SUMMARY:

• Over 8+ years of experience as Business Analyst in the HealthCare Industry.
• Business Analyst with hands on experience in business consulting in health care and application development with excellent skills in client interfacing, requirement gathering, user support, quality assurance, problem solving, and documentation.
• Skilled in determining system requirements and specifications for complex application development projects. Past experiences of leading and interacting with business teams, programmers and technical staff at all levels.
• Experience in creating and maintaining the Requirements definition documents that included Business and Functional requirements.
• Expertise in all the phases of the Software Development Life Cycle (SDLC), Agile Development methodology.
• Strong experience and understanding of health care industry, claims management process, Knowledge of Medicaid and Medicare Services.
• Experienced in conducting JAD sessions, focus group and brainstorming sessions, reviews, and walkthroughs and customer interviews for various business processes.
• Experience with ETL
• Good understanding of health care industry claims management process, Medicaid and Medicare Services and insurance sector.
• Expert in Healthcare Payer systems - Claims, Billing with backend data mapping, data integration.
• Exposure in creating and analyzing Data Flow diagrams, and Entity Relationship diagrams.
• Skills to track environment build release level at various point in the software building process.
• Excellent knowledge of Health Insurance Portability & Accountability Act (HIPAA) standards, Medicaid and Medicare regulations, Health Care Reform (HCR), Electronic Medical Record (EMR) and Electronic Health Record (EHR) and Medicaid Management Information Systems (MMIS).
• Possess Project management skills such as time estimation, task identification, risk analysis and scope management and resource management.
• Matched the requirements for programs such as Medicare and Medicaid, which are part of the Social Security Act.
• Identified Member, Provider, Coverage, Medicare, and Medicaid.
• Good experience in the EDI transactions and knowledge on EDI transaction process flows.
• Assisted the EDI team in the development and documentation of the test strategies for the EDI transactions which included all standard transactions, auditing and error correction processes, and the creation of the transactions.
• Re-engineered and captured EDI transactions with legacy systems Enrollment -834, Eligibility Transaction (270/271), Claims (837), Claim Status Request and Response (276/277), Remittance (835) .
• GAP Analysis: Analyzed the client’s applications programs to determine the impact of the HIPAA final rule on EDI Transaction Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance.
• Used Informatica ETL tool for Extraction, Transformation and Loading the data into target database.
• Created ETL test data for all ETL mapping rules to test the functionality of the Informatica Mapping
• Tested the ETL Informatica mappings and other ETL Processes (Data Warehouse Testing)
• Performed Back-End testing by using SQL commands to verify the database integrity.
• Performed Manual Back-End testing to map the source data to the target data to verify that the data does not get corrupted traveling from front end to the back end and viddce-versa.
• Strong Experience in conducting Impact Analysis caused due to migration to ICD 10 on the key business process and key application system like claim processing, payments, reporting in health insurance companies.
• Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as Inbound Claims 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions and testing in Client Server systems and Mainframe Applications.
• Next Gen EMR experience for fast, smart and simple decisions.
• EDI Claims Processing - documented enhancements to the EDI Claims Processes (EDI 837, 835, 276, 277) to ensure accurate processing of claims of members.
• Project Management experience, especially in Project Planning, Project Design and coordinating / managing multiple BI and DW projects.
• Have developed standards for data definitions, data element naming conventions, and logical/physical database design for applications and data warehouse development.
• For Executing Scripts manually, Involved in preparing data in FACETS.
• Knowledge and Implementation experience in Eligibility System, Facets Data model, Configuration Implementation of FACETS module.
• Experience with Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Good understanding of a Testing process.
• Strong knowledge of Project management skills such as time estimation, task identification, and scope management.

TECHNICAL SKILLS:

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, MS Visio

Version Control Systems: Rational Clear Case

Database: MS SQL Server, MS Access, and Oracle

PROFESSIONAL EXPERIENCE:

Confidential, Owings Mills, MD

Data Analyst/ Business system Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
• Developed a system alongside Sr. Analyst which will run in the database and spits out the appropriate data that is needed.
• Participated in meetings which reviewed the system/process which was put in place to show and analyze the best possible way to present the proper data.
• Involved in documenting the meeting minutes as well as documenting the different process that would require in order to produce an efficient and accurate report which will be used to compare and understand the data
• Worked with Trizetto Facets claims data for claims subject area, Enrollment and billing data for member/Subscriber, and Product subject areas.
• Involved with OTS under different priority levels with efficiency and effectively.
• Worked with Microsoft Access in the back end to run queries and finding information about different claims from who sent where to when it was received and who routed it as well as who closed it
• Worked with House accounts as well as governments which required special accesses to the application or processes.
• Established, documented, and maintained EDI procedures. Tasks include identifying errors and taking corrective action, reconciling EDI transactions through coordinating information with internal and external customers, and working closely with internal departments and external vendors to maintain EDI integrity.
• Did Presentations making Stakeholders understand how the changes would affect different modules w.r.t. Medicare and Medicaid.
• Worked on groups which are sensitive and confidential to ensure proper channels are used when sending the documents whether it will be internal or external.
• Involved in documents which captures data on a top level for the year end and then a comparison to the previous year as well.
• Involved in the development of Business and Technical Requirements Document (BTRD) for the project.
• Involved in identifying and studying the Facets system data for the attribute mapping purpose
• Coaches and mentors Agile team members coached 5 teams (total of fifty four team members).
• Executed test cases for the existing market’s various lines of business. (The test cases covered: Authorization of claims, Accumulator, Benefits, Claim Payment and Pricing, as well as member and provider data updates)
• Performed Functional, Regression, and system testing for Pricing Application
• Maintained a traceability matrix of the requirements and created test cases, as well as testing matrix of the test cases and any corresponding defects. Conducting business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports
• Involved in Trizetto Facets Implementation, end-to-end testing of FACETS Billing, Enrollment Claim Processing and Subscriber/Member module
• Wrote SQL queries for data validation, analysis and manipulation, and maintaining the integrity of the database.
• Worked on the Agile methodology of SDLC
• Worked with story Board
• Participated in weekly meeting with the management team and walkthroughs.

Confidential, Raleigh, NC

Business system Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO.
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Ensured all artifacts complied with HIPAA 5010 policies and guidelines.
• Involved in defining and documenting the vision and scope of the warehousing project.
• Worked with Facets claims data for claims subject area, Enrollment and billing data for member/Subscriber, and Product subject areas.
• Involved in the development of Business and Technical Requirements Document (BTRD) for the project.
• Involved in identifying and studying the Facets system data for the attribute mapping purpose
• Conducted interviews with management team
• Participated in the JAD session with the SME’s and project team members.
• Worked as a liaison between the business and technical side to convey the business needs to the system architects.
• ICD 9 - ICD 10 Conversion Project - Worked in the analysis of the ICD 9 - 10 codes conversion Project. Expertise in GEM processes and concepts.
• Wrote test plans and test cases based on the requirements and design documents
• Dealt with Next Gen EMR to make transactions or day to day services better with the fast, smart and simple techniques.
• Created members through express claim test pro for testing purposes
• Developed detailed test scenarios as documented in business requirements documents
• Executed test cases for the existing market’s various lines of business. (The test cases covered: Authorization of claims, Accumulator, Benefits, Claim Payment and Pricing, as well as member and provider data updates)
• Performed Functional, Regression, and system testing for Pricing Application
• Followed Agile Development methodology throughout SDLC.
• Maintained a traceability matrix of the requirements and created test cases, as well as testing matrix of the test cases and any corresponding defects. Conducting business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports
• Involved in Facets Implementation, end-to-end testing of FACETS Billing, Enrollment Claim Processing and Subscriber/Member module
• Wrote SQL queries for data validation, analysis and manipulation, and maintaining the integrity of the database.
• Logged the errors, reported defects, determined repair priorities and tracked the defects until resolution using Mercury Quality Center
• Participated in weekly meeting with the management team and walkthroughs.

Environment: UNIX, Epic System, SQL Advantage, Quality Center, MS Visio, MS Word, Clear Case, FACETS, Clear Quest, Agile.

Confidential, Minneapolis, MN

Business Analyst

Responsibilities:

• Reviewed existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model
• Assisted Project Manager with the creation project timelines and milestones and resource planning
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO
• Creating GANTT charts to monitor and analyze the progress of the project
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts
• Scheduled experience with managing multiple schedules across single program(s) and ability to roll-up schedule
• Understood EMEVS, the NY state's electronic Medicaid eligibility verification system & the Medicaid & Medicare intermediary along with their roles in claim processing.
• Assisted in managing and billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Involved in defining and documenting the vision and scope of the warehousing project
• Assisted with documentation updates, BRD updates, resource allocations / assignments, materials required for project review meetings and meeting minutes
• Backed-up associate on preparation and updates to all project status reports
• Assisted with training of associates on small enhancement processes; worked with ACES claims data for claims subject area, Enrollment and billing data for membership subject area
• Conducting business validations covering the following deliverables: Facets Providers, Facets Claims and Facets Membership areas
• Developed Test Plans, Test Cases for the testing.
• Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Involved in Up-gradation of HIPAA X12 4010 transactions to HIPAA X12 5010 and ICD-9 to ICD-10
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.
• Utilized survey assessment results of ICD-10 to create listing constraints, processes, projects and systems, applications and vendor software to be impacted by the ICD-10 Conversion Project.
• Tested the interface between database and the application
• Tested Client/Server and Web-based Applications
• Created Data Mapping, Database Queries, and Data Dictionaries.
• Authored and executed Test cases for Claims and Customer Service Workflow by manually.
• Identified, analyzed and documented defects, error and inconsistencies in the application using Quality Center.
• Performed “UAT” for 5010 and ICD 10 codes.
• UAT testing for HIPAA 4010 and 5010 projects including legacy testing and HIPAA requirements and compliance mandates.
• Participated in requirement walkthroughs and creation of test plan
• Worked on Unix Platform and experienced in back end testing by executing SQL Queries.
• Maintained Traceability matrix and Test Matrix
• Used HIPAA Gateway to comply with HIPAA standards (270/271, 276/277 & 837) for EDI transactions.
• 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.
• Analyzed EDI transactions in XML and X12 responses.
• Created Data Flow Diagrams (DFDs) and ER diagrams for domain modeling.
• Worked on the Agile methodology of SDLC
• Maintained various versions of Test Scripts
• Performed Sanity Testing and Smoke Testing
• Investigating software bugs and reporting to the developers using Quality Center Defect Module
• Worked in an Agile Development Environment fractioning out the functionalities of Electronic Health Record (EHR) and Practice Management and Insurance verification
• Analyzed system requirements and developed detailed test plan for testing
• Performed Usability and System Testing.
• Worked on the ICD9 to ICD10 crosswalk and coordinated the development of the crosswalk solution.

Environment: Facets, Oracle, MS Project, MS Office suite, SQL, SQL Server, Rational Suite, Quality Center, MS SharePoint.

Confidential, Boston, MA

Business Analyst

Responsibilities:

• Worked with business representatives to understand requirements and priorities and ensure that software development work is appropriately aligned
• Involved in the meeting with Business Process Owners, SME (Subject Matter Experts) and Health Center users for Requirement gathering in Definition Stage using Rational Requisite Pro
• Facilitated Joint Application Development (JAD) Sessions, as well as weekly client & team meetings
• Interacted with the Subject Matter Experts (SME) and stakeholders to get a better understanding of client business processes and gather business requirements
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the change in the proposed system.
• Participated in user meetings, gathered Business requirements for the Data- warehouse design.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations 4010 and 5010
• Created Use cases for 835 (Claim Payment/Advice transaction set) and also performed impact analysis for the 835 transaction 5010 changes.
• Converted the Business Process Requirements (BPR) into System Specification Requirements
• Performed Gap Analysis for HIPAA 5010 and HIPAA 4010A1.
• Created various Use Cases and workflow diagrams, sequence diagrams, and Class diagrams using MS Visio and used UML methodology to define the Data Flow Diagrams (DFD.)
• Developed user stories, project backlog, and prioritization for timely & smooth execution of the project.
• Maintained Traceability Matrix in Excel.
• Used IBM Rational Clear Quest as Version Control/Change Management Tools.

Environment: MS Project, SQL Server 2000, MS Access, MS Excel, MS Word, MS Power Point, XML, Rational Requisite Pro

Confidential, Nashville, TN

Business Analyst

Responsibilities:

• Analyzed the requirements for Payment Integrity fraud and abuse solution to be developed
• Worked on defining and implementing Clinical Aberrancy Rules
• Prepared high level and detailed functional requirements documents for the clinical aberrancy rules
• Mapped the Bloodhound tool (clinical editing tool) related data elements to the internal XML elements.
• Created the data dictionary for the clinical aberrancy rules
• Defined input and output data elements to and from the rules processing engine
• Analyzed the integration requirements between various tools for Payment Integrity solution.
• Worked closely with the SME’s to identify research and escalate findings and calculate the overall impact of the discrepancy in claims.
• Analyzed the healthcare domain standards for HIPAA 5010 and health care EDI transactions
• Analyzing the Facets Requirements and thus conducting gap analysis.
• Conducting business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership
• Worked together with the architects and team responsible for supporting rules processing tools during the project to assist with the required support.
• Identified and analyze the various points of integration for the new solution and required integration with other IT components
• Worked closely with the business team, development team and the Quality Assurance team to ensure that desired functionalities have been achieved by the application

Environment: Facets, Oracle, MS Project, MS Office suite, SQL, SQL Server, Rational Suite, MS SharePoint.