SUMMARY

• Around 8.5 years of experience as Senior Confidential Business Analyst along with project management with strong Analytical and strong problem - solving skills, uphold excellent interpersonal communication while working on long, complex and tedious assignments.
• Successfully worked on critical projects using methodologies of SDLC like Agile, agile (with a little ‘a’), Waterfall, and Rational Unified Process, Spiral Model.
• Worked closely with diverse clients, partners and technology teams and participated in architectural, design and product discussions.
• Proficient in executing resource management and finance projects while applying nuance software tools for better management control.
• Competent in generating and evaluating Functional Requirement Documents (FRD), Business Requirements Documents (BRD), System Requirement Specification (SRS) and Work Breakdown Structure (WBS) and suggesting changes as required by the applicable internal and external requirements gathered for process improvement.
• Efficient working experience in Business/Systems Analysis and Requirements including analysis of business and user needs, documentation of requirements, and translation into proper system requirement specifications using CA (Rally), JIRA, Blueprint, Quality center.
• Utilized the Requirements Traceability Matrix mapping to develop, document and verify business processes.
• Conducted several Joint Application Development (JAD) sessions, project meetings, reviews, brainstorming sessions, Interviews, Requirement workshops and customer/business owner interviews.
• Experience in creating and using Use Case Diagrams, Data Flow Diagrams, Activity diagrams and Sequence Diagrams using MS Visio and Rational Rose.
• Extensive experience in the Health Insurance industry especially with Enrollment, Eligibility and Billing.
• Strong working knowledge of center for Medicare/Medicare Services (CMS) claims editing policies and payment methodologies.
• Strong knowledge of Electronic Data Interchange ( EDI ) transactions, Health Insurance Portability & Accountability Act ( HIPAA ) standards, Electronic Data Interchange ( EDI ), Implementation and knowledge of HIPAA code sets, HEDIS requirements, NCQA standards, PBM operations such as retail and specialty and benefit management.
• Confidential payer industry and knowledge of Confidential Claims.
• Knowledge of Confidential Payor terms like HMO, PPO, premium, subscriber, deductible etc
• Excellent knowledge of FACETS, ICD-9, ICD-10 coding, HL7, HMO’s, PPO.
• Thorough understanding of EDI transactions including X12 and UN/EDIFACT; HIPAA. Payor
• Highly acquainted with Medicaid Management Information Systems ( MMIS ), National Provider Identification (NPI) and Patient Protection and Affordable Care Act ( PPACA ), Health benefit Exchange
• Knowledgeable of CMS Medicaid Enterprise Certification Life Cycle processes and MITA artifacts learnt and understood as part of the master’s program in Health IT.
• Submitted several documents and Use Cases for multiple transactions and worked with ANSI X12 5010 and ANSI X12 4010.
• Worked with different aspects within Power BI such as Power BI Desktop, Power Query, DAX.
• Collaborated with engineering teams to develop and implement reports and dashboard solutions using Power BI, SAP Business Objects and Tableau.
• Efficient and proven track record with handling Change Requests by the Clients.
• Proficient in working with project management tools like MS Project for status reporting and planning.
• Experienced in various MS Windows platforms, OS, Office Suite, etc.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set.
• Well versed with various Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts and experienced in determining the membership eligibility, billing experience within life and disability in health plans. 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.
• Experience with Business Process Management, Reengineering and Business Process Improvement.
• Lean six sigma Green Belt- Quality Improvement
• A motivated, committed, quick learning, detail-oriented team player with good communication, analytical, leadership, interpersonal and problem solving skills.

TECHNICAL SKILLS

OPERATING SYSTEM: IOS, Windows Server, Windows, UNIX

TESTING TOOLS: HPQC, Load Runner, Quick Test pro, Quality Care

FRONT - END TOOLS: Adobe Photoshop, MS Excel, MS Office, MS Project

REQUIREMENT MANAGEMENT: Rational Requisite Pro, Caliber RM

MODELING TOOLS: MS Visio, Rational Rose, Caliber RDM

PROJECT MANAGEMENT TOOLS: MS Project, Share Point 2010, JIRA, Primavera,CA Rally

BUG TRACKING TOOLS: Rational Clear Quest, Rational Clear Case

METHODOLOGIES (SDLC): Scrum, Agile, Rational Unified Process (RUP), Waterfall Model

DATABASE: Confidential, MS SQL Server, MS Access

PROFESSIONAL EXPERIENCE:

Confidential

Senior Business Analyst/Project Manager

Responsibilities:

• Gathered requirements and maintained project documentation for the Enterprise using requirements automation tool (CA Rally/Agile Central)
• Created user stories, acceptance criteria, milestones, releases as and when needed by the project.
• Coordinated direct development of the project by regular status discussions with the project team from initialization phase to post-deployment.
• Implemented agile management ideals by facilitating exercises such as sprint planning and team leading standups.
• Managed project timelines and communicate with management staff and clients to ensure project progress satisfactorily.
• Enacted delivery upon completion of projects and ensure that delivery adheres to agile project management practices maintained by the company.
• Researched member requests/issues as presented by the commercial/insurance vendor, clients and account management based on the Medicare Part D enrollment
• Interaction with Members edge billing platform of third party commercial payors, for claims processing system benefit analysis.
• Expert in the setup, payment, tracking and reporting of financial and rebate guarantees in accordance with CVS’S PBM client contracts.
• Authored the typical validation, qualification, and testing documentation such as Validation Plans/Summaries, Test Plans/Summaries, User Requirements, Configuration Specifications, Trace Matrix, Qualification Protocols (IQ/OQ/PQ) and Scripts, Testing Defects, etc.
• Applied FDA, MHRA, and other applicable global regulations to the development of computer systems supporting regulated business processes.
• Facilitated the system Validation Risk Assessment to identify governing regulations and validation deliverables during the development of the computer system
• Tracked and reviewed client reporting to ensure data accuracy and identified spot checking delivery, content trends.
• Reviewed the validation deliverables for projects which are contracted to third party suppliers
• Performed CSV Risk Assessment.
• Developed process mapping of current and future business processes
• Translated business user concepts and ideas into comprehensive business requirements and design documents
• Held team meetings with the SMEs to understand the Verifications and Validation process.
• Conducted meetings, Joint Application Development (JAD) sessions and interviews with the business users to gather requirements.
• Created and maintained the Requirements Traceability Matrix (RTM).
• Conducted walkthrough of the BRD for the technical teams to help understanding the requirement.
• Analyzed and updated member/eligibility information.
• Independently created Business Requirement Document (BRD) for projects.
• Working experience in SAP Business Objects XIR3/XIR2.
• Worked on projects like developing ETL architecture for overall data transfer from the source server to the Enterprise Data Warehouse(EDW) which encompasses server name, database name, accounts, tables and direction of data flow, Column Mapping and Metadata.
• Extensively involved in using BI tools like Import and Export Wizard for developing the packages
• Worked on multiple projects within the Medicaid Encounter and Response file configuration and supported within the Encounter Management System.
• Worked with NCPDP Standards (D.0, Post Adjudicated), and State Medicaid Encounter file submission systems.
• Responsible for building the Rx Claim Software utilizing the Specialty pharma Hub, which is used for Account Management for not only the commercial clients at Confidential, but the federal and state programs that they participate in, such as Medicare Part D and Medicaid.
• The RxClaim software requirements were built by aligning multiple components such as complex claims adjudication like clinical programs, transition fill, drug coverage, RxClaim benefits coding and client's benefit plan from the Hub.
• Responsible for utilizing the Specialty pharma Hub, which is used for Account Management for not only the commercial clients at Confidential, but the federal and state programs that they participate in, such as Medicare Part D and Medicaid.
• Utilization of Reference data such as common linkable vocabulary like ICD, DRG, SNOMED, LOINC, RxNorm, and order sets.
• Planned and conducted requirement elicitation meetings with the business to collect functional/non-functional requirements relating to CVS’s Salesforce technology enhancement and initiatives
• Monitored new Salesforce released features and functionality to provide recommendations for process.
• Gather requirements and design of data warehouse (EDW) and data mart entities.
• Worked on projects like involving developing ETL architecture for overall report transfer from the source server to the Enterprise Services Warehouse which encompasses server name, database name, accounts, tables and direction of data flow, Column Mapping and Metadata.
• Created ETL data mapping logic documents for transfer of multiple reports from SPARCS/SPEDM sources to the EDW and was responsible for drafting user stories/requirements for the creation of new reports from the newly transferred data from another application called MicroStrategy at CVS.
• Responsible for ensuring the requirements were comprehensive, clear, testable, well documented and maintained.
• Worked collaboratively with business representatives, project management and varied IS teams to develop and implement the specific technology and architecture necessary to deliver business solutions.
• Partnered with key staff in the functional areas (e.g. Pharmacovigilance, Risk Management, Premarket Safety Reports, Signal Enhancements, Data Mining, Data Analytics, Data Visualization and internal process improvements) when appropriate to ensure requirements conform to applicable regulations.
• Initiated Change management programs that were typical done by BPM for enhancing the current business enterprise processes.
• Assisted with analysis on pharmacy utilization patterns, clinical program impact modeling (STARS/HEDIS), therapeutic drug category trends, and other clinical reports in collaboration with a pharmacist.
• Reviewed and interpreted NCQA HEDIS Technical specifications, while working closely with Quality and Performance Improvement leadership and IT to ensure all measures are programmed accurately
• Conducts User Acceptance Testing (UAT) for testing and implementation of new HEDIS technology
• Was responsible to comprehend the business objectives, challenges, strategic direction and technologies by working with stakeholders and technical resources, then document requirements to allow for execution of solutions.
• Engaged all relevant participants regarding new HEDIS reporting needs, particularly during workgroup sessions to gather information from requests to accurately interpret and translate true end requirements necessary to meet business needs.
• Participated in business analysis activities to gather required reporting and dashboard requirements along with translating business requirements into specifications that will be used to implement the required reports and dashboards, created from multiple data sources
• Participating with other specialist and lead Power BI Report buildout in a new environment.
• Creating project plans and schedules, Use Cases and business process flows and worked through Software Development Life Cycle (SDLC) processes while working under AGILE methodology (release approach).
• Acted as an interface between Subject Matter Expert's (SMEs), Developers and QA Team on requirement gathering.
• Product Development process used for designing the application That included making Use Cases & Use Case Diagrams
• Involved in creating and analyzing current state flow diagrams of processes & UML Diagrams using MS Visio. Thereby, depicting the future state flow diagrams using MS Visio by interviewing various SMEs and feedback from IT solution architects.
• Carried out Disaster Recovery Plan (DRP) to avoid any catastrophic transition implementations.
• Conducted Risk Analysis by developing Business Impact Analysis (BIA) report and updating it throughout the transition cycle to keep track of every change in the requirements and alteration in Business Requirement Document (BRD) and System Requirements Specifications (SRS).
• Performed a bench-mark analysis between "as-is" and "to-be" process flows to realize higher levels of conformance with updated HIPAA and EHR versions
• Utilization of EDIFECS Smart trading in creation of technological solutions to reduce infrastructure and administrative cost.
• Acted effectively as point-of-contact on status of EDI Part D transactions from internal and external customers.
• Developed and prepared EDI documentation, as well as provided content and format testing for internal and external use, as per NCPDP 5.1 Standards.
• Analyzed and documented complex cross functional processes by driving user-group meetings and working with various cross-functional and virtual teams.
• Monitored and evaluated accuracy of pharmacy drug benefit through testing review and validations; report monitoring and/or live claim review.
• Reviewed and edited requirements, specifications, business processes and recommendations related to proposed technical marketing solutions with the commercial partners.
• Provided quality, objective, and professional analysis of business needs and PBM capabilities & limitations
• Coordinated and facilitated planning, tracking and install of business requirements.
• Assessed compliance with Federal and State regulations, internal policies, procedures and workflows.
• Worked with Manufacturers such as Pfizer, AstraZeneca and Biogen to accomplish contractual obligations and external reporting.
• Well-rounded understanding of GxP quality guidelines and regulations created to ensure that pharmaceutical products produced accordingly and the supply chain operations run smoothly.
• Triaged PBM inquiries to ensure servicing needs identified and addressed.

Confidential

Senior Business Analyst/Project Manager

Responsibilities:

• Involved in requirements gathering sessions with SME’s (Subject Matter Experts), Business Analysts and Architects to understand requirements in terms of business.
• Played a major role in collecting, documenting, blueprinting and managing business requirements.
• Actively worked on Business requirement analysis and Data analysis.
• Worked at different stages of Software Development Life Cycle (SDLC) with business users, developers, and stakeholders.
• Apart from the initial build of the system, I was heavily involved in initiation of various enhancements to the Show me ECHO system, such as incorporating the utilization of a new EHR (implementation)
• Managed EHR System and Integration Testing including test plan and script development, execution, and defect resolution.
• Assisted in creating an operational run book including future governance for requested optimizations to the system after go live of the project.
• Monitored and evaluated project resource needs ensuring the continuity of projects and timely communication to stakeholders, utilizing MS Project.
• Reviewed and analyzed reports about format, distribution, and purpose, identified problems and improvements, develop solutions or alternative methods of proceeding
• Developed project plans, testing plans, production deployment plans, costing and budgeting plans
• Managed vendor relationships from commercial negotiations to implementations
• Lead internal audits for applicable medical programs like Hypertension, NCQA, HEDIS, Asthma with constant guided interactions with the providers.
• Served as the Business analyst on the implementation of SAP BPC.
• Performed system testing and data validation, report creation, system security, data extracts and personnel training.
• Performed ongoing quantitative and statistical analysis of performance data to include HEDIS measures, service utilization and member/provider complaint trends.
• Provided recommendations for operational efficiencies and process improvements and assists in policy development to support change initiatives
• Provided input into the planning, organization, implementation and monitoring of management processes, tools, risk, issues, opportunity management
• Developed policies, methods and procedures to supporting and lending to improvement of business processes and in support of change management
• Planned, performed and implemented process improvement and/or change management initiatives
• Planned, performed and implemented process improvement and/or change, event, incident, configuration, root cause or asset management initiatives
• Developed HEDIS measures, service utilization and all quality report extraction specifications for SHOW ME ECHO ensuring the accuracy by working with the providers such as physicians, RN’s, respiratory technicians.
• Developed and updated quarterly, annual and ad hoc reports including analysis and narrative for NCQA accreditation and Health Plan deliverables
• Outlined the organization hierarchy and created profiles, roles accordingly in Salesforce; worked on visibility and security settings around them as required by the business.
• Served as a salesforce cloud health BA, worked with customers and team members, which include attending and speaking at conferences, conducting training sessions, workshops, and webinars for customers and team members.
• Performed other performance and process improvement activities as needed
• Worked on business process from taking a requirement from a system record to a centralized database.
• Ensured that ICD-9-CM procedure codes used for inpatient services and CPT codes for outpatient and physician services were not outdated
• Design Confidential EDI data model for managing inbound and outbound claim and payment response data.
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using MS Visio.
• Participated in the JAD sessions along with the technical team members and clients to elicit requirements for installation of SHOW-ME ECHO and care management systems.
• Actively worked with quality control teams to develop test plans and test cases.
• Developed tables, Views, Stored Procedures and Triggers using SQL.
• Writing Standard SQL queries and optimizing SQL/SSI Queries
• Responsible to meet the information demands of our business users by delivering timely, accurate, meaningful and standardized data and SSIS reporting.
• Developed test scenarios and implemented test plans for system test and user acceptance test (UAT).
• Created complete test cases of varying complexity, executing tests, measuring expected and actual results, and reported status ensuring accurate coverage of requirements
• Set up test requirements, developed test plans, and documented manual test cases using Quality Center requirements module.
• Collected and compiled statistical quality data Analyze data in the quality system.
• Developed and monitored corrective and preventive actions.
• Managed all types of functional change requests in the ‘patient’ module of the application, including defects, enhancements, issues and documentation changes with a flexible workflow process using Quality Center
• Performing downstream follow up to ensure customer needs are prioritized and worked on based on level of need. This includes proactively touching base with customers to provide follow up.
• Analyzing customer requests and resolving to actionable EDI work requests
• Monitor the flow of data through EDI applications to ensure all operational systems are functioning properly when needed.
• Elicited requirements using interviews, focus groups, document analysis, requirements workshops, workflow definitions, use cases, scenarios based on Edifecs Product Specifications
• FACETS and Facets Data Model working on data model and data extracts
• Verified the software and applications per the requirement of the commercial vendors.
• Successfully improved the ECHO initiation process, by eliminating multiple unwanted steps by using lean six sigma techniques, was able to increase the patient satisfaction by 50%.
• Worked on digital process improvement processes to increase the user access and satisfaction, by conducting JAD sessions with the providers and also with the development team.

Environment: SQL, UML, MS Project, SQL Server, MS Visio

Confidential, California

Business Analyst/Project Manager

Responsibilities:

• Suggest strategies to implement HIPAA 5010 from HIPAA 4010 in the new MMIS system.
• Involved in the creation of the Mockups and Use Cases for MACD quotes and Orders using MS Visio.
• Documented business requirements and communicated these requirements with the development team for design and implementation of business solutions.
• Researched and identified published updates to fee schedules from Medicare, Medicaid, and third-party sources.
• Worked with members edge billing platform with respect to projects involving claims management system enhancement by interacting with case managers and physicians.
• Analyzed business problems, including, but not limited to new benefit changes or products, formulary changes, enhancements to add functionality and/or redesigns of systems to improve efficiency.
• Developed or assisted with comprehensive cost/benefit analysis.
• Identified opportunities to reduce organizational risk, detects and remediates vulnerabilities and ensures compliance and audit readiness using the RMT.
• Made recommendations for corrective action and documents management decisions regarding acceptance or mitigation of risk scenarios.
• Worked with Business Analysis team to prepare a detailed Business Requirement Document.
• Analyzed Business Requirements to develop Functional and detail Design Specifications of the application.
• Conducted Requirement Gathering Sessions with the stakeholders.
• Interacted with the project team to help define the Business and System Objectives, confirmation of scope, identify constraints and the measures of success for the system to be developed.
• Conducted the JAD sessions, daily meetings, brainstorming sessions to solve the problems and enhance the workflow.
• Performed Data analysis under HEDIS measurements in support of preventive medicine strategies and Conducted business process improvement analysis, process testing, and validation based on various Six Sigma tools and reported these to the providers to improve patient satisfaction.
• Managing vendor relationships from commercial negotiations to implementations.
• Responsible for end-to-end project management covering complete project life cycle.
• Responsible for resource planning
• Developing project plans, testing plans, production deployment plans, costing and budgeting plans.
• Managing Agile / Scrum teams, and running sprints end to end by conducting sprint planning meetings as well.
• Performed data extraction, analyzed and discussed relevant HEDIS measurement information with stockholders.
• Created and designed business dashboards for the formulation of provider network KPI using Power BI and CRM tools.
• Prepped the data and mashed it up into a data model that represents the business process(es) using Power BI.
• Pulled in data from their multiple sources, cleaned, structured and stored in such a way that is intuitive for business users to understand.
• Responsible for creation of a repository and stakeholder tracker of various HEDIS data submissions to state and federal agencies on a timely basis, ensuring the quality of the data submitted meets at a minimum the various regulatory requirements.
• Worked with NCQA HEDIS certified software to obtain HEDIS measure rates for monthly and annual reporting to management.
• Created documentation and conducted JAD sessions with the Development team to ensure the accuracy of programs used to generate HEDIS data submission files.
• Involved intensively in development of a portal for care managers to identify functional errors thereby increasing patient satisfaction.
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid Claims.
• Performed data mapping and data modeling and used canonical data model to map data from X12 834 transactions.
• Defined business requirements and business process and policy changes related to the client Medicaid system during the conversion from the existing HIPAA 4010A formats to the future HIPAA 5010A format.
• Analyzed and documented Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensured these issues are documented and addressed in the approach to the HIPAA 5010 version.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Established and supported communication with product users and suppliers to share information.
• Identified and recognized opportunities and resolved problems related to EDI 835,837,270,271.
• Prioritized customer requirements and maintained continuous improvement through customer feedback.
• Acted effectively as point-of-contact on status of EDI transactions from internal and external customers.
• Educated and trained staff of assigned business areas on EDI applications.
• Developed and prepared EDI documentation for internal and external use.
• Performed Web Page Mock-Ups using MS Visio and thus defining the Business Process
• Model and Data Process Model.
• Analyzed and documented the scope of the project and kept track of changes through the product lifecycle.
• Assisted in building a Business analysis process model using Rational Rose and Visio.
• Gathered Functional Requirements from users and the management. Coordinated all the requirements in team-based environment.
• Acted as liaison between the senior management and different teams with effective presentations.
• Monitored change requests and documented requirements, integrating them with Use Cases.
• Incorporated stakeholder feedback throughout project lifecycle to ensure project quality and customer satisfaction.
• Created technical documentation for the project using tools like Visio, Word, Project etc.
• Assisted in logical and physical design sessions and in documenting developed designs
• Used MS Project for managing schedules, resources and collaboration.

Environment: MS Office, SQL, MS Project, MS Visio, Unix, XML, Windows.

Confidential

Medical Claims Supervisor and Business Analyst

Responsibilities:

• Responsible for verification of initial and ongoing eligibility/enrollment of members for assigned groups.
• Created the Policy and Procedure Review documentation.
• Approving various kinds of health insurance claims and working with multiple stakeholders to fasten the process of claims processing.
• Supervised the policy Renewals, terminations and cancellations
• Responding to e-mails from agents & clients regarding the Queries, New policies and Renewals
• Review enrollment applications to determine eligibility of individuals for coverage in accordance with applicable contracts. Process quality assurance/error reports timely and accurately to ensure appropriate coverage for members.
• Initiate billing and enrollment adjustments and coordinate reconciliation of billing problems.
• Work closely with Finance to ensure communication of discrepancies in billing.
• Developed use cases, workflow, screen mock-ups and conversion requirements.
• Coordinated work plans between project manager and client using MS Project.
• Helped in reviewing and editing of the test scripts.
• Followed UML based methods using Rational Rose to develop use cases and activity diagrams; assisted developers in creating sequence diagrams and collaboration diagrams.
• Reviewed business process, URS, and functional requirements.
• Assisted in process modeling; conducted and participated in JAD sessions with system users; helped with design walkthroughs with stakeholders for base lining architecture.
• Used Rational Clear Quest for handling change requests
• Created and tested scripts for the premium calculations and claim limits and deductible.
• Involved in detailing project mission, data process flow diagrams, and timelines.
• Developed Test plans and Test cases per business requirements with the Manager.
• Participated in automated regression and Non-functional test plans.
• Maintained Requirement Traceability Matrix throughout the project.

Environment: RUP, Rational Requisite Pro, Rational Clear Quest, MS Office, Visio, Project, Windows XP, UML, SQL.

Confidential

Responsibilities:

• Gathered and documented business requirements
• Analyzed and interpreted operational variance data to identify trends, patterns and opportunities for the business and clients
• Communicated analysis and interpretation to appropriate audience and the C suite as and when needed.
• Produced, published, distributed, scheduled and created ad-hoc client and operational reports relating to the development and performance of products, processes and technologies
• Interacted directly with business stakeholders and assisted in managing Scrum calls.
• Managed the database used for tracking the requirements.
• Reviewed vendor provided documentation and internal user manuals needed to support the product.
• Translated business requirements into product-specific designs and configuration, detailed requirement specifications and user stories.
• Supported in creation of the Functional Requirement Documents (FRD), Business Requirements Documents (BRD).
• Assisted in running the operations of the dental surgical unit.
• Performed Minor oral surgical procedures.