SUMMARY:

• Healthcare Business Systems Analyst with 6 + years of experience in Healthcare based Industries.
• Expertise in documenting the Business Requirements Document (BRD), Technical Requirement Document (TRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Good experience in the EDI transactions and knowledge on EDI transaction process flows.
• Strong experience and understanding of healthcare industry, claims management process, Knowledge of Medicaid and Medicare Services.
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and UML concepts. Tested HIPAA regulations in Facets HIPAA privacy module.
• Conducting business validations, covering the following deliverables: FACETS Providers, Facets, Claims and Facets Membership and Operational reports.
• Implementation experience in Eligibility System, Facets Data model, Configuration Implementation of FACETS module.
• Experience in developing project plans, identifying documents, validating requirements and re - engineering process. Worked extensively with professional User Interactive (UI) web applications using with the help of HTML and XML.
• Expert in creating Use Cases, Use Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and UML concepts.
• Experience in HealthCare applications for writing SQL statements to validate the database systems and for backend database testing.
• Strong knowledge of Trizetto tools i.e. Facets and actively involved in end-to-end implementation of Facets Billing, Enrollment, and Claim Processing and Subscriber/Member module.
• Worked on service oriented architecture (SOA), SOAP and REST Protocols; responsible for API documentation for JSON &XML messages in a multiple tier architecture for the trading dashboard.
• Worked extensively with the technical team in running SQL queries for data validation and comparison to perform backend testing.
• Experienced in EDI transaction 834, 835, 837I, 837P, 278 and proprietary conversions utilizing Facets extensions and development of new scripts and extensions to meet proprietary origination formats and reformat them into HIPAA standardized formats.
• Expertise in documenting PRD (Project Requirement Document) and Project Planning, Project Design, creating functional specifications and data / workflow diagrams.
• Experience with defect management tools such as HP ALM, Quality Center (QC), and JIRA,TFS
• Experience testing of Data Warehouse/ETL Applications developed in Informatica using SQL Server, Oracle and UNIX.
• Utilized FACETS for various health insurance areas such as products, enrollment, members and other modules related to FACETS.
• Ensure system configuration and functionality adheres to HIPAA, Medicare, Medicaid other market-specific regulations and business rules.
• Conducted business validations, covered the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports.
• Experience with Data Analysis, Data modeling and Data Mapping
• Extensive experience conducting JAD Session and communicated with Stakeholders, Development team, SMEs, System Analyst, Business Analyst and Project Manager.
• Knowledge and expertise in working with Claims, Provider, Enrollment, Finance, Benefits, and Vendor Management Business Areas.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.
• Experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases.

TECHNICAL SKILLS:

Project Methodologies: SDLC, RUP, UML, Agile, Waterfall

Business Modeling Tools: Microsoft Visio, Rational Rose

Platforms: Windows

Testing tools: Mercury Quality Center

Change Management Tools: Rational Clear Quest

Office Tools: MS Project, MS Office ( Word, PowerPoint, Excel, Outlook), MS Visio

Version Control Systems: Rational Clear Case

Database: MS SQL Server, MS Access, and Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Albuquerque, NM

Sr. System Analyst

Responsibilities:

• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA
• Proficient in using Agile Scrum methodologies, performed roles of Scrum Master following sprint/standup sessions and used Excel extensively to write user stories, analyzed the Iteration charts and reviewed defects.
• Worked closely with the project manager, business lead and technical lead to identify research and escalate issues and risks to the appropriate work stream for resolution.
• Documented complex Business requirements and made process flow diagram for the 834, 837, 270/271, 276/277 & 835Remittance transactions as per the implementation for the Medicaid claim processing system enhancement.
• Successfully used Agile/Scrum Method for gathering requirements and facilitated user stores workshop. Documented User stories and facilitated Story Point discussions to analyze the level of effort on project specifications.
• Integrated data from EDI reports.
• Extensively involved in decision making, such as bring all providers in Facet’s ONLY, CVS Providers, for instance, will not be included.
• Involved in FACETS Implementation, involved end to end testing of FACETS Billing, Claim Processing and Enrollment modules.
• Responsible for setting up Billing Entities using Group Profiles in Facets Billing Module.
• Responsible for checking of data in database by writing and executing SQL statements and initiating data acquisition user story after verifying with lead.
• Worked on claim processing module which involved Receipt and Verification of Claim Forms (837) and Claims Adjudication, Health Claim Payment/Advice (835) as per HIPAA guidelines.
• Performed web service testing using SOAPUI by creating Test Suite; Performed web service testing using SOAPUI by creating Test Suite.
• Worked with 834 (enrollment), 835 (medical claims payments), 837 (medical claims), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), and 277 (claim status response).
• Performed manual testing by building 837 claims, converting them into EDI file, uploading them into mainframe region and doing error resolution & testing for requirements& NPI crosswalk.
• Tested EDI X12 transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment) (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Write SQL queries to pull data from different data sources and compile various reports.
• Developed Web services scripts for a Web Service call sing SOAP
• Extensively used Visio to create dataflow diagrams for each phase of the project and posted on SharePoint.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data.
• Responsible for checking of data in database by writing and executing SQL statements.
• Gathered requirements for Process Integrator to store files like Provider Master, Paid Claim Header, Paid Claims Detail, and Provider Adjustments data and extract into FSCD.
• Wrote SQL queries for requirement analysis and data validation.
• Extracted and manipulated data using SQL.
• Designed and implemented SQL queries for the retrieval and management of data.
• Performance tuned and enhanced different complex SQL inquiries.

Environment: Waterfall Agile-Scrum, Microsoft SQL, MS Visio, Trello, Jira, HTML, XML, Rest API, JSON, MS Office Suite, MS SQL Server, UML, MS Visio, MS Project, MS SharePoint.

Confidential, New York, NY

Business System Analyst

Responsibilities:

• Conducted User Interviews and Gathered/Analyzed Requirements. Managed Change Requirements by implementing Change Management Methodology.
• Member and provider portal requirements, Member ID cards, Explanation of benefit documents (EOB), Benefit Summary Docs, Billing & Online Payments etc.
• Documented process flows, identified business rules, prepared Functional Requirement Documents and diagrams using MS Office tools and MS Visio
• Facilitated Joint Application Development (JAD) Sessions for communicating and managing expectations involved in FACETS Implementation, involved end to end analysis of FACETS Billing, Claim Processing and Subscriber/Member module
• Documented Functional Specifications for Enrollment (834), Customer Service Interface, Claim (837) including Encounter Claim and Capitation Payment (820) and Authorized Representative for Members.
• Manipulating the data in the database tables using SQL queries to create various testing conditions.
• Worked on EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Responsible for data modeling, creating logical and physical model. Created tables, views, procedures and SQL scripts.
• Responsible for providing on-site support for multiple implementation projects featuring a vast array of products, including Health Rules, CaseNet, and Facets.
• Tested EDI X12 transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment) (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Strategize configurations of Facets modules such as claims, Membership, billing, benefits and plans.
• Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication).
• Responsible for completing functional testing and regression testing for Core Facets, interfaces, extensions, reports and letters.
• Attended daily Scrum/Agile stand-up meetings with the team to discuss on Soap UI Testing
• Develop and automate Web Services API testing using SoapUI. Inspected and worked on HTTP web services application and on SOAP APIs.
• Experience in integrating claims, eligibility, provider and data information using facets
• Conducted analysis, assessments and cost/benefit analysis using facets
• Worked under Agile (Scrum) methodology using Team Foundation Service (TFS) ticketing system to log day to day activities.
• Create and maintain SQL Scripts to perform back-end testing on the oracle database.
• Involved in testing Web services/ APIs and XML with SOAP UI.
• Write SQL queries to pull data from different data sources and compile various reports.
• Worked on requirements of the 835 HIPAA projects, 276/277, 278, 837, and HIPAA EDI Transactions across enterprise.
• Supported data mapping between old and new system for Medicaid claims processing system (MMIS - Claims, Eligibility, provider etc.).
• Closely worked with Database team, wrote SQL queries to extract and analyzing data.
• Perform user acceptance testing (UAT) to ensure the business intent is correctly implemented in Facets.
• Created/scheduled SQL server jobs and maintenance activities of database.
• Created Use Cases, Process Flow Models, Data Flow Diagrams, and Logical Flow Diagram using UML for various functionalities.
• Created QA and UAT test strategies including Regression and Integration Testing.
• Managed testing, defect reporting and change requests.
• Involved with the QA team in monitoring software testing including

Environment: Waterfall Agile-Scrum, Teradata, Rest API, JSON, Microsoft SQL, MS Visio, JIRA, MS Office Suite, MS SQL Server, UML, MS Visio, MS Project, MS SharePoint, Confluence.

Confidential, Madison, WI

Business /Systems Analyst

Responsibilities:

• Performed GAP analysis on membership management and claims processing to evaluate the adaptability of the new application with existing processes.
• Analyzed a wide range of Trizetto FACETS configuration change requests for the purposes of determining the technical scope of the change, its impact on existing systems configuration.
• Involved in claim adjudication process of Facets application.
• Troubleshoot any problems found within FACETS and when testing the SQL database while validating the business rule
• Worked on developing the business requirement and use cases for FACETS batch process, automating the billing entities and commission process.
• Developed tables, Views, Stored Procedures and Triggers using SQL Scripting
• Writing Complex SQL queries and optimizing SQL Queries.
• Validate and review the EDI 834 feed to Health Rules Manager.
• Tested EDI X12 transactions 837 (Claim for Institutional, Professional and Dental Claims), 835 (Claim Payment) (Claim status), 834 (Enrollment), 270/271 (Member eligibility).
• Modified and Edited the XML to validate the SOAP UI Services.
• Performed Extensive database integrity testing by executing SQL statements.
• Involved in end-to-end testing of Facets Billing, Claim Processing and Subscriber/Member Eligibility/Membership module.
• Create REST API tests using SOAP UI. Strongly participated in the web based testing using Soap UI.
• Assist in data mining in terms of sections and packages integration with data tables, particular claims or membership data and other incoming vendor inquiries, as requested by various teams.
• Accepted inbound /outbound EDI (X12) 837, 834, 820, 835, 999, 276, 277(Claims, Provider, Portal, Billing, Benefits) transactions from multiple sources.
• Involved in HIPAA EDI 834, 270/271, 837/835 transactions according to test scenarios and verify the data on different modules. Tested HIPAA regulations in Facets HIPAA privacy module.
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database
• Strong SQL programming skills include writing Functions, Triggers etc.
• Tested the billing and rendering provider, member subscriber, and payment modules of FACETS in the UI as well as in terms of database validation through SQL Queries
• Analyzed and mapped different data sets from system with the new MMIS system
• Write Use cases and producing Use Case Model, Analysis model, Behavior diagrams based on UML Methodology &Business process flow diagrams using Visio
• Worked on the claims and utilization management application to set parameters and linked claim processing to UM to ensure accurate processing of claims for review, referrals and authorizations.
• Involved in impact analysis of HIPAA 835 and 837P transaction sets on different systems
• Facilitated the Meetings with Business owners, SMEs and Business user to gather the requirements. This includes face to face as well as WebEx interaction.
• Organized meetings and led JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met.
• Used Query Tool for Querying Oracle, SQL server for Teradata SQL Assistant for Querying.
• Involved in the testing of web portal of New MMIS system
• Involved in analysis of requirements for Medicaid and Commercial line of businesses.
• Followed agile methodology to gather the Business Requirements and designed Functional specifications.
• Highly involved in Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the change in the proposed system.
• Played major role to create the Business Requirement Documentation (BRDs), using MS Word and MS Visio that provided appropriate scope of work for technical team to develop prototype and overall system.

Environment: Oracle, Java, HTML, MS Office/Visio/Project, SQL, UNIX, MS Windows, MS Word, MS Excel, MS PowerPoint, DFD,¬ ALM, UAT, XML, Jira, SOAP UI.

Confidential, Chicago, IL

Business Analyst

Responsibilities:

• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD.
• We were also working for facets migration/conversion from one version of facets to another higher version and from one environment to another environment.
• Supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
• Conducting business validations, coveting the following deliverables: Facets Providers, Facets Claims adjudication and Facets Membership and Operational reports.
• Analysed the mainframe Reports for Member/Eligibility/Claims/Billing and mapped the fields with Facets batch jobs and reports.
• Gathered and documented functional requirements for testing and verification of HIPAA.
• Web Portal Development - Worked as a Business Analyst gathering requirements to develop a referral portal.
• Created process flow diagrams describing provider and member access to the web portals.
• Analyzed and evaluated User Interface Designs, Technical Design Documents and the performance of the application from various dimensions.
• Developed micro service using REST API which loads information from the database table and returns the data in JSON format.
• Documented Functional Specifications for Enrollment (834), Customer Service Interface, Claim (837) including Encounter Claim and Capitation Payment (820) and Authorized Representative for Members.
• Tested the changes for the front-end screens in Facets related to Membership, Benefit and Plan modules.
• Worked on claim processing module which involved Receipt and Verification of Claim Forms (837) and Claims Adjudication, Health Claim Payment/Advice (835) as per HIPAA guidelines.
• Modified and Edited the XML to validate the SOAP UI Services.
• Designed and implemented basic SQL queries for reports and data validation.
• Gathered requirements from the clients and developed crosswalks for HIPAA EDI820, 834,835, 837 P/I claim.
• Analysed and worked with Facets for claims, member enrollment, billing transactions.
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application
• Benefit coordination and configuration, updated, adjusted, and revised fee schedules, coding, rates, provider contracts, database, claims and information via FACETS
• Created Business Requirement Documents as a result of meetings with the Business Areas. Obtained business sign offs on the documents after reviewing the final documents with them.
• Created and maintained SQL scripts and UNIX as a part for backend testing on the oracle database.
• 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.
• Create SQL queries to read data from databases.
• Worked closely with the business team, development team and the quality assurance team to ensure that desired functionalities will be achieved by the application.
• Provided business and technical suggestions and recommendations during the project life cycle.

Environment: MS Office, Visio, SharePoint, SQL, Windows, ALM, UAT, Jira, UML, MS Word, MS Excel, MS Access, SQL, HIPAA, Facets, Waterfall, UML, Medicaid and Medicare claims.