SUMMARY:

• 7+ years of experience in business analysis, business requirements modeling and development of Web Based, and Client/Server applications extensively in business domain of Healthcare.
• Strong knowledge of managed care payer requirements and procedures.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications (FRS) and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Expertise in Business Process Modeling, Business Process Re - design and in designing Process Architecture.
• Strong knowledge of managed care payer requirements and procedures.
• Extensive experience in configuring data mapping between different Databases.
• Sound understanding of Gap Analysis, requirement management, risk analysis and project plans.
• Solid understanding of Rational Unified Process (RUP) using Rational Rose, Requisite Pro, Unified Modeling Language (UML).
• Good understanding of trading partner management for 4010 and 5010 files.
• Extensive experience in configuring data mapping of files using Edifacs Specbuilder.
• Knowledge of various RDBMS like DB2, Oracle, MS-Access and MySQL Server.
• Thorough knowledge of HP Quality Center and Defect Lifecycle Process.
• Preparing graphical depictions of use cases including state diagrams, activity diagrams, sequence diagrams, use case diagrams, component-based diagrams, collateral diagrams, including the business workflow.
• Ability to communicate effectively with Business users and Senior Management.
• Worked as productive team member with excellent communication and presentation skills using MS OFFICE AND MS PROJECT
• Through knowledge of various phases of Edifacs Specbuilder- Analyzer and Mapper.
• Experience with various ETL, data warehousing tools and concepts.
• Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Knowledge of the Back-End processes like Voucher Creation, EOB, Letter generation and 835 etc.
• Experience in development methodologies like RUP, SDLC, AGILE, SCRUM and Waterfall
• Experience in Risk Management process and technology reengineering, Sarbanes Oxley implementation, valuation review process and technology, strategic sourcing, metrics and benchmarking
• Design and review of various documents including the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM) and testing documents.
• Strong experience in Business and Data Analysis, Data Profiling, Data Migration, Data Integration and Metadata Management Services.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Experience in conducting Joint Application Development (JAD) sessions and White Board Sessions with end-users, Subject Matter Expert (SMEs) team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.
• Involved in training of end users and Documenting Training Manuals.
• Focused troubleshooter and a team player with excellent interpersonal and communication skills. Ability to work cohesively with developers, other team members, and testers.
• Analytical, methodical and resourceful approach to Problem Solving, Root-Cause Analysis, Conflict Resolution, Negotiation Strategies and providing corrective actions to meet business requirements.
• Proven record of Leadership skills. Excellent Presentation skills in regards to communicating with both business and technical teams.
• Expert in developing BRD (Business Requirement Document), TRD (Technical Requirement Document), URS (User Requirement Document) and FRS (Functional requirement Specifications) following Agile methodology.
• Hands on experience in Requirement gathering and analysis, Planning, scheduling and Tracking Projects.

PROFESSIONAL EXPERIENCE:

Confidential,Buffalo,NY

Sr. Business Systems Analyst

Responsibilities:

• Gathered requirements from stakeholders for provider management and member management.
• Identified and validated business rules and data elements.
• Created 837(P, I, D) claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837(P, I, D), 835, 270/271, 276/277 and 278.
• Modeled the ‘as-is’ process flow and the ‘to-be’ process flow and analyzed the gap and developed the action steps to fill the gaps.
• Analyze EDI - X12 data elements captured by the existing system to validate it against the data elements required for new system.
• Worked with legacy team in developing BRD for multiple system change requests and participated in system testing.
• Worked within project team to identify and interpret state Medicaid policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
• Conducted Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD) and Systems Requirements Specification (SRS).
• Facilitated meetings with the technical team and client team to analyze the current process and gather requirements for the proposed process.
• Created functional requirement specification documents such as UML diagram, use case diagram, scenarios, activity diagrams and mapping.
• Developed the User Interface (UI) prototypes to capture and validate requirements and spike solutions to the current problem.
• Created Logical/physical Data Model in ERwin and have worked on loading the tables in the Data Warehouse
• Identified, researched, investigated, analyzed, defined and documented business processes and Use Case Scenarios.
• Analyzed requirements for developing a cross-walk for understanding major changes from ICD-9 to ICD-10 with the help of SME’s.
• Facilitated JAD sessions for Requirement Validation with Dept. of Cleveland clinic to gather requirements for the new MMIS.
• Participated in developing test plan, test scripts, and test scenarios and designed user documentation.
• Examine the system design deliverables & validating it against the SLA.
• Developed UAT test cases associated with the functional requirements.

Environment: MS Office, Windows, .NET, Agile, MS Visio, MS SharePoint, TFS, MS Project, MS Visio, SQL, Oracle, SOA, HTML.

Confidential,Austin,TX

Sr. Business Analyst

Responsibilities:

• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Medical Claims experience in Process Documentation, Analysis and Implementations in 835/837, 270, 276/277processes or Medical Claims Industry from the Provider/Payer side
• Involved in HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Accepted inbound transactions from multiple sources using FACETS
• Identified gaps and performed gap analysis with respect to CMS requirements
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Analyzed CMS comparison documentation highlighting changes of ICD10 diagnosis and procedure codes.
• Assisted with project planning, requirements development and completing ad hoc change management activities.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Documented the Traceability Matrix for tracing the Test Cases and requirements related to them.
• Performed Unit Testing and User Acceptance testing and documented detailed results.
• Provided input (scope, goals, risks, constraints, timelines and interfaces) to PM for project planning and control.
• Played a substantial role in the process definitions and business and functional requirements gathering, in an effort to develop a practical technology solution for automating sales methodology.
• Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Created Use Cases / Activity Diagrams / State Chart Diagrams, Sequence Diagrams, and Collaboration Diagrams thus defining the Data Process Model and Business Process Model.
• Responsibility included creation, member enrollment, billing, letter generation, contract administration and claim adjudication.
• Created workflow scenarios, designed new process flows diagrams and documented the Business Process and various Business Scenarios and activities of the Business from the conceptual to procedural level.
• Met with various HMO, PPO, Medicaid/Medicare Representatives discussing benefits of contracts on behalf of facilities or appeals from denials and compliance issues
• Used Facets to receive 834 inbound files and processing of the files across different modules in the application
• Collected business requirements to set rules for proper data transfer from Data Source to Data Target in Data Mapping.
• Developed business process models in RUP to document existing and future business processes.
• Prepared Demo on SharePoint for various Business to get new approvals like the Therapist and Nursing divisions.
• Used Quality Centre to track required changes and Quality Centre to maintain different versions of the project documentation.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Developed Test Plans and Test Cases according to Business Requirements.
• Acted as User Acceptance Testing coordinator and monitored business testing and interfaced with the development team regarding defect status and fixes on a daily basis.
• Involved in generation and execution of SQL queries.

Environment: SQL, HP Quality Center, Facets, Share Point, MS Office, UML, Rational Rose, Windows, MS Visio, MS Project.

Confidential,Baton Rouge,LA

Business Analyst

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 full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• 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.

Environment: Rational Unified Process (RUP), SQL, MS Visio, MS Project, MS Office, UML, Windows, HP Quality Center.

Confidential, Naperville IL

Business Analyst

Responsibilities:

• Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
• Working within a growing knowledge of X12 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, process flows, and prototypes and management reporting requirements
• Performed Unit Testing and User Acceptance Testing and documented detailed defects.
• Developed Test Cases to validate the requirements and documented the Traceability Matrix for Test Cases and Requirements
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements
• Developed Functional Specifications and Q/Testing Requirements.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Involved in all phases of software development life cycle in RUP framework.
• Developed detailed Developer specification to reflect technical details of the business requirements
• Was responsible for data mapping of HL7 messages into relational database.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams
• Assigned tasks among development team monitored and tracked progress of project following agile methodology.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Developed business process models in RUP to document existing and future business processes.
• Created Business Requirement Document (BRD), Functional Requirement Specification (FRS) document, User Requirement Specification (URS) and Change Request (CR) document for system application development.
• Provided management support to the off-shore End to End Integration / Regression Test Team
• Prepared UAT Materials UAT Test Cases to include various steps involved for UAT and to have proper coverage of requirements
• Involved in integration of various Customer Data Sources and provided Data Mapping from various sources into the target centralized customer data source with help of Erwin team.
• Acted as a Subject Matter Expert on Application knowledge for preparing training presentation, Quick Reference Guides and assisting with any issues/questions that arose from training
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.

Environment: Agile/Scrum, UML, HP ALM, Rational Clear Quest, Windows, MS Office, HTML, Windows

Confidential,Nashville, TN

Business Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Documented and tracked requirements in Mercury Quality Center.
• Acted as a liaison between the development team, QA team and the Business team and resolved any conflicts due to change in requirements.
• Introduced Agile and RUP methodologies to reflect liquid nature of front-office improving time-to-market
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Conducted GAP Analysis between the existing projects and the proposed project to map the systems and evaluate their utility toward the new project.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, leveled technique for building Business Process Models.
• Establish documentation for Agile methodology for implementation with a very water-fall-centric development team.
• Designed and developed Use Cases using UML and Business Process Modelling.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Designed and developed project document templates based on SDLC methodology
• Ensured that all Lines of Business specifications were consistent in form and function to the Diamond Base System.
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Involved in analysis for wide range of Six Sigma and Web-based initiatives, including user requirements.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database
• Analyzed and Documented Business Requirement Document (BRD), Functional Specification Documentation, and System Requirement Documentation, using UML methodologies
• Involved in DB2 Performance tuning projects where the existing modules are analyzed for optimum use of system resources.
• Reviewed test scripts and made sure that the Test scripts covered all scenarios of the requirements.
• Conducted group (JAD) sessions with business units and stakeholders to define project scope and deliverables.
• Logged defects into QC while doing Functional Testing and followed through the process until the defects were closed.
• Reviewed the Defects entered by the QA team and prioritized the defects and assigned them to the development team
• Interacted with the users and logged any defects, enhancements from the UAT.
• Worked with the Training Group to build training materials as well provided any suggestions/ tool tips to assist in User Training
• Prepared documents and conducted interviews and JAD sessions to facilitate a smooth transition during merger.
• Documented changes that needed to be done before, during and after possible mergers.
• Documented website availability and availability of dashboard reporting and other resources before, during and after merger.
• Introduced banking procedures to business analysts and other members of merged entity.
• Performed data analysis and gap analysis to keep projects on track.
• Helped in user acceptance tests (UAT) and other tests.
• Authored user manuals for customers of merged entity.
• Was instrumental in a smooth transition of entity, and in a much broader client base.

Environment: RUP, Rational Requisite Pro, UML Use Cases, VB.NET, SQL Server, Rational Rose, XML, Use Case Documentation.