SUMMARY:

• 6+ years of experience as a Business Analyst in Healthcare Industry with extensive knowledge and experience of Software Development Life Cycle using different SDLC methodologies and expertise in HIPAA regulations, EDI and ICD 
• Worked closely with various project stakeholders, SMEs, and Expertise in preparing Business Requirement Document (BRD), Functional Requirement Document (FRD) and Non - functional Requirement Document and also maintained a Requirement Traceability Matrix 
• Proficient in facilitating and conducting Joint Application Design (JAD) sessions, focus group and brainstorming sessions, reviews and walkthroughs and customer interviews for various business processes 
• Strong business analysis skills through an in depth understanding of Software Development Life Cycle (SDLC) and understanding different methodologies at all stages of Rational Unified Process(RUP), Agile, Waterfall and Business Process Re-engineering
• Strong knowledge of modeling the system using Use Case Diagram, UML Diagrams (Activity diagram, Sequence diagram, State diagram and Class diagram) and also knowledge of Impact Analysis, Scope Definition and Change Management through MS Visio 
• Experienced in the analysis and design of application using OOAD techniques, UML and design patterns. Performed Gap Analysis, SWOT analysis, Risk Analysis, Feasibility study and Cost/Benefit Analysis.
• Proficient in processing batch jobs related to Benefit Enrollment (834) and Claims (837) 
• Experience in real-time EDI transactions such as Benefit Inquiry and Response and Claim status Request and Response (276 / 277) 
• Involved in Forward Mapping from ICD-9 to ICD-10 and Backward Mapping from ICD-10 to ICD-9 using General Equivalence Mapping (GEM) 
• Experience in Managed Care Plans (HMP, PPO and POS) and Government Sponsored Programs (Medicare, Medicaid, Medigap) with understanding of compliance and regulation of CMS and other State/Federal regulations 
• Created/recruited/hired RCM and supporting staff for 3 clinics
• Involved in the HIPAA 4010 to 5010 conversion analysis including the documentation of HIPAA 5010 changes to EDI 837, 834, 835, 276, 277 transactions, strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10
• Knowledge of SQL Queries and identifying various test scenarios. Extensive experience working in AGILE and SCRUM development .
• Development and documentation of policies and procedures to support RCM workflows and processes.
• Involved in AS IS and TO BE process analysis 
• Facilitated scrum ceremonies (release planning, grooming, sprint planning, retrospectives, daily stand-ups, etc.) 
• Created and implemented policies for RCM operations 
• Proficient in all phases of Requirement Management; including gathering, analyzing, detailing and tracking requirements using RTM, create Business Requirements Document(BRD) and Functional Requirements Document(FRD) 
• Proficient in preparing project sizing and CAPEX document for contractual work RCM (Revenue Cycle Management) according to clients ROI and obtain approvals 
• Managed internal projects improving project planning, resource management, and time billing using MS Project, SharePoint, CA Clarity, TeamTrack and IQ Navigator for prototyping and process simplification
• Expertise in Healthcare Industry including, Care Management, Primary care services, HMO, Managed Care, Medicaid, Medicare Services, EDI, XML, American national standard institutes (ANSI), Accredited Standard Committee (ASC), HL7 and X12 Standards 
• Proficient in creating and transforming Business Requirements into Software requirement Specification (SRS) 
• Provided 3rd tier support (as defined in the Support SOP) to EMR/LIS-Interface related problems 
• Practiced in EMR Vendor Certification Process 
• Strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10, analysis & compliance experience from, payers, providers and exchanges perspective, with primary focus on Coordination of benefits 
• Expertise in State Medicaid Management Information System (MMIS) projects implementation(Provider enrollment & Contact Management) 
• Oversaw claim processing and EDI transactions - 837, 834, 835, 270/271 
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules

TECHNICAL SKILLS: 

Tools: DOORS, Clarity, JIRA, Clear case, Clear Quest, Rational Rose, UML, Requisite Pro, MSP, Bugzilla, Quality Center, Informatica, CVS, Winscp, BPEL, Apix, Filezilla, winmerge, CA Clarity , IQN, TeamTrack, 7edit(HL7), Apix, Putty, Toad, Rally, Erwin 

Project Methodologies: Agile, Rational Unified Process (RUP), System Development Life Cycle (SDLC), Waterfall, SWOT, Cost/Benefit 

Microsoft Tools: MS Word, MS Excel, MS PowerPoint, MS SharePoint, MS Project, MS Visio

Management Tools: Rational Requisite Pro, ClearCase, ClearQuest, Quality Center  Modeling Tools Rational Rose, UML, Axure, Erwin, Balsamiq Mockups

Database: MS Access, MS SQL Server, Oracle 9i/10g, Sybase 

Testing Tools: WinRunner, Quicktest Pro, Loadrunner, Testdirector, HP Quality Center, Rational Suite 

Operating System: Windows98/XP/ NT/ 2000, DOS, UNIX 

Data Modeling UML, E-R Diagrams, Data Flow Diagrams, Data Dictionary, Data mapping, Visual Basic  Reporting ToolsCognos, Report Net, Microsoft Reporting Services, and Crystal Reports  Healthcare Knowledge HIE, EMR/EHR, PPACA, ICD9, ICD10, HIPAA4010, HIPAA5010:
 

WORK EXPERIENCE:

Sr. Business Analyst

Responsibilities: 

• The objective of this project was to resolve the issues of the consumers related to EDI transactions, especially on the form 1095-A which is an IRS tax statement form. Different consumers had a different issue on 1095- A form which was ultimately resolved and consumers were able to file their taxes properly for 2014. 
• Performed root cause analysis to resolve the issues related to 1095-A form. Performed data mining to support consumers issues related to 1095 -A form. 
• Validated 1095-A form data related to consumers policy start/end date, Issuer name, mailing address update, monthly premium, coverage etc
• Worked as a coordinator and attended meeting with team lead, development team and QA team related to different issues and resolution on 1095 A- form.
• Processing and reconciling records in the Health Benefit Exchange (HBX) 
• Establishing eligibility for health care or overriding a HBX system generated eligibility decision 
• Played a role in analyzing business requirements and translating requirements into functional and technical design specifications and estimating effort required to set up the health insurance exchange
• Prepared Project Requirement Documents (PRDs) and distributed for review and approval according to Requirements and Solution Analysis (RSA) process
• Provided report analysis that differentiates both existing Medigap plans as well as the newly modernized Medigap plans. 
• Handled HIPAA ANSI X12 4010, 5010 formats and primary analysis for business processes using EDIs (270, 271, 276, 277, 835, 834, 837, 997). Familiarity with HL7 and Migration Environments for HIPAA 4010 to 5010 and ICD 9 to ICD 10 Conversions. 
• Analyzed the ICD conversion information provided by the CMS (Centers for Medicare & Medicaid Services) to gain understanding of the ICD-9 versus the ICD-10 code sets 
• Analyst for the Centers of Medicare and Medicaid Services' (CMS) Consumer Information and Insurance Oversight (CIIO) Healthcare.gov marketplace enrollment discrepancy resolution and 1095-A Form remediation program. 
• Provide training and mentoring to over 500 plus employees and managers on the 1095 reconciliation processes
• Responsible for troubleshooting and resolving errors in 834, 820, and 1095 transactions for health insurance exchanges and perform root cause analysis. 
• Identified scope systems that will be modified by the ICD-10 project to accommodate ICD-10 code and/or downstream impacts steaming from ICD-10 codes. 
• Used GEM (general equivalence mapping) in forward mapping and backward mapping of ICD9 and ICD10 code sets
• Support all levels of RCM associates in the use of applications and processes used in RCM.
• Received and acknowledged Exchange HIX membership Enrollment /Termination / maintenance file from EDI Gateway (EDI 834/999). 
• Conducted weekly meetings for deciding the Policies and Procedures to be followed working on 1095 issue cases. 
• Created Decision Matrix for the reprints, Missing 1095A, Missing Info, and mailing address updates to benefit the entire 1095A Project.
• Assisted in preparing the consolidated SOP containing all the process of processing 1095A. 
• Conducted JAD Sessions to gather the project Requirements and gain more understanding of the various 1095A processing- Reprints, Serco Letters, BUU Updates, BUU Rejects and HICS Updates. 
• Developed high level design of new processes and graphically presented them to the project teams. 
• As is and To be scenarios created for the Reprints- 1095A 
• Worked with the Functional Specialists and SMEs to document high level workflows for the Claims processing, EDI, and Reporting
• Support Senior Level Analyst in projects within RCM
• Provided Support for all insurance teams throughout the Revenue Cycle Business Office. 
• Prepared ICD-10 GAP documents and involved with 837, 835, and 278 transactions in collaboration with other team members
• Assured HIPAA 4010 and 5010 with ICD-10 analysis & compliance 
• Prepared Project Requirement Documents (PRDs) and distributed for review and approval according to Requirements and Solution Analysis (RSA) process 
• Experience in Managed Care Plans (HMP, PPO and POS) and Government Sponsored Programs (Medicare, Medicaid, Medigap) with understanding of compliance and regulation of CMS and other State/Federal regulations 
• Created Training Documents for Health Care Reform Guide as per ACT. 
• Conducted the Walkthrough meeting with Business user to illustrate HCR Group Structure, HCR Plan and Product, HCR APTC Billing Group. 
• Conducted Impact Analysis across more than 750 applications to identify those affected by ICD 10 conversion while working directly with senior leadership, program manager, SMEs and multiple app management teams.
• Designed and developed Use Cases and UML diagrams (class diagrams, activity diagrams, sequence diagrams) using MS Visio 
• Assisted in writing test strategies, test plans, test cases, test scenarios, and performing UAT (User Accepted Testing) 
• Established System Analysts taskforce to facilitate testing and supervised development of test cases based on requirements for ICD 10 compliance. 
• Developed and executed SQL queries to validate/update Diagnosis / Procedure code for ICD 10 
• Involved in reviewing results from test submissions.

Business Analyst

Responsibilities: 

• Involved in gathering and documenting the requirements that were critical to the business process and using those requirements to design application software using a Use Case approach. 
• Involved in Pre -Project Analysis and in pre-implementation tasks coordinating with project coordinators for contractual work, change management, quality and impact analysis. 
• Handled multiple projects including ICD-9, ICD-10 and claim processing in test environment 
• Interviewed several business area experts, asking detail questions and carefully recording the requirements in a format that can be reviewed and understood by both business people and technical team
• Conducted Functional Requirement reviews and walkthroughs with the designers, developers and stakeholders 
• Works directly with the President, COO of corporation to design and oversee an industry-leading RCM. 
• Recognize and identify RCM process challenges and escalate concerns in a timely fashion.
• Interviewed business users to gather business wants and needs around project ideas and translate them into business and technical requirements
• Coordinated with 12 practices of implementing six sigma RCM collections strategies and initiatives. 
• Interacted with clients and end users in order to understand the process and gather User Requirements 
• Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims 
• Helped developers with the following list of HIPAA-EDI Transaction Code sets: 837,834,835,270/271,277/275 & 276/277 
• Understanding of HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims. 
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats 

Business Analyst

Responsibilities: 

• Gathered Business Requirements by close interaction with business teams. 
• Performed auditing the functional documents. 
• Organized the review meetings. 
• Involved in the Analysis & Design workflow for various processes by following the Rational Unified Process (RUP) and Business Use Cases. 
• Conducted one on one interviews with Business Leads. 
• Summarize revenue cycle inefficient findings and reports to practice directors and administrators. 
• Recognize and identify RCM process challenges and escalate concerns in a timely fashion
• Implemented numerous Revenue Cycle enhancing electronic solutions including AHIQA registration accuracy, electronic lockbox and insurance verification in the practices and Hospitals.
• Involved in alignment of hospital/clinic workflows and technology with patient satisfaction and revenue turn around.
• Created Business Process Diagrams, Use Case Diagrams and Activity Diagram for business problem and solution requirements. 
• Assisted the QA team in designing test scripts, test scenarios and test plan for integration and user acceptance testing (UAT). 
• Quality Center was used to perform bug tracking and reporting, also followed up with development team to verify bug fixes, and update bug status. 
• Coordinated the defect management process using Quality center. 
• Implemented processes, procedures, guidelines and policies for the Development and Quality Assurance Teams. 
• Assist with long range strategy by participating in the planning, design, development, implementation, maintenance, and evaluation of information systems and services in a Technology delivery environment.
• Used Rational Clear Case version control system to keep track of different versions of artifacts generated within the life cycle. 
• Performed Lean Analysis for various business processes by following the Rational Unified Process (RUP) to document  Business  Use Cases and create Process scenarios. 
• Setting up document hierarchy and standers to define different level of requirement using Requisite Pro. 
• Conducted walkthrough with the development team and stake holders. 
• Identified critical areas of business risk and modified the business process to reduce the same.    

Business Analyst

Responsibilities: 

• Responsible for ensuring the business requirements are captured, documented, maintained and met throughout the life of the program. 
• Created user stories from epics and made sure that it is scheduled in product backlog for the respective sprint. 
• Tracked status of multiple projects from Initiation through Completion. Developed various status tracking reports, ad hoc report requests, and develop and maintain management and resourcing procedures.  
• Created business cases for enhancement requirements, which may be as a result of either brainstorming sessions between the stakeholders, users and BA's, through client feedback, or both. 
• Provided business and analytical contribution to the development and technology delivery team, enhancement and implementation of a workflow based service components, in line with the overall business strategy.
• Reconcile daily file imports/exports of the Revenue Cycle systems. 
• Monitor overall client performance, identify potential loss or delay in revenue to ensure maximized reimbursement for assigned clients 
• Contribute and update documentation on the Revenue Cycle system applications to SharePoint. 
• Developed more efficient and effective processes in support of project and program management reporting, identify report automation opportunities, and implement technology resourcing effective solutions. 
• Assist in other Revenue Cycle Systems Coordinators for backup, projects and problem solving as needed. 
• Assisted project team leads in tracking budget and status of multiple medium and large scale projects, and also maintained all process documentations using MS Visio.  
• Managed entire project lifecycle and performed GAP analysis to differentiate between the "as is" and "to be" systems. Involved in business process reengineering (BPR). 
• Held JAD sessions to facilitate resolving of conflicts and to on various issues discuss the release notes for every build during the course of projects.
• Elevated to high customer satisfaction levels through assessment, analysis and continual improvement initiatives. 
• Tracked record of involvement in successful on-time, on-budget delivery of projects. 
• Developed standard upgrade guides, procedures and presentations for major version upgrades. 
• Held walkthroughs with the developers and QA teams in order to create a better understanding of the system requirements. 
• Interacted and effectively communicated with project managers, customers and management team. 
• Used SQL to query Oracle Database and resolve data issues, also compiled business intelligence reports based on results.