SUMMARY:

• 9+ years of project experience primarily with Healthcare organisation - Optimally motivating and directing team to meet the project manager’s goal, knowing team’s strengths and weaknesses inside-out, rallying the team around a common goal with hands-on guidance and the constant reiteration of best practices, ensuring all resources are clear on where they fit into the achieving the goal at hand and identifying for each member of my team, where their current tasks at hand fit into their professional aspirations.
• Senior Healthcare Sr. Business System Analyst with 9+ years of hands-on experience turning business needs to software solutions for complex implementations involving coordination from multiple teams and integration of multiple systems.
• In-depth knowledge of payer operations including claims, enrollment, eligibility, underwriting, etc.
• Expert 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.
• Excellent knowledge of HIPAA (4010, 5010) transaction codes such as 270/271, 276/277 470 (benefit codes), 835(payment or remittance advice), 837(claims) and 834 (benefit enrollment).
• Experience in conducting SWOT Analysis, cost benefit and ROI analysis.
• Adept in writing SQL code in Teradata, Oracle, MySQL and MS SQL Server with experience in data warehousing.
• Involved in FACETS Implementation, involved end to end testing of FACETS Billing, Enrollment Claim Processing and Subscriber/Member module and also set claim processing data for different Facets Module.
• Proficient with billing and collections on Governmental, Commercial, HMO also Medicare and Medicaid and Post Charges and payments as well as Electronic Billing.
• Extensive knowledge and understanding of MITA, MMIS, Electronic Medical Health Record (EMHR) and Pharmacy Benefit Management (PBM).
• Experience in PEGA Direct Capture of Objectives (DCO) methodology.
• Working experience in documented implementations in the areas of Web Content Management, Workflow and Document Management.
• Experienced in gathering requirements and facilitating DCO sessions to capture the business objectives.
• Worked with different Business Areas like Claims, Enrollment and Pharmacy to analyze and implement proposed ICD 9 - 10 Code changes.
• Knowledge about Business Process Modelling and Notation (BPMN)
• Strong understanding of ICD-9, ICD-10-CM, ICD-10-PCS codes, HCPCS, CPT codes, J-codes, HCFA-1500, CMS-1500 claim forms and reimbursement forms.
• Experienced in documenting requirement using Unified Modelling Language (Use Case and Activity Diagrams) and building business Process Flow Charts.
• Expert in organizing and managing all phases of the application testing process using Mercury Quality Centre.
• Knowledge of web based applications and user interface (UI) design using tolls like ADOBE fireworks, illustrator, VISIO for wire framing and mock ups.
• Experience creating Proof of concepts in collaboration with system analysts and developers.
• Proficient in documenting business requirements and developing training programs, documents and materials in line with the necessary requirements
• Excellent understanding of Relational Database Systems, Normalization, Logical/Physical Data Modeling and Data Warehousing.
• Created and maintained requirements models including use cases, activity and sequence diagrams.
• Worked with HMO and PPO data and HIPAA.
• Facilitated and participated in JAD sessions, document results of JAD sessions, develop use cases, and obtain client approval of completed use cases.
• Working knowledge of relational database management systems.
• Extensive knowledge of SQL queries and back end system integration testing.

TECHNICAL SKILLS:

Reporting Tools:: Report Painter, Report Writer, LSMW

Other Tools:: MS-Office, MS-Visio, HP ALM, HP Quality Centre, Teamsite, Quick Test Professional

Operating Systems:: Ms DOS, Windows 95/98/2000/XP/2007, UNIX, Linux, Mac OS

Databases:: DB2, Oracle, SQL Server

Languages:: PL-SQL, VB.Net

Accounting Tools:: QuickBooks, Peachtree, Vertex

UI Diagram Tools: Axure, Adobe Illustrator, Fireworks, Pega 7, Microsoft Visio.

Requirement Tools: Rational Requisite pro, Clear Quest, Pega DCO.

PROFESSIONAL EXPERIENCE:

Confidential, Detroit, MI

Sr. Business Analyst

Responsibilities:

• Attend regular meetings with the Production Support Management team to discuss issues, concerns, and reasons contributing towards discrepancies in File Exchange, Date Exchange and Claim Posting metrics.
• Attend regular meetings with team members to discuss steps taken and needed, along with roadblocks faced, to be taken towards resolving Incidents and Inquiries.
• Met with business on Multiple one on one sessions to gather requirements, understand the current data source and document the future data sources
• Gathered requirements for Enterprise Data warehousing (EDW) for the client reporting needs.
• Involved in drawing data flow diagrams and process flow diagrams using MS Visio for the Claim Adjudication module.
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/ Medicaid claims processing.
• Gather requirements for the Medicare Secondary payer (MSP) for NON-GHP contract according to CMS guidelines.
• Validate all aspects of the MSP operations to support and facilitate quality, effective, and efficient operations.
• Validate business requirements for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Analysed requirements of the claims adjudication process within a healthcare payer.
• Gathered the process as to the audience for these initiatives from business and the purpose of these upgrade
• Met with various users from Membership, Health services, Provider network for requirements and changes
• Provide input into the development of work efforts in support of proposed system changes
• Develop Requirement Traceability Matrix across multiple projects in HP ALM/ QC.
• Support HP ALM administration tasks to support multiple projects teams.
• Create customize reports and graph in HP ALM, Edit/update business requirements, functional requirement and use case in HP ALM.
• Assigned to take over a floundering content management project using the Teamsite architecture and bring it to the point where it could be launched.
• Worked closely with PM, LSA, and QA Lead to size and define scope for project sprints using the Pega Sizing Tool.
• Used SQL, Toad, Data Warehousing and Data Cleansing for the arrangement of customer data.
• Mentored staff on BPM, Agile/Scrum methodology, and implementing Agile Test Driven Development (ATDD) on Pega implementation.
• Responsible for working with Potential users developed detailed gap requirements to bring the project up to speed including details content management data model documentation and application flow.
• Involved in the early DCO session, captured the direct business requirements using Pega tools.
• Created Application profile and executed Application Accelerator using PEGA DCO tools and assisted in creating use cases and various documentation.
• Worked on the project Initiation and Elaboration for Pega DCO and deployed successfully in multiple releases.
• Lead the requirements gathering and facilitated the DCO sessions to capture the business objectives.
• Researched claims aging for predefined date ranges, finding duplicate claims retrospectively, assessing the impact of group additions or deletions.
• Regularly check for files in Mainframe ensuring variances are in check, empty files are found and investigated and old files are recalled as necessary for daily analysis purposes.
• Assist in setting up Groups newly added to each vendor by gathering requirements.
• Entered relevant data in Group set up portal in terms of particular group code(s), umbrella group names, particular BCBS product line the group would be added to, information pieces to be sent to and received from vendors and cost share information.
• Created SQL queries for data validation.
• Extensively involved in the modeling and development of Reporting Data Warehousing System
• Performed manual Back-End testing on the application by writing complex SQL queries.
• Inserted different types of Verification points to capture and store information about the objects.
• Maintained Test matrix and Traceability matrix and also performed Gap Analysis.
• Participated in meetings with the developers on a regular basis to update the test documents.
• Tested Group set up data updates by comparing requirements, portal updates and concurrent database and Mainframe updates.
• 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.
• Reviewed functional requirements documents, high level design documents and finalized the testing in scope and scenarios for testing each assignment.

Environment : Agile, Scrum, Excel, HP ALM, Pega DCO, COGNOS, MS SQL, SQL, TOAD, Teamsite, Java, J2EE, HTML, XML, EDI, HIPAA, MS Office, UNIX and Windows NT.

Confidential, Woonsocket, RI

Sr. Business Analyst

Responsibilities:

• Gathered analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Served as a Business Systems Analyst designing web based application presentation approaches to project development needs managing the project life cycle from design, coding development, Unit System QA Testing, Implementation, and Post Implementation maintaining over site of the project status.
• Performed Data mapping on the extracted data, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data.
• Worked with Product owners to gather and system requirement document all the requirements of project.
• Worked with project manager for defining the scope of project, Business Architecture and system analysis.
• Conducting walkthroughs across the system requirements documentation and system testing deliverables
• Created Test execution metrics, Defect Metrics for daily status meeting.
• Designed Content Delivery solutions for code and web contents deployments using CMS tools Teamsite and XML.
• Worked in Data Warehousing & Business Intelligence and experienced with its tools.
• Integrated web application with Content Management System (Team Site)
• Worked with development team to deploy Java apps and .Net applications using Content Delivery tool.
• Conducted weekly status meeting with the Business/Executive team about system requirements.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Health Insurance Claims. Worked on HIPAA Standard/EDI standard transactions: 270, 271, 276, 277, 278, 834, 835, and 837 (P.I.D), 997 and 999 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Designed and developed Use Cases and Use Case scenarios, Activity Diagrams, Sequence Diagrams, High Level and Low Level Process Flow Diagrams, OOAD using UML and Business Process Modeling.
• Performed validation of Medicare OPL Claims, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Helped train the auditors on claim issues with the Training department (HPA, Institutional Pricing, OPL, CostShare).
• Implemented automated COB processing of Medicare claims into Facets.
• Experience of FACETS in Billing Entity, Premium Rates, Product Billing Component, Billing Group, Fees and Discounts, Adjustments, Claims, Provider, Member.
• Overseeing the development, implementation and ongoing maintenance of HIPAA 837(claims), 834 (Enrollment), 835 (remittance), 276/277 (claims status enquiry and response), (278 (referral authorization) EDI transactions as required to ensure quality claims.
• Wrote Test Cases for Enterprise Data Warehousing (EDW) Tables and Data Mart Staging Tables.
• Reviewed EDI 837 claims and flagged HIPPA non­compliant claims received from the Payer side.
• Conducted meetings, Joint Application Development (JAD) sessions and interviews with the business users to gather requirements.
• Analyzed requirements for next generation mobile/web applications, enterprise components framework, customer engagement and design pattern.
• Worked with other designers, coordinated with the Software Architect, Art Director and Project Manager.
• Worked with all key stakeholders, contributors, business, operations management, contributors to complete assigned tasks within the parameters of the project charter.
• Responsible for preparing Business Requirement Document (BRD), System Requirement Documentation (SRD), Functional Requirement Document (FRD) and then translating into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Performed Gap Analysis in every phase and stages to check the compatibility of the existing system infrastructure with the new business requirements.
• Wrote SQL Queries to perform Back-End Testing for data verification.
• Identified and documented all issues and defects to ensure desired quality of the application functionality.
• Worked with development team members to better understand system functionality in order to improve testing quality.
• Worked closely with the data warehousing team to analyze the existing database capabilities.
• Demonstrated ability to engage business stakeholders, by leading and assisting in the identification and definition of requirements, use cases in Pega DCO, process flows and user interfaces.
• Worked on PEGA (BPM) testing, PEGA test framework. PEGA Project management framework
• Responsible for complete Pega Implementation cycle including modelling of business process in DCO, development, testing in Dev/ QA/ UAT and deployment
• Prepared Role Based Access group for the Pega Workflow team such as Pharmacists, MDs, Appeals Analyst, and Intake Analyst etc.

Environment: SQL, MS Word, Excel, Quality Centre, MS Visio, PEGA, Teamsite, FACETS, Basic, SharePoint, AXURE. SharePoint, Rally

Confidential, Newark, NJ

Business Analyst

Responsibilities:

• Creating BRD and FRD for conduction of tests and enhance business process cycles
• Reviewed design documents & business requirements to learn the function and scope of the application.
• Involved in Test plan development, writing and implementation of the Test Cases.
• High Level Requirement Document using UML-based case models and process and state flow diagrams.
• Managed communications with offshore teams in multi locations.
• Created and authored UML diagrams like Use Cases and Use case Narrative, Activity Diagram, Sequence Diagram, class diagram and coloration diagram using MS Visio.
• Checked the data flow through the front end to backend and used SQL Queries to extract the data from database.
• Written multiple Test Cases (System, Integration) for multiple transactions include 837I, 837P, 835, (both inbound and outbound) transactions
• Performed User Acceptance testing (UAT) with Business and Users.
• Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions and also for Medicaid and Medicare Claims
• Worked on Scrub enhancement project related to Medicare Part D.
• Clearly understood coding standards required for all Medicare Part D Users transactions involving electronic data interchange as provided by department of health and human services and incorporated at every stages of the project wherever found necessary
• Performed Security Testing to ensure secure login and payment access.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Integrated Requisite Pro with Rational Rose to provide all teams visibility and maintain tractability among requirements, use cases and change requests.
• Compiled the Vision Document and composed detailed Use Case Specification Documents in Rational Requisite Pro.
• Implemented Facets Benefit configuration changes and new configuration requirements for Health Benefit Exchange Plans for Medical, Vison and Dental benefits including configuration analysis, design, build and test.
• Design, build and test Facets configuration in support of business requirements
• Analyzed the results using online monitors and graphs to identify the server resources.
• Performed Backend Testing using SQL queries.
• Completed several HIPAA 4010 and 5010 Projects, included Medicaid and Commercial entities. Projects include claims and enrolment testing as well as NPI and medical coding and ICD-9 EDI testing
• Performed Validation Testing using Quality Centre.
• Used Quality Centre for reporting Bugs and Issue Management.
• Used Quality Centre for tracking and reporting defects found during the functional and regression testing.
• Supported clients in all testing phases through UAT (User Acceptance Testing).
• Participated in weekly meetings for reviewing progress and future testing efforts.

Environment: SQL, MS Word, Excel, EDI, SQL, FACETS, Quality Centre, MS Visio, SharePoint.

Confidential, Atlanta, GA

Business Analyst

Responsibilities:

• Responsible for the requirement-gathering phase and project plan.
• Responsible for requirements analysis, design and developing technical requirements.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Performs in-depth investigation, analysis, and evaluation to determine project feasibility.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got
• Involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837, 835, and 834.
• Upgraded HMO Medicare EDI and reporting.
• Acted as a SME for the application team and the Infrastructure team.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between the 4010 and 5010.
• Used Requisite Pro for writing/analyzing project vision, goals, specifications and requirements.
• Conduced Joint Application Development (JAD) sessions and walk in interview with the business users to gather requirements.
• Managing and Billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Used FACETS Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in Rational Rose for the Business Use Case and System Use Case.
• Conducted the FRS and URS reviews and walkthroughs with designers, developers and stakeholders. Also conducted feasibility and adaptability study.
• Conducted JAD Sessions with Infrastructure management team, SME, policy holders and stakeholders for issues which were open and pending.
• Analyzed forms and successfully crosswalk details to corresponding ANSI X12 formats.
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc).
• Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents.
• Interacted with database developers for formulating the ER diagrams and data flow diagrams.
• Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.
• Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Performed configuration/ compatibility and user interface testing manually.
• Worked with QA lead in validating Test Plan and Test Scenarios.
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Executed test cases manually. Compared and analyzed actual with expected results and reported all deviations to the appropriate individual(s) for resolution.
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release
• Review of high-level design document and low level design of classes and sequence diagrams.
• Ensuring that deliverables were delivered on time as scheduled.

Environment: SQL, EDI, Lotus Notes, File Viewer, FACETS, PEGA, Quality Center, MS Visio, SharePoint.

Confidential, Norristown, PA

Business Analyst

Responsibilities:

• Studied existing business application and processes, collected end user requirements and suggested the improvised business process model.
• Wrote specifications that would read an order and generate an enrolment card showing the medical plan and ancillary coverage's such as prescription plans, vision and dental care chosen by a member.
• Defined and documented the vision and scope of the project.
• Being a Project Manager for multiple concurrent projects, including several where I served as the Lead Business Analyst. Tasked with identifying impacted systems, defining team members role's, setting time lines, facilitating meetings, identifying and assigning ownership of tasks, while adhering to budget and time line constraints. Monitoring problems that arose until resolution was achieved.
• Managing and Billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Worked with subject matter experts (SMEs) internally and externally, and participated with software developers in Scrum team meetings, documenting agile software processes.
• Worked as a liaison between the business and technical side to convey the business needs to the system architects.
• Organized all of the Quest System Specifications and reports into an easy to access and use reference library. Implemented a system, which allowed users to quickly access detailed information relating to specific diagnostic testing..
• Generate all Medicare claims review and transmits to Medicare.
• Validate EDI Claim Process according to HIPAA compliance.
• Conducted Requirement Analysis, Test Plan and Test Case generation.
• Participated in weekly status meetings to present status and in corporate any digressions from the original scope.
• Conduct Enterprise Analysis and define Solution Scope and Solution Approach
• Created and managed project templates, Use Case project templates, requirement types and trace-ability relationships in Requisite Pro.
• Carried out a thorough target organization assessment and risk analysis.
• Involved in cross-functional teams, developing new ways to boost efficiency and delivering results in a fast changing environment to achieve company goals.
• Provided the management with test metrics, reports, and schedules as necessary using MS Project and participated in the design walkthroughs and meetings.
• Documented the test plans and developed related documents
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
• Create test strategy, developed test plans, Mentor Testing team, Address defects
• Worked with the clients on the final signing process in the User Acceptance stages.
• Coordinate with Development and Business team to develop high level Business and Technical documents)
• Coordinated testing for UAT Team.

Environment: Windows XP, RUP, UML, SQL, Rational Tools, MS Visio, MS Word, Excel, PowerPoint, Access.

Confidential, New York, NY

Business Analyst

Responsibilities:

• Conducted GAP analysis between two applications to understand the differences and identifying the scope of the new product.
• Interacted with various members at the management level to understand business processes, decision models and project scope.
• Used questionnaire, surveys, JAD sessions and Brainstorming sessions as requirement elicitation techniques.
• Extensively used Rational RequisitePro for maintaining requirements and ClearQuest for tracking changes and defects in the development of the project.
• Worked with different phases of RUP starting from Inception through Transition. Generated and maintained multiple RUP artifacts including UML models.
• Wrote use cases and managed use cases that could be traced back to the functional requirements as specified in the Requirement document.
• Developed sequence diagrams to show the interactions between objects in the sequential order that those interactions occur.
• Defined business processes, identified gaps, evaluated requirements and change requests, managed scope and transferred knowledge.
• Utilized technical tools to develop business, financial and system requirements analysis with supporting variance reports, current and target business process flows and traceability matrices
• Worked closely with the Quality Assurance team and developed test cases, test scripts using the developed use cases as the platform, and conducted User Acceptance Testing (UAT).
• Worked with the project manager to develop a standard change management process to continually improve the software processes used in the organization with the intent of improving software quality, increasing productivity, and decreasing the cycle time for product development

Environment: Rational Requisite Pro, UML, RUP, MS-Project 2000, MS-Visio2000, MS-Office, Windows 2000

Confidential, Seattle, WA

Business Analyst

Responsibilities:

• Interacted with the users by interviewing them, and also by preparing questionnaires and getting their feedback.
• Acted as a liaison between end users, developers, architect and the QA team.
• Maintained clear understanding of project goals among stakeholders by conducting walkthroughs and meetings involving various leads from BA, Development, QA and Technical Support teams.
• Worked with management to create and communicate critical information to the user community via email and discussion boards.
• Conducted interviews with the clients for gathering requirements and evaluation/analysis of their data to convert the business requirements into IT specifications.
• Created project plans, detailing projects Scope, process flow, timelines, and requirement documents and analyze risks.
• Developed the business and functional requirements specification describing and prioritizing of the requirements in detail.
• Created well-defined business vision documents, business glossaries and requirements management plan as per the Rational Unified Process (RUP).
• Conducted JAD sessions to develop architectural solutions to open and conflicting issues
• Participated with QA team to conduct major functionality testing of the different module such as enrolment, report etc by manually
• Extensively wrote functional test scripts and cases on Quality Centre and run the scripts on Test Lab module of Quality Centre
• Analyzed the Traceability matrix and conducted GAP analysis
• Analyzed “AS IS” and “TO BE” scenarios, designed new process flows and documented the business process and various business scenarios.
• Wrote use cases and relevant UML diagrams such as Use Cases, Activity and Sequence diagrams
• Analyzed user requirements; attended change request meetings to document changes and manage them using EA.
• Involved to write UAT test plan and conducted User Acceptance Testing at the end of the testing process and write the signoff document for the future reference
• Worked directly with the UAT team to test various scenarios in the desktop application.

Environment: .NET, Quality Centre, MS Visio, MS Word, MS PowerPoint, MS Excel, Mainframe, Oracle, TOAD, Manual Test