SUMMARY:

• 13+ years of combine Healthcare experience with 10+ years of full scope experience as a Business Analyst/Project Manager with Healthcare systems (Providers and Payers).
• Strong Experience on Government programs (Medicare, Medicaid) Member Enrollment processes.
• Strong Experience & Expertise in US Healthcare Payer - EDI(X-12 EDI Transactions like 837 Claims, 835, 997 Acknowledgements, 834 - Member Eligibility, 270/271 Eligibility Inquiry, 276/277 - Claims inquiry)
• Experience in implementation- upgrade of applications and projects
• Project management - as Scrum Master (Agile)
• Sr.Business Analyst in Bundle Payment (Episode based Payments) claims building Project
• Worked on Healthcare Payer Systems - HealthTrio 3.8, QNXT 3.4 ( Trizetto ), XCYLES(Paradiagm/Diamond)
• Successful Completion of QNXT 3.4 - Business and Technical Training
• Partial Knowledge on Mckesson Claims Check 8.0, Microdyn Pricing, APC, DRG Pricer
• Strong research and analytical skills
• Successfully led a team size of 35 resources at offshore and 15 resources onsite.

TECHNICAL SKILLS:

• Computer skills
• Algorithm designs
• MS-Projects
• MS-Visio
• MS-SQL
• Database design
• MS Access
• MS Office products - like MS office Excel
• Word
• PowerPoint presentation

PROFESSIONAL EXPERIENCE:

Confidential

Business System Analyst

Responsibilities:

• Liaising with business and functional owners during requirements discussions and review sessions to derive and execute action plans, meet deadlines and standards
• Defined and documented clear, complete detailed business requirements and functional specifications using SDLC methodology.
• Met with business users to prepare and update Business process requirements and system requirements.
• Worked with difficult business partners and successfully achieved goal in defined timeline.
• Documented Business and Functional requirements on various complex projects. Guiding team to find correct solution for project.
• Played role of Subject matter experts and peer reviews documents for other team members.
• Working on multiple projects at the same time with multiple priorities and reporting status to upper management.

Confidential

Business Analyst

• Implementation of Enrollment correspondences, enrollment application and process including Requirements gathering, template design, CMS/State approvals, Creating BRD, FSD review, QA and UAT.
• AEP readiness - Enrollment Correspondence configuration, Gap analysis of CMS guideline for enrollment processes and correspondences
• Implementation of member and Provider materials (e.g. OOSA, PWO, PCP term)
• Play key role in Acquisition and Medicaid contract addition projects (FL MMA, Health Exchange)
• Project co-ordination with lead project manager to prepare requirements and perform project management with cross departments
• Creating business requirements, Step action, and Process documentations

Confidential

Project Manager / Sr. Business Analyst - Consultant

• Collection of business requirement and analysis of health plan EDI system.
• Prepared business requirement document to implement EDI 4010 to EDI 5010 Conversion
• Project Management for EDI X12-5010 Implementation for HMO - Health Plan for different EDI transactions (837I, 837P, 834, 835) with clearinghouse Availity
• Project co-ordination with onsite and offshore development team
• Project co-ordination, functional testing and business analysis for a newly developed specialty EMR

Confidential

Sr. Business Analyst-consultant

• EDI 004010X096A1-005010X223 data conversion projects for 837, 835 transactions
• Resource analysis, requirements, specification and implementation planning for various projects
• Detailed study and analysis of EDI 5010 conversion rules for 837 transactions and system requirement, Gap analysis and technical requirement documents for 837 4010 to 5010 migration of MedicareRT product. Analyze Import program and database structure.
• Documentation and recommendations for revenue cycle management in term s of 005010 EDI HIPAA transactions.
• Collection of business requirements and system study on Billing products
• Business analysis and requirements on the Bundle Payment solutions (Episode Payment). Detailed study and analysis of bundle payment solution for the provider and payer.
• Defining role of claims in Episode based payment system development and reporting at project level for claims and billing management module.
• Technical evaluation and UI changes implementation for environmental specific to Caremedic systems for MedicareRT billing product
• Agile management -Initiate Scrum and manage scrum by playing Scrum Master Role for Audit management product using RTC (Rational Team concert).

Confidential

Business Analyst / Claims Manager

• Resource Management, Resource Allocation, Scheduling - day to day claims operation.
• Healthcare Payer System - Health Trio - Claims Processing and Monitoring of daily operation
• Project Management - oversee the claims processing functions of outsourcing company.
• Coordination with Clearing house and responsible for EDI claims workflow Management
• Coordinated work of employees and outside contractors to meet deadlines, budgets, and client demand.
• Responsible for providing EDI training.
• Experience with X-12 EDI Transactions like 837 Claims, 997 Acknowledgements, 834 - Member Eligibility, 270/271 Eligibility Inquiry, 276/277 - Claims inquiry
• Designing of Policies and procedures for claims department as per Medicare and Medicaid guidelines.
• Responsible for delivering daily, weekly and monthly claims reports.
• Quality Assurance/Project Review - Develop test cases, Perform functional analyses of EDI portal, understand and followed SDLC (Software Development Life Cycle) process.
• Content producer and stakeholder to conduct interim project reviews project tweaks prior to launch.
• Design Claims processing workflow including Technical and Business Processes
• As PM and core tester - EDI - 837 Implementation, Rule Engine - Edits and Fuzzy logic development, Implementation training
• Design of Ad hoc reports for claims using the SQL - Access and SQL Server 2005
• Perform Unit testing, acceptance testing and implementation of Information Systems like QNXT 3.4 (Trizetto Payer System), modules and subsystems.
• Develops requirements tractability matrix to be used in software development and QA testing.
• Articulates and presents business analysis results clearly and concisely to stakeholders.

Confidential

Research Analyst

• Method Validation, Process Validation and Dissolution study of the generic drugs.
• Method Validation study and Method development.
• USP guidelines, cGMP, quality control testing
• HPLC, Method Validation, Process Validation, Dissolution, Data reporting

Business analyst /programmer

Confidential

• Developed business intelligence tools for healthcare systems
• Designed algorithms to meet technical requirements of systems
• Business modeling, project management
• Reviewed programming requests and works with business users and technical staff to identify, gather, analyze, and document business system requirements for program development.
• Actively involved in the requirement development, design and testing process of Visionary Medical System - Practice Management and Electronic Medical Records.
• Done minimum programming but understand the full spectrum of programming techniques.
• Experience in the field of Software Testing & Quality Assurance, primarily on Client/Server and Web-based Applications
• Proficient with entire Software Development Life Cycle (SDLC) process in program development.
• Expert in Product and Project Testing with sound knowledge in Business flow
• Passion for Quality, Customer Empathy and Results-Oriented
• Experienced in Test Plan Preparation including Automation Test Plans, designing Test Cases, developing and maintaining Test Scripts