SUMMARY

• Extensive knowledge of Software Development Life Cycle (SDLC), Software Development methodologies (Waterfall, Agile, Agile/Scrum, RUP).
• Strong knowledge of US Health Care industry, specifically group health insurance, Affordable Care Act, Medicare and Medicaid programs, roles of CMS and HIPAA standards.
• In depth understanding of ANSI X12 flat - file format, EDI transaction sets 820, 834, 835, 837, 270/271, and 999’s and data flow relationship between patients, providers and payers.
• Understanding of HIPAA Standards and compliance issues, HIPAA Privacy policy, HIPAA 4010 and 5010 implementation and ICD 09 - ICD 10 conversions.
• Strong knowledge and handful experience on the U.S. healthcare domain, business process flow, healthcare data, file formats, data transfer protocol, healthcare tools and technologies.
• Experienced on requirement gathering, analysis, design, development, implementation, testing and deployment.
• Working knowledge of Testing Methodologies such as planning Test Strategy, writing Test Plans, defining Test Cases, developing and maintaining Test Scripts and executing manual and automated testing, recording test results and reporting defects in all phases of Test Life Cycle.
• Sound knowledge of RDBMS, SQL/PL SQL, data warehouse and data marts.
• Strong knowledge of SharePoint Content Management, including folder creation, document upload, version control, generate report, manage user access, maintain document library and send updates.
• Familiar with using various tools such as IBM eRoom, SharePoint, PowerPoint, Microsoft Project, Visio and Excel; and experience in working with healthcare transaction adjudication system such as HP Quality Center, mainframe, Facets, NASCO, MetaVance, Edifecs, QNXT and various home grown claims and enrollment systems.
• Strong analytical, technical, and decision-making skills with ability to manage multiple projects.
• Excellent client relationship management, analytical, problem solving, written and oral communication, and presentation skills
• Strong oral and written communication skills with hands on experience on leading meetings, presenting deliverables, writing meetings minutes and notes and drafting business requirements.

TECHNICAL SKILLS

Methodologies: SDLC, Waterfall, RUP, Agile

Project Mgnt./Modeling: MS Project and Microsoft Office, Rational Rose, SharePoint, Microsoft Visio

Change Management Tools: Rational Requisite Pro, Clear Quest, ClearCase, SharePoint, IBM eRoom

Testing Tools: Rational Suite, Quality Center, Win Runner, Load Runner 9.0, Test Director

Languages: C, C++, Java, .Net, XML, UML, HTML

Databases: Oracle, MS SQL Server, DB2, BizTalk Server, MS CRM, MS Access

Operating Systems: Windows, DOS, Familiar with UNIX and LINUX

Reporting Tools: Business Object, IBM Cognos, and Crystal Report

Healthcare: ANSI X12, HL7, HIPAA EDI, Enrolment/Claims, Facets & NASCO

PROFESSIONAL EXPERIENCE

Confidential, Louisville, Kentucky

Business Analyst- Consultant

Responsibilities:

• Elicit requirements using interviews, document analysis, surveys, JAD sessions, site visits, business process descriptions, use cases, scenarios, business analysis and workflow analysis.
• Assist in writing sections of BRD’s, FRD’s and Technical design documents.
• Provide day-to-day support on 834 file processing and on the member enrollment issues to State-Based Exchanges (SBEs) and Federal Exchange Program (FEP Marketplace)—aka Obama Care.
• Stay tuned with HIPAA compliance, rules changes, version changes (i.e., 4010/5010), codes (ICD 9/ICD 10), and other healthcare related laws including Patient Protection and Affordable Care Act 2010 that impacts healthcare transactions such as claims, payments, beneficiaries, vendor/customer information for the Center for Medicare and Medicaid services.
• Review functional and technical specifications, master test plans, and test scripts/results documents; and provide comments.
• Support the analytical needs of a Business/Functional Unit by participating and conducting JAD sessions and working group sessions with business users, SME’s and stakeholders for specific project tasks.
• Define, analyze and review Business Requirements (BRD), Functional Design (FRD) and Technical Design (TDD) specification documents.
• Facilitate the Open Enrollment group implementation, account and online enrollment portal set-up for small businesses and broker accounts; work with the groups to identify group’s requirements and custom logic to resolve enrollment issues.
• Review Test Plan, Test Cases and Test scripts to cover overall application functionality based on the requirements.
• Review and interpret ANSI X12 guidelines to ensure data integrity, compliance and accuracy of data mapping; knowledge of EDI data mapping, i.e., loops, segments, fields, data type, usage requirements and EDI file structure.
• Extensively work on various benefit enrollment, claims scenarios such as patient information, provider, demography, COB, Health plan, coverage types, PCP, dependents, capitation, subscribers, members, Medicare and Medicaid specific business rules.
• Utilize SharePoint Content Management, including folder creation, document upload, version control, generate report, manage user access, maintain document library and send updates.
• Attend application walk-through and UAT Sessions to train business users and answer technical questions.

Confidential, CA

EDI Business Analyst - Consultant

Responsibilities:

• Gained exposure to HIPAA 5010 implementation, ANSI X12 guidelines, BSC companion guidelines and EDI X12 flat-file formats and NASCO STEP file format.
• Worked with an array of EDI implementation vendors such as ADP, Benefit Focus and AON teams to set up employer portal profiles, test 834 files and process production enrollment data.
• Conducted research in inbound/outbound file formats, validated data, codes and field values and resolved data mismatch issues, file rejection and discrepancies, and proposed solutions on EDI 834 and 837 interface related issues.
• Created and maintained data mapping document(s) in reference to the HIPAA 834 and 837 transactions.
• Performed GAP analysis of 4010 and 5010 EDI transaction using implementation guide to identify the changes in the segments and data elements
• Monitored automated enrollment data and batch files for Facets and NASCO systems for Medical and Dental transactions; provided customer service for members and trading partners.
• Participated on Facets systems enhancement calls.
• Reviewed, analyzed and commented on Facets systems enhancement integration requirements, business rules, logic and HIPAA compliance.
• Tested EDI 834 and 837 files and conducted group enrollment audits (using source system file and destination system files) to ensure that the data transmissions are correct and the enrollment accuracy is maintained.
• Created daily batch processing reports, TRMS reports, error reports from BAM, MBE, Mainframe and other engines in PROD and Testing environments, and analyzed such using Access, Notepad++ and Ultra Edits tools.
• Reviewed and analyzed the Business Requirements (BRD) with the business and development team to understand the architecture and functionality of the application.
• Provided technical expertise for identification, research and resolution of technical issues.
• Performed root-cause analysis to determine more efficient and customer valued solutions; provided solutions to management for process improvement, including productivity, quality and systems.
• Liaison between Business Stakeholders such as the group, vendor and Sales departments to obtain, refine and finalize requirements cross-functional transactions regarding claims and enrollments.

Business Systems Analyst

Responsibilities

• Attended project review meetings and discussed issues, status for tracking the progress with development, project teams and business groups.
• Interacted and worked with business analysts and development team to develop, maintain, and execute quality assurance testing procedures.
• Prepared and maintained Test Cases, test scripts and requirement traceability matrix and other project related documents in SharePoint document library.
• Validated field (data) and field length constraints, data types and attributes against the mapping document in preparing test cases.
• Participated in JAD sessions, solutions delivery, working group sessions and project status meetings as required.
• Assisted in gathering high-level requirements through interviews, document analysis, creating business processes and use cases, and standard analysis of workflow.
• Collaborated with business users, systems analysts, and development teams in defining, analyzing, and interpreting detailed business and technical requirements.
• Assisted in writing test scripts and test cases from requirements; creating sample test data; and testing the test cases against the requirements.
• Responsible for performing various QC activities such as opening issues, monitoring deviation status, communicating status, retesting and closing deviations using Quality Center.
• Executed and enhanced automated scripts to perform basic variable checks, stress tests and performance tests using Test Director.
• Using SQL Server Enterprise Manager viewed tables, modified queries, executed queries in the Console Root and validated data through the website.
• Responsible for systems analysis, design phases of system development life cycle and testing, deployment/implementation and maintenance.
• Performed functional, UI, usability, platform compatibility, and stress testing for company’s applications.
• Gained hands on knowledge of web-based tools and engines such as Oracle, PeopleSoft, SharePoint, SQL, BizTalk Servers, Load Runner, WinRunner BluePrint, ClearCase, ClearQuest, Cognos and Facets applications.