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Edi/ Qa Specialist Resume

Southborough, Ma


  • 8 years of IT experience in Software Development Life Cycle (SDLC) and Project Life Cycle working as Business Systems Analyst mainly in Healthcare sector.
  • Well Familiar with current industry standards, such as HIPAA, SOX, ISO, Six Sigma, and Capability Maturity Model (CMM).
  • Strong experience of working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, and Insurance Claims.
  • Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as 837 for submitting claims, 835 for payments, 834 for benefit enrollment, and 820 for premium payments to insurance products, 270, 271 for healthcare benefits and eligibility, 276, 277 for claims status and 278 for transmitting health care service information.
  • Strong knowledge of software development life cycle (SDLC), waterfall, Agile/Scrum, and RUP (Rational Unified Process).
  • Well versed with ICD9, ICD 10, CPT, HIPPA, claim adjustments, claim processing claim review, identifying claims processing problems, their source and providing alternative solutions.
  • Experience in working with Microsoft Office suite (word, excel, Access, Visio, Power Point and Outlook) for documentation, analysis and presentation.
  • Extensive knowledge of HIX, PPACA, Medical Management Information Systems (MMIS), and National Provider Identification (NPI).
  • Extensive experience in gathering Business and Functional Requirements, Business Scope & Vision Document, developing Business Requirement document, Functional specification document, communication plan, Use Cases, conducting Gap Analysis and Risk Analysis.
  • Conducted JAD sessions and Interviews. Adapt in implementing requirements, creating project status reports and presentations.
  • Experienced in creating Sequence Diagrams, Collaboration diagrams, Activity Diagrams, Class Diagrams using Rational tools and Microsoft Visio.
  • Worked with Software Development Life Cycle (SDLC) including Feasibility Study/Gathering Requirements, Analysis, Design, Development, Testing, User Acceptance Testing (UAT), Implementation and Post - Implementation Validation.
  • Expertise in creating and executing Test plans, Test scripts, Test cases, for Manual and automated testing.
  • Experience creating Traceability matrix to better manage the requirement gathering process and keeping track of the milestones.
  • Created data flow diagrams, system Use cases and UML models.
  • Conducted SWOT analysis, impact analysis, cost-benefit analysis, gap analysis and risk analysis.
  • Performed data validation using SQL Scripts for various business scenarios.
  • Strong knowledge of Data Modeling, Data warehousing and Data Mapping.
  • Strong Knowledge of Business Intelligence Applications.
  • Highly creative and illustrated positive and productive team environments with integrative thinking skills which was used to problem solving and making sound decisions.
  • Good experience with Rational Rose, Rational Requite Pro, Rational Clear Quest, Rational Clear Case, MS Project, MS Visio
  • Proven success as a business analyst through the years, providing a well-balanced understanding of business relationships, business requirements, and technical solution.
  • Excellent computer skills including advanced proficiency in Microsoft Access, Excel (pivot tables, Vlookups, macros etc) SQL server, HTML, PowerPoint, Microsoft word etc.
  • Proficient with MS Project, SQL, relational database Sybase and UDB, Oracle and Access


Operating Systems: Linux, HP UNIX, Sun Solaris, and Windows 2000/XP/Vista

MS Office Tools: MS Word, MS Excel, MS Access, MS PowerPoint 2003/07, MS SharePoint

Languages: C, C++, SQL, PL/SQL, JAVA, .Net.

Packages: MS Office, MS Visio, MS Project

Tools: Clear case, Clear Quest, Rational Rose, Requisite Pro, HP Quality Center, SOAP UI.

Databases: SQL, Oracle, MS Access, SQL Server 2000

Methodologies: Rapid Action Development (RAD), Joint Application Development (JAD),Rational Unified Process (RUP), Unified Modeling Language (UML), System DevelopmentLife Cycle (SDLC), Waterfall Model.


Confidential, Southborough, MA

EDI/ QA Specialist


  • Responsible for building/ maintaining high end scalable applications for healthcare insurance.
  • EDI processing system has data and processing criteria stored in tables which involve claim data, provider info and member info
  • Develop EDI transactions using X12 transaction.
  • Involved in writing Test Plan, Test cases and responsible for executing test scripts.
  • Responsible for designing, developing test plans use cases and executing test cases.
  • Hand on experience with daily claim processing and uploading 837 files into database.
  • Involved in testing HIPAA EDI Transactions and transactions focused on were 270,271, 834, 835 and 837.
  • Worked Extensively with Inbound 837 I and 837 P, 835s (Outbound) claim processing systems.
  • Created EDI files for encounters and did 5010 gap analysis for all EDI transaction such as 837, 835 and 999.
  • Prepared and created Test Cases/ Test Data according to 5010 Business requirement.
  • Expertise in developing QA Test Plan, Test Condition and Test Cases; ensuring adequate testing of application both before and after completion; conducting and documenting UAT.
  • Created Requirements v/s Test Case Matrix in Excel Spread Sheet template.
  • Worked on 837,835,276 and 277 Institutional and Professional, EDI Gateway.
  • Extensively worked with Edifecs for compliance check, analyzed all EDI test files with 5010 implementation guides and gap analysis of EDI transaction.
  • Supervised the work of junior technical writers and worked in collaboration with them.
  • Used SharePoint to store document and version control.
  • Well versed with Claim processing from point to point.
  • Conducted workflow analysis to bring out the identified gaps and documented it.
  • Conducted queries of SQL server, MS Access and DB2 database.

Environment: UML, Windows 7, EDI X12N 5010, BizTalk, Edifecs, sFTP, XML, MS Acess, HIX, MS Word, MS Excel, MS Visio, MS SharePoint,SQL, Mercury tools and Manual Testing.

Confidential Oklahoma City, OK

Sr. Business Analyst


  • Supported the development of training curriculum, matrices, and materials to conduct the MITA Education and Training. This includes creating a MITA Training Schedule with dates, times, and participants as well as arranging the logistics for the meetings.
  • Co facilitated workshop sessions for intermediate business and functional requirements and documents resulting decisions.
  • Used MITA Tracer Tool to gather information for the DOH during the Workshops.
  • Accountable for activity/progress reporting.
  • Assisted in the documentation of Business Processes.
  • Assisted senior level staff with the analysis of client business processes and functional or reporting requirements. Assists in the preparation of appropriate documentation to communicate and validate the information.
  • Supported team in gathering and developing Visioning Workshop materials to include agenda, handouts, and documents relevant to topics for scheduled sessions
  • Identified SMEs to be included in workshops according to their area of specialization.
  • Responsible for scheduling workshop sessions according to availability of the SMEs.
  • Managed the meeting and issues log for the project.
  • Responsible for implementing changes in the workflows using MS- Visio and documentations based on the results of the workshop.
  • Updated and monitored activity tracking for status reporting.
  • Responsible for operations activities.

Environment: UML, Windows 7, Java, SOAP, MITA Tracer Tool,SQL, HIX, MS Word, MS Excel, MS Visio, MS SharePoint

Confidential Raleigh, NC

Sr. Business Analyst


  • Performed a baseline assessment of Hospital-Provider systems and related interfaces, the existing service level agreements and/or policies and operational business procedures for readiness to comply with HIPAA as well as ICD-10 requirements.
  • Analyzed HIPAA 4010 and HIPAA 5010 standards for 837P, 837I and 835 transactions and prepared gap analysis document for each transaction.
  • Worked on analysis of the Facets claims processing application in order to gather requirements to comply with HIPAA 5010 requirements.
  • Utilized Mercator as an EDI mapping tool to map the claims data that passes through the EDI gateway to the Facets claims processing application.
  • Used Rational Requisite Pro for overall Requirements Management and to build the Requirements Traceability Matrix.
  • Actively worked on Data analysis and Report analysis with respect to ICD-10 impact.
  • Identified risks, problems, requirements and concerns of the Hospital in order to comply with ICD-10 changes.
  • Highly involved in understanding of department workflows and process flows with respect to applications.
  • Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and created awareness within the departments regarding the need, impact, benefits and risks of ICD-10 code application.
  • Re-Organized the collected data and prepared documentation for implementation.
  • Involved in providing education about the ICD-10 codes and 5010 standards, its requirements, complexity and accuracy to Physicians and Nurses of the hospital. Performed impact analysis on applications for deadliness of ICD-10 conversion.
  • Met the information demands of business users by delivering timely, accurate, meaningful and standardized data and reporting.
  • Mapped the collected data with the existing data provided by the hospital departments.
  • Hands-on experience and good understanding of the hospital working system including Registration, Scheduling, Radiology, Laboratory, Pharmacy, Patient Accounting, Claim Processing etc.
  • Performed XSD validation for the XML messages generated.
  • Wrote PL/SQL statement and stored procedures in Oracle for extracting, as well as writing data.
  • Used SQL queries to the integrity of data by querying the database Interacted with the development team to assure that all the defects are addressed in time.

Environment: Windows XP, RUP, Quality Center, Mercator, SQL Server, Jira, SOAP, Java, Rational Requisite Pro, Clear Quest, MS Office, MS SharePoint, MS Visio.

Confidential, Springfield, IL

Sr. Business Analyst


  • Gathered Business Requirements, analyzed data/workflows and defined scope for the Claims Business area and updating EDI Transactions with the HIPAA 4010 to HIPAA 5010 Changes and participated in full life cycle implementations (SDLC) from project initiation to final deployment.
  • Analyzed inpatient and/or outpatient medical records using International Classification of Diseases, Ninth Revision (ICD-9/10).
  • Updated ICD-9 and CPT code changes.
  • Created Business Requirement Documents (BRDs), Use-Case Narratives including business process workflow diagrams and Requirements Traceability matrix.
  • Performed GAP analysis in order to indentify the changes in 837, 270/271,275,276/277,834 and 835 transactions being proposed in the upgrade from HIPAA 4010 to HIPAA 5010.
  • Created business use-cases, flow diagrams and validated business rules and data elements for EOB and adjustment application
  • Mapped 4010 and 5010 differences
  • Participated in the JAD sessions along with technical team members and client to elicit requirements.
  • Created Test cases, test plan and Companion Guide development from stage to production, including both internal and external requirements. UAT testing for ICD10 and HIPAA 5010 projects including legacy testing and HIPAA requirements and compliance mandates. Unit testing documentation developed using Excel.
  • Documented the UAT plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
  • Maintained the traceability matrix table to uniquely trace the identified business requirements of general design to testing as proof that requirements requested have been developed into a solution and tested to understand the current flow of business and its working conditions.
  • Acted as interface between technical and business users to prepare business and technical requirement document
  • Designed requirements traceability matrix to trace/manage business requirements.

Environment: Java, RUP, Rational Requisite Pro, UML Use Cases, SQL Server, Rational Rose, XML, Use Case Documentation, Clear Case, Clear quest, HP Quality center, EDI, SharePoint, MS Access, MS Excel, Flash and FrontPage.

Confidential, Menomonee Falls, WI

Business Analyst


  • Developed an improved system whereby the members could share and communicate information easily.
  • Served as the primary liaison between the business and IT for E-Commerce Project (internal search).
  • Gathered Business Requirements, through constant interaction with the Users, Designers and Developers, Project Manager and SMEs to get a better understanding of the Business Processes. Developed business process models in RUP to document existing and future business processes.
  • Analyzed and optimized the process, prepared Business Requirement Document (BRD) and Functional Specifications.
  • Followed Waterfall Software Development Methodology and gathered the requirement and interviewed stakeholders and end users.
  • Used the knowledge of Product Lifecycle Management (PLM) in integrating all the resources such as human resources, business systems, processes and data to provide information to support the company and its research staff.
  • Creating different types of diagrams (using MS-Visio) & charts for E-commerce.
  • Identified Use Cases from the requirements.
  • Created UML Diagrams including Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and Collaboration.
  • Created Diagrams, Data Flow Diagrams (DFDs), ER Diagrams and Web Page Mock-Ups thus defining the Business Process Model and Data Process Model.
  • Communicated with design, development and test team using MS exchange messaging.
  • Provided technical assistance in identifying, evaluating, and developing systems and procedures that were cost effective and met business requirements.
  • At an individual project level worked cross functionally to define plans and schedule timelines to meet project objectives.

Environment: Java, .Net, SOAP, JAD, MS Visio, Windows 2000/2003,Jira, RUP, Rational RequisitePro, Rational Rose, Oracle, SQL, PL/SQL, SharePoint, MS Office

Confidential, Hartford, CT

Business Analyst/UAT Tester


  • Conducted detailed and comprehensive Business Analysis by working with end users and other stake holders to identify the system, operational requirements, and proposed enhancements.
  • Facilitated Joint Application Development (JAD) sessions with all IT group members for communicating & managing expectations and to discuss various means for integrations with current system using an adoption through execution strategy.
  • Identified all necessary Business and System Use Cases from requirements, created UML diagrams including Use Case Diagrams, Activity Diagrams, and Sequence diagrams using Microsoft Visio.
  • Understood the Business Logic, User Requirements and test-objectives to develop Test plans, Test cases, Use Case Scenarios.
  • Validated the business process flow for the claims processing (EDI transactions) which included hospital claims (Part A, B) and prescription drug claims (Part D).
  • Involved in comprehensive testing of the system to check it satisfies functional specifications.
  • Conducted Gap Analysis on the AS-IS and TO-BE business processes and technology; and identified potential pitfalls, risks, and issues.
  • Prepared Test Plan, test cases and test scripts for the Application.
  • Performed Manual and Automated Testing.
  • Performed Sanity Testing, Integration Testing, System Testing, Regression.
  • Performed regression tests and repeated the testing cycle until the defects are eliminated.
  • Created High Level Test Scenarios, Test Cases and Test Scripts for Data Hub requirements as described in RSD (Requirement Specification Documents) and DSD (Design Specification Documents) as well as HIPAA.
  • Gathered Data Hub requirements and responsible for creating test cases and test scripts under Quality Center Test Plan and Test Lab modules.
  • Worked with ICD 9 codes, CPT codes required for processing the claims required in compliance with HIPAA 4010.
  • Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test Conditions the performance of the application from various dimensions.
  • Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
  • Data Hub testing scope includes testing the Data Hub requirements, documenting and testing source system records, change requests and assist SMEs with validation of daily error files.
  • Verified and validated all the build or release related issues and resolve then through discussion with business analysts with the users approval.

Environment: Scrum, HTML, MS Project, MS Office, UML, MS-Visio, Visual SourceSafe, Rational tools, SQL, Win Runner, Load Runner, QTP.


Business Analyst

  • Gathered requirements and prepared business requirement documents (BRD).
  • Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
  • Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
  • Involved in business and technical to develop business requirements for implementation
  • Developed and maintained all operational and technical flows using Visio and Power point
  • Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models
  • Defined Use cases from requirements and helped convert them into software specifications
  • Involved in developing and executing test scripts, test cases, data sets and user procedures
  • Aided in workflow analysis and process design
  • Analyze business requirements from Black Box Testing perspective, business process and system architecture/design
  • Maintained Requirement Traceability Matrix (RTM).
  • Performed Regression Testing and created test scenarios for User Acceptance Testing (UAT)
  • Used MS Office Tools (Word, Excel, Outlook), MS Visio, MS Access, Lotus Notes and Clarity
  • Maintained documents for change request and implemented procedures for testing changes.

Environment: Rational Rose, MS Office Suite, Windows NT/XP, Rational Requisite Pro, Web Services, JAVA, Tag Libraries, UML.

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