with stakeholders, SME's, Developers and system architects.
• Performed several levels of testing of the conversion from 4010 to 5010 which included syntax verification, balancing of the segments, situational cases and verification of the loops as per the guidelines of the implementation guides and companion guides.
• Have experience in healthcare industry in working with various modules which include claims processing using EDI X12 transactions like 837, 834, 835, 270/271, and 276 which fall under the HIPAA compliance.
• Strong Analytical skills in determining and conducting Feasibility Analysis, Cost/Benefit Analysis, GAP Analysis, Risk Analysis and Mitigation and Change & Configuration Management for complex process and systems.
• Adept at gathering Functional requirements and specifications through interviews, facilitated sessions, brainstorming, questionnaires and organizing JAD to accomplish user-client objectives and results .
• Performed User Acceptance Testing (UAT) with business users.
• In depth understanding of Software Development Life Cycle (SDLC) starting with requirement gathering, analysis and documenting the requirements as various deliverables and validating output of each phase from the SME's and Project Manager.
• Proficient in creating UML Diagrams, including Use Case Diagrams, Activity Diagrams, Class Diagrams, Sequence Diagrams using various tools such as MS Visio, Rational Rose
• Strong Project Management skills including planning, scheduling, monitoring and budgeting with proficiency in MS Project for planning & reporting and assisted Project Managers in the development of weekly and monthly status reports.
• Conducted communication between the client and IT department, involved in gathering, analyzing, and documenting Requirements. Understand the Business Rules and can effectively implement them in Business Process Flow.
• Excellent communication and analytical skills with strong problem solving capabilities to interface with end users, business representatives and development teams.
• Experience in EDI 837 testing which involved writing test cases which forced security, data integrity and usability with special emphasis on 837 syntax validation.
• Considerable experience in preparing the impact analysis due to migration from 4010 to 5010 and ICD-9 and ICD-10 on the business process model and the application.
• Knowledgeable in User Acceptance Testing with experience in performing UAT with business users.
• Clear understanding of testing concepts and hands on experience writing test cases, test plans and planning test strategy using testing tool Quality Center.
• Experience in GUI, Functional and web testing both with manual testing and automation testing using tools as Quality Center and Rational Robot.
• Proficient in writing advanced DML and DDL SQL Queries for Backend Testing to check and analyze data integrity and validation.
• Skilled at reviewing Test Cases making sure they are in accordance with requirements, and assist the overall testing process by activities such as Change and Defect.
• Highly motivated team leader with excellent communication, presentation and inter-personal skills, always willing to work in challenging and cross-platform environments.
• Knowledge and implementation experience of Quality Assurance, Testing Principles, and Configuration and Change Management Disciplines.

Technical Skills:

Defect Tracking tools: Quality Center, Rational Clear Quest

Web Technologies: XML/XSL, HTML

Operating Systems: MS Windows, DOS, UNIX, XP, Vista, Mac OS

Database: SQL, MS Access, Oracle

Tools and Applications: MS Visio, MS Office, MS Project, Excel, MS Word

Requirement Management Tools: Rational Clear Quest, ReqPro, MS Project, VISIO,
Mercury Quality Center

Related Experience:

Confidential, Sacramento, CA
Jan 11 - present
Sr. Business System Analyst

The project was an integrated online management web applicationthat allowed the providers toautomatetasks like Patient, Management Appointment, schedulingandRecalls,Accounts Receivable ManagementandCollections,Reporting, andFiling Claimsthrough EDI (ANSI) X12 transaction sets in compliance with HIPAA standards which included the conversion of the EDI837 Benefit Enrollment and Maintenance EDI format from 4010 X12 formats to the 5010 X12 format as per HIPAA compliance and also Process the received claim using EDI 835.
Also worked on CalFresh also known as Supplemental Nutrition Assistance Program (SNAP) and Child Care Assistance program aimed at assisting the needy families with appropriate services and nutrition.

Roles and Responsibilities:

• Interacted withstakeholdersto get a better understanding of clientbusiness processesandgathered requirements.
• Involved working with the HIPPA-EDI ANSI X12 Transaction Code sets:
• Worked on EDI 837 for checking that if receiving claims has all the required information or not.
• Responsible for Processing benefits and vendor enrollment.
• Involved profoundly in theGAP Analysisof thetransitionfromHIPAA 4010 to 5010(EDI 835 and 837)focusing on how current transactions and system was going to be effected by the new5010compliance.
• Organized and facilitatedmeetingswith themanagementanddevelopment teams..
• Reporting experience with business intelligence tools such as Cognos products, Crystal Reports.
• Validated the data in EHR.
• Testing 837 claims coming to us from providers.
• Conducted requirement gathering sessions with the purpose of creating and defining theBusiness Requirement Document(BRD) and theFunctional Requirement Document(FRD) usingRationalRequisite Pro.
• Conductedfunctional requirement reviewsandwalkthroughswith the designers, developers, and stakeholders.
• Worked with the development of data modeling tool by the use of Erwin Data Modeler
• Involved inRequirement Scopingand analyzing high priority requirement for implementation.
• Conductedsign-off meetingswith IT teams to lock down the requirements.
• Created high-levelUse Casesfrom Business Requirements and createdUML diagramslikeUse CaseandActivitydiagrams usingMS-Visio for CalFresh.
• ConductedJAD sessionsto allow different stakeholders to communicate their perspectives with each other,resolveanyissues and come to an agreement quickly.
• Tracked stakeholder requested enhancements and changes usingRequirement Traceability Matrix(RTM) for CalFresh.
• Configured HL7 Messages with User interface and developed User interface specification document.
• Involved ingapandfeasibility analysisfor the design and architecture of the new application.
• ExecutedSQL queriesto test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Knowledge and implementation experience of Quality Assurance, Testing Principles, and Configuration and Change Management Disciplines.
• Involved with the Quality Assurance Team to developTest planand driveTest Cases for CalFresh.
• Also developed a (UAT) User Acceptance Testing plan to guide a select group of key end-users in testing the user interface and functionality of the application.
• Mapped data sources to targets by the use of Warehouse Builder Mapping Editor.
• Involved in support of System testing when performed on the entire system in the context of a Functional Requirement Specification (FRS) and System Requirement Specification (SRS).
• Environment:Rational Rose, Rational Requisite Pro, UML,MS Project, MS Visio, MS Office Suite, PL/SQL Developer, HTML, Visual Basic, SQL, Toad, Windows XP, Unix, HIPAA, Outlook, Test Director, HL7.

Confidential, is one of the leading Medicare payers, which is an incorporated Health Maintenance Organization in Florida. The project was to customize and implement software called IKA, Web-based application for healthcare payer organizations. Ika Medicare Gateway is the key component of the software which allows payers to significantly expedite and increase the accuracy of Medicare application processing, eligibility verification, and enrollment, membership and payment reconciliation through online functionality and real-time access to information from CMS\' MARx database. Worked extensively on enrollment and the claims module .The enrollment process begins with an online application portal, which members, brokers or administrative staff can use to start the enrollment cycle. Through Ika Medicare Gateway, instant eligibility queries and beneficiary look-ups are performed against the MARx database. In the Claims Module, the secure online platform allows claims adjusters to access their claims files from anywhere with an internet connection and to stay organized by employing various features such as: diary notes, alerts, reminders, and progress reports.
Project Scope:
Application Integration of IKA web-based for healthcare and customize, which included the conversion of the xml format to the 837 EDI format.

Roles and Responsibilities:

• Helped developers with the following list of HIPAA-EDI Transaction Code sets: 837.
• Thorough knowledge about HIPAA ANSI X12 transaction code sets (4010A1 and ICD10).
• Conduct detailed requirements gathering sessions for Business Intelligence project
• Perform assessments / gap analysis to identify opportunities for new Business Intelligence project.
• Involved in process analysis and defined executed data migration plans for local data for global applications.
• Involved working with the following list ofHIPPA-EDI ANSI X12 Transaction Code sets:
• Responsible for receiving Claims and Encounters using EDI 837.
• ConductedJAD sessionsto allow different stakeholders to communicate their perspectives with each other,resolveanyissues and come to an agreement quickly.
• Database support that includes activities required to correct, delete or summarize medical history of members as well as provider information.
• Integrated HL7 with HIPAA rule sets.
• Developed business cases and provided Use Case and Activity Diagrams in MS Visio.
• Collaborated on the development of user requirements and design specifications using standard UML techniques such as use case, activity, sequence, and class diagrams.
• Conducted JAD sessions, Focus groups and individual interviews to facilitate elicitation with regards to analysis, specifications, and design of the relevant business processes and systems.
• Designed User Interfaces for several modules using Adobe Photoshop version 7.0.
• Using SQL Query generated reports.
• Developed Project Status metrics for weekly evaluation of Project Status.
• Documented detailed business, functional, and User Interface system specifications using standardized company templates for the business, development, and QA team.
• Produced clear user manuals & training guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and created appropriate GUI screenshots.
• Responsible for writing SQL Queries to find out that the data is correctly populated in each field.
• Knowledge of System Development and Bug Life Cycle to perform testing and defect tracking.
• Environment: MS Windows XP, Snag IT, Nitro PDF, HTML, Visual Basic, Rational RequisitePro, MS Visio, MS Project, MS Access, Web trends, Toad , SQL, Oracle, Crystal Reports, Rational Clear quest, QC, HL7
  

Confidential, Baton Rouge, LA
Nov 2007-June 2009
Business Analyst

The Louisiana Medicaid Program provides health services to low income individuals, has an annual budget of 7.2 billion dollars and provides services to more than 1 million recipients annually. MMIS processes 51 million Medical claims annually for more than 30,000 Medicaid providers.

Project Scope:
The focus of the project was the replacement of 22 year old Medicaid Management information System (MMIS). It included technical and professional services related to analysis and assessment of the current MMIS and EDI claims, documentation of business and technical requirements, preparation of cost analysis and implementation of new MMIS automation system.

Roles and Responsibilities

• Coordinated with the stakeholders and project key personnel to gather functional and non-functional requirements during JAD sessions.
• Studied the existing business process and created AS-IS workflow to illustrate the existing system.
• Responsible for the fullHIPAAcompliance lifecycle fromgap analysis, mapping, implementation and testing for Medicaid Claims.
• Responsible forgap analysisin changing old MMIS and Involved in testing new MMIS.
• Responsible forMedicaid ClaimsResolution/Reimbursement for peach state health plan usingMMIS.
• Recorded requirements in the Requirement Traceability Matrix (RTM) defining each technical requirement in detail from areas like: main hardware, application software, networks, servers, internet and desktop configuration.
• Assisting the project manager in creating the business case and project plan.
• 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.
• Work with business representatives to understand data marts requirements and priorities and ensure that IT works is appropriately aligned.
• Responsible for creating business work flows and processes and creating management reports based on the analysis.
• Followed the UML based methods using Rational rose to create use cases, activity diagram, sequence diagram, collaboration diagram that include functional and non-functional specifications to hand off to development teams.
• Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.
• Defects and bug testing by using Rational Clear-Quest, Configuration management and Version control with Clear-Case.
• Propose strategies to implement HIPAA 4010 in the new MMIS system.
• Environment: Rational Unified Process (RUP), UML, Windows, SQL, Microsoft Office, HTML, XML, Java Script, Java, ASP, HTML, MS Access, DB2, Oracle, Test Director.

Confidential, Rite Hospital for Children is a world leader in the treatment of pediatric orthopedic conditions. Improve the care of children worldwide through innovative research and teaching programs, training physicians from around the world TSRHC treats Texas children with orthopedic conditions, such as scoliosis, clubfoot, hand disorders, hip disorders and limb-length differences, as well as certain related neurological disorders and learning disorders, such as dyslexia.

Project:

Texoma Claim System (TCS) has a web based application that the providers can use to manage patient information and file claims electronically. There are five basic functionalities in the UCS Namely Patient Access module, Forecast module, Electronic Medical Record (EMR), Claims filing and Billing module to process claims through Electronic Data Interchange. The reporting tool is used to query, print and display tracking reports in compliance to HIPAA Act. Project was to update new version of HIPAA ANSI X12 transaction code sets 4010A1 for 837 claims form.

Roles and Responsibilities:

• Facilitated JAD sessions, which focused on the definition of business requirements, security access groups and third party insurance company's business process.
• Conducted detailed walkthrough of business requirements and functional requirements with Business users, Development and QA Team
• Created use cases that defined the role of customers, medical practitioners, clearing house Administrators and healthcare plans such as: Medicare, Medicaid insurance plan.
• Used Data flow diagram, sequence diagrams and business process models that describe how predefined HIPAA compliant formats are used to submit a claim with EDI.
• Created Copybook for the development team which included data length and data type.
• Performed GAP analysis of requirements and used them to write detailed system specification requirements.
• Acted as a liaison by working closely with the development and testing team for achieving milestones.
• Performed manual testing of the functional items by checking a summary of all claims entered and submitted.
• Created various documents such as Use Cases and Activity Diagrams in a format that can be reviewed and understood by both business and technical people.
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in a claims application.
• Produced clear user manuals & training guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and created appropriate GUI screens

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