SUMMARY

• Experienced as Healthcare System Analyst with 7years of diverse experience as Business system Analyst /Configuration Analyst and practices while providing me the opportunity to utilize my extensive knowledge of Facets Configuration, Facets implementation, building and testing products, Medicare, Medicare Advantage, Commercial Plans, Medicare & Medicaid, HMO, PPO, CMS, Employee Benefits and Medicare Compliance background.
• Knowledgeable in various aspects of health care, such as health information management, health care business analysis and health insurance reimbursements
• Worked with Provider, Member, Claims Adjudication, and Prior Authorization.
• Have experience with claims entry, claims retrieval, claim adjudication and claim review.
• Experience withICD9/ICD10, NDC, DRG, APC, CPT, NCPDP codes and NSF formats for interfaces and images to clearing house / trading partner’s applications.
• Experienced in designing and reviewing Business Requirement Document (BRD), Functional Requirement Document (FRD), Use Case Specifications, Requirements Traceability Matrix and Testing Documents.
• Skilled in creating Sequence Diagrams, Collaboration Diagrams, Activity Diagrams and Class Diagrams.
• Documented User Stories and facilitated Story Point discussions to analyze the level of effort on Project Specifications
• Experience in all phases of the Software Development Life Cycle (SDLC) including requirements gathering, analysis, design, implementation, testing and deployment as well as software engineering methods like Waterfall, and Agile.
• Experience with Facets system implementation, claims and benefits configuration set - up testing
• Experience in interacting with stakeholders like business clients, end users, vendors, SDLC team, configuration manager and production team to identify information needs and initiate process change.
• Proficient in writing SQL queries to manage customer database, good knowledge of Data Warehousing
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as EDI 837, 835, 834, 270, 271, 276, 277, ICD 10.
• Maintenance, development and implementation of Facets system upgrades, new releases and change packages.
• Extensive knowledge of Medical Management Information Systems (MMIS), Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process.
• Worked on configuration of FACETS with Benefits, Claim processing, Subscriber/Member and Enrollment.
• Possesses strong understanding of test plans, test cases, test scripts and defects tracking / reporting
• Possesses extensive knowledge of SQL queries and back end system integration testing
• Conducts User Acceptance Testing (UAT) and verification of performance, reliability and fault tolerance issues for web based and client/server applications
• Executes Functional, Integration, System, and Regression testing.
• Expert in tuning the performance of SQL queries and ETL process.
• Involved in testing Member, provider, Claims Processing and Utilization Management, Contracts and Benefits modules.

TECHNICAL SKILLS

Methodologies: Agile, Waterfal

Requirement Management Tools: Rational RequisitePro, JIIRA

Project Management Tools: MS Project

Business Modeling: MS Visio

Defect Tracking: ALM, Test Director, Rational Clear Quest/Clear Case

Databases: MS SQL Server, MS Access

Operation Systems / Platforms: MS Windows

PROFESSIONAL EXPERIENCE

Confidential, Norfolk, VA

Facets Configuration Analyst

Responsibilities:

• Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with Busienss requirements.
• Organized impacted systems into high, medium and low impact to help business analyze the level of effort for remediation activities and ease resource allocation work.
• Configuration in Medical Plan, Subscriber/Member, Claims Processing and Billing modules
• Run reports and queries to validate configuration
• Create Benefits Matrices and document Facets configuration
• Benefit configuration for dual members Medicare-Medicaid in Facets Applications
• Run Access queries against Facets tables to validate configuration and identify defects
• Validate current configuration against the Policy Summary of Benefits
• Handled incoming calls from Providers and Members regarding status of claims and Benefit information. Trained staff on ICD and CPT coding.
• Worked with the compliance and audit team to made sure we were following correct HIPAA guidelines/protocols throughout the project lifecycle.
• Experience with Facets System implementation, claims and benefits configuration set-up testing, inbound/outbound interfaces and extensions, load and extraction programs involving HIPPA 837 and proprietary format files and reports development
• Worked on NetworXPricer which routes the Claims based on Configuration made on FACETS and configured with Benefits and member enrollment.
• Provided Expert Application Knowledge and Implementations for global business area. These applications support core business processes such as Facets Benefit Configuration, Claims, Provider and Enrollment.
• Used MS SQL for extracting the claims report for ETL (Extraction, Transformation and Loading),imported the report in excel for analysis.
• Included in selection committee for the selection of a code-mapping tool.
• Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by such as EDI Claims Intake, FACETS, Claims Adjudication, Medical Management, Utilization Management, Case Management Provider Reimbursement and Provider Payment.
• Tested configuration of Facets for Commercial and Medicare/Medicaid Products
• Gathered and created functional and non-functional requirement documents, IRD’s, Use Cases, Wire Frames, end to end system workflows, interface diagrams, mapping documents, presentations, message specifications, test scripts for enrolling and maintaining groups and individuals.
• Worked on specifically member enrollment, care connects and claims information system for creating a bridge between Business owners, stakeholders and development teams.
• Create Requirements Traceability Matrix and support in creation of enterprise solution architecture to integrate business rules across domains.
• Used SQL, data warehousing and data cleansing for the arrangement of customer data and used data mapping for collecting the data
• Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins
• Owned the business rules document which documented the business rules across different systems.
• Contributed in the build and design of organizational Wiki that provided comprehensive knowledge of workflows, policies and procedures, patient care objectives, regulatory requirements, and industry best practices for membership management
• Worked on the EDI 834 inbound and 834 outbound data movement with our trading partners
• Conducted process mapping to identify current As-Is business processes and To-Be road map for reengineering the products
• Worked with the Project Manager on various Project Management activities like keeping track of Project Status, Deadlines, Environment Request, and Compliance Issues
• Tracked and updated status of issues based on the daily meetings with the offshore team
• Facilitated in various meetings and discussed enhancement and modification request issues.
• Facilitated and participated in various enhancement meetings. Involved in the meeting with Business process owners, SME (subject matter experts) and Marketing Team for Requirements gathering in definition stage.
• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center managers and stakeholders of the project.

Confidential, Grand Rapids, MI

Facets Configuration Analyst/Business System Analyst

Responsibilities:

• Writes and prepares business requirements documents (BRDs), system requirements specifications (SRS), system design specification (SDS), functional specifications, defining project plan and change request
• Run reports to validate configuration
• Provided feedback on incorrect benefit configuration and provided solution
• Conducts analysis, configures, tests and document configuration solutions for the following functions:
• Benefit package configuration setup and maintenance
• Group/member premium configuration set-up and maintenance
• Medical management configuration set-up and maintenance
• Benefit configuration for dual members Medicare-Medicaid in Facets Applications
• Conducted data analysis using SQL on the backend databases for producing mapping documentation and transformation rules for developers
• Performed data analysis, writing SQL Queries for testing and troubleshooting against data warehouse
• Worked on EDI transactions 835 and 837 to identify key data set elements for designated record set
• Interacted with claims, payments and enrollment hence analyzing and documenting related business processes
• Worked with Facets Team for Facets Accumulator Validation and Verification Process and assisted in version upgrade and impact analysis on data warehouse tables.
• Worked on Facets Accumulators to help the production support team to keep check on the errors and rectifying them.
• Configured the payer and line of business details into Facets to support claims payment and financial reporting
• Conducted analysis on migration and conversion of provider and member data, group configurations, premium billing, benefit set-ups, fee schedules, provider pricing, capitation set-ups from Legacy system to Facets
• Extensive use of FACETS backend tables and frontend application system for data validation purposes.
• Worked on calculation of the benefit amount by analyzing the history of claims and updating as and when required.
• Attended meetings to capture business and functional requirements for data migration and demonstrated them using Visio.
• Worked on analyzing the gap between the accumulated amounts of benefit in Facets accumulator and advising the reason behind the errors.
• Experience with TriZetto Facets Application Groups: Claims Processing, Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Worked with TriZetto Facets team on different modules like Claims processing, Claim Pricing, Provider network management and Reporting.
• Involved in the Data Migration meeting and process to provide feedback from Facets side based on its technical functionality.
• Involved for defining the data conversion meetings and historical requirements and build systematic data conversion programs accordingly and provided Facets prospective in those processes
• Strong analytical, organizational, time management, multitasking, prioritizing, problem solving, presentation, facilitation and written and verbal communication skills.

Confidential, Albany, NY

Facets Business Analyst

Responsibilities:

• Gathered and created functional and non-functional requirement documents, IRD’s, Use Cases, Wire Frames, end to end system workflows, interface diagrams, mapping documents, presentations, message specifications, test scripts for enrolling and maintaining groups and individuals.
• Worked on the creation of user stories with the business team and then creation of functional requirements from them.
• Created architecture Solution flows, UML diagrams, service charters and detailed message specifications for development of messages/interfaces which using Business Process Modeling Notations (BPMN).
• Create Requirements Traceability Matrix and support in creation of enterprise solution architecture to integrate business rules across domains.
• Prepared Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio 2.0 for complex processes and walks business and development team through the documentation.
• Conducted Joint Application Development (JAD) sessions to expedite and streamline the requirement gathering process.
• Experience with FACETS solution for healthcare.
• Experience with TriZetto Facets Workflow for the Facets functional areas like Enrollment and claims data extracts.
• Worked on provider, subscriber, NetworX, Medical Fee Schedule modules.
• Worked on Medical NetworX Configuration under NetworX module in Facets to gather agreement information while processing claims like allowed amount and contract terms and Pricing details to process claims and for successful adjudication.
• Worked with the testing team to understand the Facets Claim adjudication process in order to ensure that they prepare valid test scenarios.
• Worked in testing the Professional, Institutional Claims processing and adjudication and validate data with facets.
• Involved in creating Adhoc reports related to the invoice backlog using SQL queries.
• Executed SQL queries for data reconciliation, data cleansing, data validation, and ad-hoc reports.
• Extensively created Business Process Modeling Diagrams/Swim Lane Flows using BPMN notations and MS Visio indicating transformations and feeds.
• Created crosswalks to support list of values across enterprise for reusability and for supporting CDM.
• Performed extensive GAP analysis and created Message Specification Documents for service calls.
• Perform source to destination mappings for internal systems for successful enterprise integration.
• Conducted process mapping to identify current as-is business processes and To-Be road map for reengineering the products.
• Implemented agile methodologies (e.g. Sprint Sycle, burn down chart, velocity, backlog grooming) to transform into agile from waterfall environment.
• Followed agile methodology and participated/arranged daily sprints to keep the pace of task assignments and achieve desired target dates.
• Skills include Agile Lifecycle Management, IT Strategy and cross functional project team leadership.
• Worked with the Project Manager on various Project Management activities like keeping track of Project Status, Deadlines, Environment Request, and Compliance Issues
• Tracked and updated status of issues based on the daily meetings with the offshore team
• Facilitated in various meetings and discussed enhancement and modification request issues.
• Facilitated and participated in various enhancement meetings. Involved in the meeting with Business process owners, SME (subject matter experts) and Marketing Team for Requirements gathering in definition stage.
• Developed prototype of new information processing application. Facilitated collection of functional requirements from system users and preparation of business requirement documents.

Confidential, Austin, TX

Business Analyst

Responsibilities:

• Facilitated Provider Enrollment, Setting up Provider profile & Trading Partner Agreement.
• Helped creating Provider Reports i.e. Financial, Claims processing.
• Gathered user stories (Requirements) for modules Enrollment/Registration, and medical billing and payments
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid claims
• Responsible for Business Process Management (BPM) for development of various projects.
• Developed Use Cases, Sequence Diagrams, Activity Diagrams and Class Diagrams.
• Requirements Document for the three functional areas
• Participated in all aspects of testing the New MMIS; Primary responsibilities is to ensure that the system functions as designed, meets the requirements of the business community and conforms to all applicable Federal and state laws. Worked on the claims and provider modules of the New MMIS system.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Responsible for employing the User-Centered Analysis techniques such as Interviews, direct observations, JAD sessions, to understand the business needs (MS Dynamics).
• Creating source-to-target mapping files
• Involved in the testing of web portal of New MMIS system.
• Conducted integration testing and regression testing with developers in development and QA, also conducted user acceptance testing with UAT team. Safety reporting on system-based projects, acted as a liaison, writing documentation and increased project coordination.
• Analyzed and documented system release/deployment issues according to version management, backward compatibility, load balancing of components in production environment.
• Did impact analysis for changing requirements and coordinated with business users for prioritizing the testing/release of the changes.
• Maintained a very close interaction between business users and developers to avoid any gaps in understanding or implementation of requirements.
• Did data analysis, created data mapping and data interface documents and kept the documents updated with changes in requirements and functional specifications.
• Developed Reports and Graphs to present the Stress Test results to the management
• Created BPR charts for AS IS and TO BE processes of different business functionalities.

Confidential, Albuquerque, NM

Business System Analyst

Responsibilities:

• Analyzed end-user requirements, their strategies, and their objectives to create Requirement Specification Documents and Use Cases.
• Created Requirement Specification Documents based on interviews with End Users, JAD Sessions and analysis of their existent systems.
• Analyzed the Business Modules and their impact on the current system.
• Created Use Cases, Use Case Models, Workflows, and System Specification Document using RUP Methodology.
• Extensively worked on Facets, the claim processing tool used in the project.
• Conducted business validations, covering the following deliverables: FACETS Providers, Facets Claims, and Facets Membership.
• Used Component business modeling for improving strategic planning and efficiency.
• Generated documentation and designed Use Cases, State Diagrams and Sequence Diagrams.
• Maintained Traceability Matrix throughout the project.
• Involved with querying Facets data via SQL
• Involved with root cause analysis of issues
• Created standards/guidelines for Business Process Modeling, Use Cases, Workflows, Data Dictionary, and Requirements Specifications.
• Mentored end-users on Requirements Specifications techniques and the Software Development Life Cycle.
• Scheduled meetings with technical personnel to determine technical parameters for EDI and other related processes including communication, security, and privacy.
• Created transaction sets requirements, usually with MS Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837 (I, P, & D), 835 Remittances and others.
• Analyzed requirements and formulated a Test Plan for Functionality Testing, Navigation, and Integration Testing of the application.
• Involved in creating requirements that comply with HIPAA and ANSI X12 format regulations to protect the privacy of the employee insured under any policy.
• Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI).