SUMMARY

• Over 7 years of experience in Business Analysis, primarily on business requirements gathering and analysis, technical writing, functional and non - functional requirements gathering, and analysis
• Experience in developing business and functional requirements around HEDIS information
• Strong knowledge of Facets and actively involved in end-to-end implementation of Facets Billing, Enrollment, Claim Processing and Subscriber/Member module.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as EDI 837, 835, 834, 270, 271, 276, 277.
• Well versed in testing Enrolment, Billing and claims processing in FACETS.
• Involved in testing Member, provider, Claims Processing and Utilization Management, Contracts and Benefits modules
• Profound Knowledge working on Inbound (I834) and Outbound (IC 834) 834's according to FFM (Federally Facilitated Marketplace) and Issuer perspective.
• Good knowledge of HEDIS (Healthcare Effectiveness Data and Information Set).
• Have worked in Guidewire Policy Center from End-to-End and involved in Policy Info, Person Info, Losses and Violations, Coverage's, Risk Analysis Customizations
• Expertise in creating various artifacts like BRDs, Functional Specs, Used Cases, UML Diagrams, Data Mapping Documents, Test Plans and Test Strategies, pre and post RTMs and Status Weekly Reports etc.
• Strong visual modeling and Business Process Modeling (BPM) skills using Rational Unified Process (RUP) with tools like Rational Rose, and MS Visio.
• Comprehensive knowledge and experience in different SDLC methodologies like Agile/Scrum, waterfall, RUP, V-model
• Excellent analytical, organizational, communication and documentation skills along with good project management skill to gather requirements to bring out the quality product.
• Knowledge in Data Modelling, Data Extraction, Transformations and Loading, Mappings Workflows, and Customized Analytics Reports.
• Expertise in the Data Analysis, Design, Development, Implementation and Testing using Data Conversions, Extraction, Transformation and Loading (ETL) and SQL Server, ORACLE and other relational and non-relational databases.
• Excellent written and oral communication skills with the ability to communicate appropriately in business and technical situations at all levels of project management.
• Assisted with implementation and ongoing support of Health Insurance Exchange (HIX)
• Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Well-versed in MS Visio, MS Project, Mockup screen, and Microsoft suite (Word, Excel, Access, Visio, Power Point, and Outlook) for analysis and presentation
• Expert in facilitating Joint Application Development (JAD), Rapid Application Development (RAD), interviews, and requirement elicitation sessions with end-users, clients, stakeholders and development team
• Experience in creating UML diagrams, Data Flow Diagrams (DFD), Use Cases, Class Diagram, Activity Diagrams, Sequence Diagram, and UML Modeling.
• Strong working knowledge in Guidewire Policy Center product & Billing Center
• Facilitated User Acceptance Testing (UAT)and test strategies with developers and testers, and participated in manual front-end testing to check all functionalities of different modules
• Ability to create and analyze Business Requirement Documents (BRDs), Functional Requirement Documents (FRDs), Process flows, and Use Cases

PROFESSIONAL EXPERIENCE

Confidential, Hartford, CT

Business / Data Analyst

Responsibilities:

• Gathered detailed business & technical requirement and participated in the definitions of business rules and data standards.
• Reported and updated FACETS data to ensure proper configuration process
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (PID) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrolment hence analyzing and documenting related business processes.
• Performed gap analysis of claims and enrolment business process for changes from SSN identifier to USI (Unique Subscriber Identifier) affecting for HIPAA EDI X12 transactions 837, 834, U277, 276/277, 270/271, 278,835 and 820.
• Delivered advanced health insurance analytics and development of statistical, predictive models.
• Created specifications for EDI HL7 (A28, A31, ADT) and X12 (837/835) transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers.
• Worked with data migration and file mapping for various EDI transactions. Enhanced the Provider/Patient verification criteria using additional parameters based on the information retrieved from the EDI 837 I/P transaction files.
• Translated the EDI X12 data into XML format for initial transformation/migration.
• Facilitated functional requirement gathering from system users and prepared BRD.
• Created Business Process Mapping Diagrams and Documentation for the process improvement recommendations.
• Used MS Visio for flowcharting, Use Case process model and architectural design of the application.
• Implemented the Rational Unified Process (RUP) methodology guidelines with its various workflows and artifacts in Requirements Management and Development.
• Gathered and documented functional requirements and use cases for automation of operational and administrative business processes.
• Provided overall project management of multiple projects; successfully completed on-schedule and on-budget.
• Documented the "AS-IS" Business Workflows adhering to UML standards. Conducted JAD sessions to define requirements and finalize the Functional Requirement Document (FRD).
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML and Visio.
• Interfaced with team leaders, identify and analyse the given information, procedures and decision flows, evaluated existing procedures, methods and technical documentation. Communicated with executives, managers and other stakeholders regarding project scope.
• Responsible for business process analysis that includes requirements facilitation, definition & analysis, alternatives, software selection, prototyping, business process design and mapping.
• Maintained a Traceability Matrix to ensure that all functional requirements are addressed at the use case level as well as the test case level.
• Involved in identifying use cases, actors and writing use case narratives. Created use case diagrams and activity diagrams using MS Visio.
• Conducted meetings and JAD sessions for project definition, resource identifications and deliverable prototype identification.
• Interfaced with developers, analysts, customers and project managers to discuss requirements and recommended solutions, to help resolve issues.
• Led the User Acceptance Testing efforts to verify that the developed reports meet the requirements.
• Involved in developing the test strategy and helped in developing QA Test plans for Functional, Integration and System Testing

Confidential, San Antonio, TX

Business Analyst

Responsibilities:

• Involved in Inception Phase and prepared vision statement and initial data models that contain Business Requirement Documents and supporting documents that contain the essential business elements and detailed definitions.
• Worked on 834 Re-enrollments/Renewals and Reconciliation of patient encounter data
• Involved in processing 834 Files upstream and downstream, identifying Enrollment Scenarios and deriving test scripts from the scenarios and adjudicating Claims effectively.
• Defined a repeatable process that is followed in the early stages of the Concept phase which defines risks and impact of product development.
• Hands on experience with the 834 ANSI X12 transaction understanding loops, segments, elements and structure
• Performed Data mapping and data modelling and used Canonical data model to map data from X12 834 transactions.
• Worked with cross functional teams to define KPI's for each stage of the Product Development and Release Process.
• Working with functional teams in an agile environment, analyse factors and components of systems and processes to manage interrelationships and facilitate change. Detects inefficiencies or conflicts in systems and processes and helps to identify effective improvements.
• Interacted with other team members and participated in daily scrum meeting to make sure the all team members are on the same page.
• Prepared Test Cases based on business requirements and business rules for HIPAA EDI Transaction 834, 837, 835.
• Facilitates communications between customers, SME's and Technical staff. Participate in various testing functions (i.e. string and acceptance tests) to verify that results are correct.
• Analysed data and created class diagrams and ER diagrams for designing databases.
• Planned and defined Use Cases created Use Case diagrams, Scenarios and Use Case Narratives using the UML methodologies.

Confidential, Albuquerque, NM

Business Analyst

Responsibilities:

• Created User Stories, UML Diagrams and Data Flow Diagrams to determine the data flow via various Systems.
• Actively participated in Product Backlog/Refinement meeting, Sprint planning, Daily Scrum, Sprint review and Sprint retrospective meetings.
• Elicited requirements, created As-Is and To-Be process, Cost Benefit analysis, Risk assessment and SWOT analysis for the project.
• Worked on adding functionalities for payment processing system which allowed users to process payments to selected payees
• Accomplished projects and design documents on HIPAA 835 and 837 calculations and EDI transactions, Health Statements and Explanation of Benefits, Healthcare Reform and 5010 CMS occurrence and field expansion for 835 and 837 EDI formats
• Worked with UtilizationManagement,CareManagementwork stream to help Development, and Quality Assurance team to produce business efficient product by providing Product design and business understanding.
• Facilitated Joint Application Development (JAD) sessions to focus on definingCareManagementand UtilizationManagementRequirements of the portal.
• Worked with configuring the Business rules to automate many tasks associated with thecaremanagement, UtilizationManagementincluding auto referrals and auto generating education materials.
• Identified actors and use cases forCaremanagementand utilizationmanagementfrom the requirements and prepared Use Cases Diagrams, Business Process Flow, Activity Diagrams and Work Flow Diagrams to understand the interaction between actor and the system using MS Visio.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set.
• Involved in testing Member, provider, Claims Processing and Utilization Management, Contracts and Benefits modules.
• Coordinated the upgrade of EDI Transaction Sets 837, 835 and 834 to HIPAA compliance.
• Work on EDI 834-file load in Facets through MMS (Membership maintenance sub-system).
• Experienced in software development life cycle such as Waterfall, Agile-SCRUM methodologies, Business Analysis and Modelling.
• Updated Current internal systems to integrate New data and functionalities of the payment arrangement system.
• Worked on securing all patient data that was exchanged within systems and made sure the exchanges fell within HIPAA guidelines and mandates.

Confidential, West Reading, PA

Business Analyst 

Responsibilities:

• Prepared Business Requirements Documents, Functional Requirement Documents.
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential.
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery
• As a Business Analyst Involved in implementation of HIPAA EDI Transactions (834, 835,837)
• Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
• Excellent knowledge working on 834 Re-enrollments/Renewals and Reconciliation patient encounter data
• Conducted JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.
• Used EDI tools to verify mapping to X12 format.
• Recommend changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA/ EDI formats and accredited standards ANSI.
• Facilitated all Aspects of scrum framework, including product backlog, release backlog, sprint planning session, daily scrum meeting, sprint reviews and sprint retrospectives.
• Created data mappings to transform the data according to business rules.
• Developed Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.
• Prepared various diagrams by using MS Visio.
• Prepared documents for the wireframe and prepared a data dictionary for the same
• Managed testing for various functionalities using Quality Center tools.
• Worked closely with QA and Developers to clarify/understand functionality, resolve issues and provided feedback to nail down the bugs.
• Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.
• Conducted project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.