SUMMARY:

• 6+ years of Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollment and eligibility processes.
• Complete knowledge of registration, scheduling and billing processes for Revenue Cycle and Patient flow.
• Excellent knowledge of E-Commerce, healthcare IT along with HIPAA regulations, EDI transaction Code Sets, and CMS regulations.
• Firm ability to research, analyze and translate complex business and technical information to stakeholders, SMEs, and developers at all levels of the organization. Also, in Defining, Gathering, Documenting, and Managing requirements to identify the real business need of the client company.
• Excellent communication, interpersonal consulting and facilitation skills.
• Working expertise in Software Development Life cycle (SDLC), Project Life cycle, Business Process Modeling (BPM), Software Development Methodologies including Rational Unified Process (RUP), Waterfall, Spiral, and Agile with SCRUM process
• Organized in Joint Application Development (JAD) and Rapid Application Development (RAD) sessions with business/end users, expert team and technical team.
• Developed use case diagrams, sequence diagrams, state diagrams and activity diagrams, business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML).
• Experience in producing documents like Business Requirements Documents (BRD), Functional Requirement Documents (FRD), Software Requirement Specifications (SRS), Creating Request for Proposals (RFP), creating Requirements Traceability Matrix (RTM)
• Experience in creating Prototypes and Wire frames and documenting them using MS Visio and Enterprise Architect
• Involved in all phases of Testing life cycles including integration testing, User Acceptance testing (UAT) Functional testing/Black Box Testing, Regression testing, GUI testing, and performance testing.
• Hands on experience with Object Oriented Analysis and Design (OOAD); work side by side with technical managers; senior design engineers/ analysts; used UML extensively with emphasis on Use Case diagrams, state diagrams, sequence diagrams, activity diagrams and collaboration diagrams using Rational Rose and MS-Visio; solid hand-on experience working with MS Excel, writing very complex Excel macros to pull data in Data Mining and Data Warehousing environment; help in designing the ETL processes.
• Gathering business requirements for ICD 10 Groupings/ classes pertaining to maintenance process, ICD 10 business rules remediation process, Medical Claims Processing System (MCPS)
• Creative and aggressive self-starter and a versatile team player with excellent analytical, problem-solving capability for collecting clear and detailed Business Requirements and Functional Specifications.
• Team player, hardworking, highly self-motivated, fast-learner and goal-oriented individual committed in pursuing a long-term career in Information and Communication Technology.

TECHNICAL SKILLS:

Project Methodologies: Agile/SCRUM, Waterfall

Business Modeling Tools: Rational Rose, MS Visio

Bug Reporting Tools: Jira, Quality Center

Languages: SQL, HTML, XML, JSON

Requirement Management Tools: Rational RequisitePro

Defect Tracking Tools: Rational ClearQuest, HP QC/ALM

Operating Systems: Windows, UNIX

Business Applications: MS Project, Microsoft Office Suite, MS Outlook

Environment: SQL Server 2008

PROFESSIONAL EXPERIENCE:

Confidential - Denver, CO

Senior Business Analyst

Responsibilities:

• Good working knowledge of HIPAA ICD10 and HIPAA transaction requirements. Experience with commercial insurances in HIPAA ANSI X12 formats including 270/271, 276/277, 834, 835, 837, 997, and NSF formats for interfaces and images to third part vendor applications
• Experience with Healthcare systems like FACTES in various areas like Enrolment, Customer Service, Billing and Network X Pricing
• Good knowledge of Health Plans managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and Disability claims in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS
• Maintained pricing configuration in Facets System for Medicaid, Medicare and Dual Eligible Products; creating new and updating existing provider contracts
• Adept with different methodologies which include Agile, Waterfall and Rational Unified Process (RUP)
• Well versed in Requirement Gathering through techniques such as JAD sessions, Interviews, Document analysis and Reviews
• Expertise in documenting Business requirement document (BRD), Functional and Non-functional requirements, Requirement Traceability matrix (RTM), Use case Specifications and the complete System Requirement Specifications (SRS)
• Creation of a Gap/Impact Analysis Document for changes of the EDI Transactions (837, 835, 276/277, 270/271)
• Creation of Gap/Impact Analysis and Operational Analysis Document for Medicaid Subrogation. Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System.
• Expert in Tracking and Managing the Requirements using Requirement Traceability Matrix (RTM) that controls numerous artefacts produced by the teams across the deliverables for a project
• Analysis and Design of the Trizetto FACETS Data Model to ensure optimal system performance and tuning.
• Identified and analyzed the data requirements for the various site teams and made sure that the required data is available in the testing environment.
• Involved in meetings for Test Planning, Test Preparation, Test Execution and Issue Resolution and Report Generation to ensure that all aspects of a Project are in Compliance with the Business Requirements
• Responsible BA for Reports and Feeds development for daily high-level report of the file imports and summary status for Data Stewardship and Compliance groups, daily detailed report of MARS database discrepancies reconciliation for Business Information Systems Department (BISD)
• Reviewed Test plans to make sure all the requirements have been covered and corresponding test cases have been created
• Excellent analytical & problem solving skills and a team player with strong interpersonal and communication proficiency
• Interface with clients from Operations, Marketing, Sales, Technologies, and Outside Vendors and act as their customer interface point as the lead of the Projects
• Highly motivated team player with excellent Interpersonal and Customer Relational Skills, Proven Communication, Organizational, Analytical, Presentation Skills, and Leadership Qualities.

Environment: EDI, HIPAA, Windows NT, UML, Facets Trizetto, ERWIN 4.0, SQL, Rational Requisite Pro, Test Director, MS Project, MS Office Suite.

Confidential, Chicago, IL

Sr. Business/Systems Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Designed a claim processing system for the healthcare management client system. It allowed the user to inexpensively capture information regarding patient, summary of medical history, symptoms (ICD-9 codes), and treatment (CPT).
• 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.
• Created Mapping Documents, Report Mockups and modified existing report mockups as to CMS requirements and finalized for development.
• Utilized Visio diagrams, data flow diagrams, use case diagrams and process flow diagrams using the CMS-MITA guideline.
• Lead abstraction of core measure data from EHR and submission of these data to CMS. Data converted to knowledge and wisdom contributed to the establishment of objective measurement, performance transparency, best practice sharing, and standardization.
• Utilization of CMS technology to identify trends in payments by various types of insurances like Commercial, Federal, Workers Compensation, Managed care.
• Project managed all CMS requirements in Enrollment and Billing including Policies and Procedures and Medicare Enrollment Letters.
• Assisted (Acquisition & Contracts) on Federal (CMS) proposals.
• Understand the overall business model of Medicare Part D products, CMS guidance, and the PBM claim adjudication system.
• Understand the overall business model of Medicare Part D products, CMS guidance, and the PBM claim adjudication system.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Project managed all CMS requirements in enrolment and Billing including Policies and Procedures and Medicare Enrolment Letters.
• 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.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Wrote Test Cases and performed User Acceptance Testing, documented the in detail defects using the Defect Tracking report.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created Use cases, activity report, logical components and deployment views to extract business process flows and workflows involved in the project. Carried out defect tracking using Clear Quest
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.

Environment: Requisite Pro, Rational Rose, Agile, HL7Interfaces, PL/SQL, HTML, MS Office, MS Visio, EDI, Rational Clear Quest, Rational Clear Case, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.

Confidential, Toledo, OH

Application Business Analyst

Responsibilities:

• Implemented an integrated RUP solution with complete line of traceability for all the artifacts of web development projects.
• Created and updated tasks in the MS Project and Project Management Directory for the senior management reviews.
• Performed GAP analysis and documented business and system level use cases to derive the requirements illustrating the functional behavior.
• Collaboration and reviews with different application owners and SME’s to ensure the GAP Analysis was performed accurately.
• Business Process Modeling: Business process improvement and optimization, Document and model business processes, automated workflows and Manage business rules.
• Involved in documenting Business Requirements Documents by conducting interviews with the project stakeholders, SME’s and Business users.
• Maintained JIRA team Confluence System Engineering pages that included: Process Flow Management, Team Requirements, Roles and Responsibilities, and COP User Metrics.
• Assist in creating and updating tickets in JIRA, along with implementing improvements in Jira to track and produce metrics for all phases of Intake and Development processes.
• Created reports and dashboards in JIRA to track hours and project status to report to finance team.
• Documented Traceability to ensure all the features for the project has been captured and mapped back to the requirements in the BRD.
• Performed application functionality user acceptance testing (i.e. front-end application testing) in a controlled testing environment that replicates the end user usability of the application.
• Tested different functionality of the application like Medicaid eligibility data, state available funds program, Medicaid claim processing etc.
• 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.
• Ensured UAT test scripts review sessions with business owners to test the application functionality, providing necessary training material.
• Clear quest and HP quality center to log defects and assign to the right team to ensure the defects are addressed on a timely manner.

Environment: RUP, Rational Rose, Business Objects, Clear Quest, RequisitePro, UML, SQL, MS-Office, MS Project.

Confidential, Washington DC

Business Analyst/Data Analyst

Responsibilities:

• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Interacted with various cross-functional teams on building business use cases, and understanding expenses and revenue stream.
• Gathered requirements for the inputs in the Competitive Intelligence System from the stakeholder’s including methods like personal interviews, questionnaires, surveys, JAD sessions and joint team meetings. Identified systems requirements that would help create the CI System by meeting up with the technology team and then having a JAD session to include SME’s from the business side.
• Developed the systems implementation project management plan with milestones and steps from procurement of vendors to project implementation and maintenance.
• Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs. Ensured that critical requirements are not missed.
• Aided management in standardizing web applications by preparing GUI standards and recommending alternatives for in corporation in a phased, iterative manner.
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Serve as a point of contact for the client’s stakeholders and provided customer support in addition to team building with on and off shore agile teams.
• Involved in mentoring specific projects in application of the new SDLC based on the Agile Unified Process, especially from the project management, requirements and architecture perspectives
• Worked as a part of scrum team, in an agile methodology with sprint cycles, daily stand ups and story implementation, large cross functional project and support teams.
• Designed new database tables to meet business information needs. Designed Mapping document, which is a guideline to ETL Coding.
• Responsible for developing, support and maintenance for the ETL (Extract, Transform and Load) processes using Oracle and Informatica PowerCenter.
• Worked as functional Analyst in the software development team for outsourcing Electronic medical records (EMR) and paperless office system implementation to the medical facilities.
• Responsible for EMR interface development and implementation. Specialized in Nephrology EMR, Internal medicine EMR, Psychiatry EMR, Oncology EMR, Anaesthesia EMR etc.
• Lead abstraction of core measure data from EHR and submission of these data to CMS. Data converted to knowledge and wisdom contributed to the establishment of objective measurement, performance transparency, best practice sharing, and standardization.
• Effectively manage EHR staff by hiring, developing, training, and overseeing personnel to meet the needs of the practice.
• Supported the physician applications and ordering module during the initial EMR go-live and provided support to end users during maintenance and optimization activities
• Observed and analyzed corrections-specific workflows to adapt the EMR and optimize provider efficiency and success.
• Owned the entire reporting process. Interacted with the ETL team, developer(s), management, and account holders to get the requirements, document them, design templates, and write specifications.
• Analysis of the new requests specified by the end users for the future releases and discussion with the functional and technical teams.
• Identified and clearly defined functional issues and support IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle.

Environment: J2EE (JSP 1.1), EJB(2.0), Servlets 2.2, JMS, Java2 (JDK 1.3), STRUTS,JDBC2.0, XML, XSL, Rational Clear Quest, Rational Clear Case, Rational Requisite Pro, Rational Rose, UML,RUP, EDI, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.