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Edi Analyst Resume

MD

SUMMARY:

  • A Senior Analyst with Over 7+ years of diversified experience in areas like Business / Data Analysis, Project Management and Testing.
  • Extensive experience Healthcare and Insurance applications.
  • Designed the ETL system for populating the Data warehouse from the operational DBMS
  • Knowledge and vast experience of PMBOK and BABOK.
  • 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.
  • Extensive experience on interaction with system users in gathering business requirements and involved in developing projects. Chaired and conducted JAD sessions with business and technical teams.
  • Expert in analyzing/troubleshooting and providing technical support for Oracle/Unix applications and their interfaces.
  • Worked extensively in Data consolidation and harmonization
  • Experience in Data alignment and Data cleansing
  • Strong knowledge of Data Integration, validation and processing methodologies.
  • Experience in Data Analysis using PL/SQL.
  • Vast experience of working in the area data management including data analysis, gap analysis and data mapping.
  • Worked extensively with Dimensional Modeling and Data Migration.
  • Expertise in SQL and PL/SQL programming - Functions, Stored Procedures and Triggers.
  • Experience in working with Microsoft Office suite (word, excel, Access, Visio, Power Point and Outlook) for documentation, analysis and presentation.
  • Worked with HL7, EDI ANSI 4010 Standards
  • Strong knowledge of HIPAA (EDI), ICD, OIR, CMS, Claims, Under Writing, Membership / Billing, Medicare, Medicaid, Claims and Medical management systems.
  • Solid understanding of SLDC, Waterfall and Agile / SCRUM (User Stories and Use cases)
  • Expertise in Software Development Life Cycle (SDLC), Use Cases, Business Process Modeling Notation (BPMN), Object-oriented Analysis and Design, Rational Unified Process (RUP) and Rational tools used during all four phases of RUP: Inception, Elaboration, Construction, and Transition.
  • Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
  • Knowledge of 837, 835, 277, 270, 271, NCPDP, 5010 and ICD-10.
  • Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
  • Experience in conducting Gap Analysis (GAP), User Acceptance Testing (UAT), SWOT analysis, Cost benefit analysis and ROI analysis.
  • Extensive knowledge of Medical Management Information Systems (MMIS), and National Provider Identification (NPI).
  • 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.
  • Authored test plans, test cases for various test scenarios and helped testing team to better understand the test scripts.
  • Executed Test Cases Manually, once the application is stable and documented the successful or unsuccessful completion of each test case in HP Quality Center (QC) for End-to-End Scenario based testing.
  • Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.
  • Established traceability matrix using Rational Requisite Pro to trace completeness of requirements in different SDLC stages.
  • Extensive experience working in back end tester by writing SQL Queries and PL/SQL scripts on large data warehouse systems involving Terabytes worth of data.
  • Experienced in creating Business Requirement Documents, User Requirement Specification, Functional Requirement Specifications, Models and RPF.
  • Worked on Facets - a product for Healthcare Insurance sector. Good working knowledge of Claims processing, HIPAA Regulations and 270, 837P, 837I, 837D EDI Transactions for health care industries.
  • FACETS experience in the areas of Enrollment, Enrollment Pre-processing (834 & proprietary enrollment file mapping, Business rules design & Enrollment Keyword creation) MMS Batch processing, Provider, and Claims Strong understanding of test plans, test cases, test scripts and defects tracking/reporting
  • Well versed with ICD9, CPT, HIPPA, claim adjustments, claim processing claim review, identifying claims processing problems, their source and providing alternative solutions.
  • Experienced in creating Data Flow Diagrams, Use Cases, Use Case Diagrams, Activity diagrams, Entity Relationship Diagrams
  • Experience in Forward Mapping and Backward mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes)..
  • Well versed in Process Narratives, Flow charting Techniques using UML, and Good Documentation Practices.
  • Experienced in developing Object Oriented Analysis and Design Models; Use Case Model and UML.
  • Good Knowledge of Unified Modeling Language (UML), Class Diagrams, Use Case Diagrams, Activity Diagrams, Sequence Diagrams.

TECHNICAL SKILLS:

Methodologies: Rational Unified Process (RUP), Waterfall, Agile (Scrum)

Microsoft Applications / Tools: Microsoft Office Suite, Microsoft Project,, Microsoft FrontPage, Microsoft SharePoint, Microsoft SQL Server

Reporting Applications / Tools: Oracle PeopleSoft Suite,, SAP Business Objects, SAP Crystal Reports

UML Application / Tools: Microsoft Visio, IBM Cognos, IBM Rational Suite

Testing Applications / Tools: Oracle TOAD, HP Application Lifecycle Management (ALM), HP QuickTest Professional (QTP)

Integration Applications / Tools: TriZetto Facets, NASCO, Informatica HIPAA Validator

Languages: UNIX, HTTP, HTML, UML, XML, SQL

PROFESSIONAL EXPERIENCE:

Confidential, MD

EDI Analyst

Responsibilities:

  • Assist with creation and maintenance all necessary documentation and training materials for Epic Ambulatory application
  • Performed analysis, design, development and maintenance of the Epic Ambulatory applications and other clinical information systems
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
  • Interacted with the DST (off shore) teams for QA support and training purposes. Responsible for running test region EDI loads on AS400 Series. Updated records in AS400 before processing for testing purposes.
  • EPIC EMR to deliver high quality patient care. As part of the project
  • Support testing for EPIC ASAP, Clin Docs and Orders & Results and Optime modules.
  • Knowledge of workflows in EPIC Inpatient Modules.
  • Responsible for design, build, testing and implementation for Epic Home Health and Hospice Billing and Clinical applications.
  • Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
  • Developed an implementation guide for Partners for EDI X12 transactions such as 834, 835,837,270 and 271.
  • Experience with EPIC user and provider record provisioning, including the development of role-based access, security classes, and user profiles
  • 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.
  • Experience in Epic Resolute product implementation and deployment
  • Hands on experience with Epic Hospital Billing and Ambulatory
  • Full knowledge of application interoperability configurations and managed the implementation tasks of HIE clinical applications.
  • Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrolment hence analysing and documenting related business processes
  • Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
  • Experience with Epic Healthcare Information Systems
  • Conducted user interviews, gathered requirements, and analysed the requirements.
  • Trained thousands of medical providers w/ ten member team on HIE software and insurance proprietary software Managed 1500 medical provider accounts including group practices, large health systems and hospitals
  • Worked with the business team to collect the business requirements, security and service level requirements and documented them.
  • Analysed set behavior and contribution to business performance, critical business metrics & tracking underlying business trends using Business Objects.
  • Working with different IT & Business groups to understand and determine the Impacts to the Data Warehouse and/or Data Marts for different projects
  • Participated in the logical and physical design sessions and developed design documents.
  • Designed new process flows for the existing system as well as for the enhanced system.
  • Conducted and lead status report meetings with the business and the IT team on a weekly basis.
  • Manage Scope and change throughout the life cycle of the product.
  • Performed collection, coding, and assessment and reporting of adverse event data using ARISg.
  • Worked in the ARISg Implementation of the EHR-Pharmacy Module.
  • Supported integrating EDI batch processing and real-time EDI
  • Recommend tactic to implement HIPAA 4010 (EDI X12 837,834,278,270) in the new System
  • Worked on Electronic health record system as a CRM web based application.
  • Working Experience in Electronic Submissions in standard format E2B.
  • Knowledge of regulatory issues including State, Federal, AABB, CAP, CLIA, and JCAHO

Environment: Windows 7, MS Project, Microsoft Visio, SQL, Data Warehouse, BI, BO, EPIC, HL7 and Business Objects.

Confidential, Dayton, OH

Business/Data Analyst

Responsibilities:

  • Gathered business requirements by driving user-group meetings and working with various global, cross-functional and virtual teams
  • Extensively involved in data modeling
  • Provided full life cycle support for company’s Facets enhancement to Facets e2 Workflow and Network Management Suite with Pricing Modeler and Network Modeler application--including Business Requirement gathering, Functional Design, Technical Design, and Production Support documentation for multiple outgoing interfaces.
  • Gathered legacy system requirements by shadowing Customer Service Representatives (CSRs), Customer Relationship Representatives (CRRs), preparing questionnaires, to identify limitations in the current system and GAPS in the proposed system.
  • Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies from Initiation to Deployment.
  • Worked on changes for HIPAA Transaction and proposed changes to be made in the current system for an easy transition from version .
  • Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, business process flows, and prototypes and management reporting requirements
  • Experience in Customer Service Request handling
  • Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) 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 ETL (Extract, Transformation & Load) strategy to populate the Data Warehouse from the various source systems feeds using Informatica PowerMart, PL/SQL.
  • Worked on the MMIS (Medicaid Management Information Systems).
  • Worked on HIPAA 5010 and ICD10 mandated changes passed 1/16/09 by CMS HHS
  • Performed Data Analysis using procedures and functions in PL/SQL.
  • Researched upstream data sources and ensured all source data sources were attested by its owners.
  • Responsible for creating mapping documents required for the ETL team.
  • Created report specifications containing mapping to source data sources.
  • Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
  • Performed Data Analysis, writing SQL Queries for Testing and Troubleshooting against Data Warehouse.
  • Collaborated with management and senior-level engineers to develop code for new features used within a Health Information Exchange (HIE).
  • Worked with FDA guidelines (21CFR), HIPAA (Health Insurance Portability and Accountability Act).
  • Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes
  • Using MITA improved managing and monitoring of programs through the sharing of data.
  • Used Facets 4.71 to receive, store and send HIPAA-standard transactions (835, 837, 270, 271, 276, 277) and to administer HIPAA privacy rights.
  • Mapped provider data from source to target Facets 4.71 data layout for the claims and benefit configuration.
  • Participated in Facets Table data modeling; planning, designing, implementation of the data warehouse and conducted testing by developing complex SQL queries.
  • Translated high level business / data requirements into Process, Workflow, and Data Flow Diagrams using Rational Rose / MS Visio / BPMN towards facilitating clear understanding of the business process.
  • Supported SOA, data warehousing, data mining, and Enterprise Service model standards in designs, and developed standardization of processes like configuration management.
  • Created the conceptual, Logical and Physical Model for the data warehouse with emphasis mutual funds and annuity using Erwin data modeling tool.
  • Developed HL7 messaging for bi-directional case and disease report exchange, in text and XML formats, in accordance with HL7 specifications;
  • Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
  • Used the CMMI Model to guide process improvement across a project
  • Experience in providing the backward compatibility from Facets 4.71 to all earlier versions.
  • Identified authoritative data sources; specified business rules for data feeds utilizing HL7 protocol.
  • Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
  • Responsible for conducting gap analysis as is to be for ICD9 and ICD10. Prepared Data Flow Models for code sets validating in Facets and Claim Process Engine.
  • Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
  • Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
  • Responsible for GAP analysis of ICD9-ICD10.
  • Created test plans, test cases and test scripts for UAT.
  • Created test scripts and plans for UAT Phase

Environment: Windows XP/2000, Oracle, PL/SQL, MS-Project, MS-Office Suite, MS Visio, Rational Requisite Pro, UML, Clear Case, Clear Quest, MS Visual Source Safe.

Confidential, Beaverton, OR

Business Analyst

Responsibilities:

  • Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
  • Created and Analyzed Business Requirement Document (BRD)
  • Defined and documented the vision and scope of the project.
  • Provide AGILE project management controls, project plans, timeline schedules, facilitate RAD sessions, and review software defects.
  • Responsible for providing business requirements within an AGILE software development SCRUM environment.
  • Used requirement elicitation techniques like interviews and JAD sessions to gather and document information regarding upcoming changes.
  • Contributing to software process-reengineering efforts aimed at evolving current software development practices to adopt Lean/Agile
  • Participated in weekly status meetings to present status and in corporate any digressions from the original scope.
  • Worked on analysis of FACETS claims processing system and to gathered requirements to comply with HIPAA 5010 requirements
  • Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
  • Worked as a liaison between the business and technical side to convey the business needs to the system architects.
  • Worked with SME close to analyze the Claim Adjudication Process setup in Facets.
  • Prepared the Business Workflow using MS-Visio with input, output, Pre and Post conditions
  • Strong knowledge of FACETS and actively involved in end-to-end implementation of FACETS Billing, Enrollment, Claim Processing and Subscriber/Member module.
  • Worked on different EDI healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.
  • Proposed FACETS claims adjudication procedures, standards and editing guidelines.
  • Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc).
  • Extensively worked on Facets, the claim processing tool used in the project.
  • Created Test Scripts, Test Plans, validation Plans and Testing Metrics Reports.

Environment: SQL, Windows XP, RUP, Rational Clear Case, UML, MS Visio, Word, Excel, PowerPoint and MS-Access.

Confidential

Business Analyst

Responsibilities:

  • Defined a complete set of metrics report requirements including a framework that will meet the needs of regional and national business leaders
  • Provided analytical data to enable management to make informed decisions to drive continuous revenue cycle improvements by realizing gains in operational efficiency, cost savings and member experience
  • Created drill down from the high level summary metrics to the supporting detail in the current report format
  • Identified performance indicators that provide reliable daily trend information as a primary input towards the monthly executive dashboard report.
  • Developed HIPAA EDI Transmissions. Work includes complete business cycle management and hands-on production as well. Create EDI Testing process, documentation, and performance matrices.
  • Technical Specification Creation for EDI. Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy.
  • Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837-(I,P, &D), 835 Remittances and others.
  • Drafted the existing and known requested list of metrics to the Revenue Cycle process context map
  • Analyzed and drafted a functional and technical features list for each vendors, thus identifying the best to send out a RFP
  • Created a prototype presentation in Visio for the SCAL region, thus showing a pictorial representation on the various drill downs from the report to the metrics to the database.
  • Identified and drafted the calculations used for various regions, using their source SQL’s for standardization purpose.
  • Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose
  • Prepared for GAP Analysis; identified and documented improving areas to meet capital requirement regulations.
  • Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
  • Involved in interactions with Subject Matter Expert, Project Manager, Developers, and the end-users in more than one JAD sessions. MS Project proved useful in coordinating activities with project manager and various other team.
  • Modelled the information and then came up with the requirements prioritization. Eliminated false requirements by screening out multiple versions of user input. Final prioritization was based on both, product and process requirements.
  • Provided clear and concise documentation regarding requirements management plans, functional requirements, supplemental requirement
  • Performed GAP analysis for the modules in production, conducted feasibility study and performed impact analysis for proposed enhancements.
  • Coordinated JAD session with system analysts, development team, project manager for application development and Pre-validation specifications

Environment: Windows XP/2000, Oracle, PL/SQL, MS-Project, MS-Office Suite, MS Visio, Rational Requisite Pro, UML, Clear Case, Clear Quest, MS Visual Source Safe

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