SUMMARY

• Complete Understanding of Software Development Life Cycle (SDLC), involved in various phases like Requirements Gathering, Analysis/Design, Development and Testing.
• Experience working with project management tools such as MS Project and Planview - Creating WBS, Allocating resources, Resource and budget Tracking and Updating project plan
• Proficient in creating Use Case diagrams, Class diagrams, Sequence Diagrams, Collaboration diagrams, State Transition Diagrams and Activity Diagrams.
• Experience with BlueCross, Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12 formats including 270/271, 276/277, 834, 835, 837(I/P/D)
• Experience with Data Mappings including HIPPA ANSI X12 4010A to 5010 for all EDI transactions.
• Proficient in UB-92, HCFA-1500, ICD-9, ICD-10, HCPCS
• Expertise in ICD-9 to ICD-10 Conversion.
• Functional knowledge of, NASCO, NPI, ITS, FEP, SHBP, MMIS, MITA and claims data elements and adjudication processes, Automated Clearing House Transactions and Functional knowledge in developing and implementing Claim processing systems.
• Experience with Healthcare systems like FACTES in Membership & Enrollment and Claims subject area
• Acted as liaison between management and development team for Requirements and QA.
• Experienced in understanding Business processes and creating As Is models and To Be models and conducting GAP analysis.
• Proficient in Rational tools including Rational Rose and Rational Requisite Pro.
• Expert level skills in MS office Suite, Visio, and MS Project
• Experience in implementing the Rational Unified Process (RUP) in all four phases of a project: Inception, Elaboration, Construction and Transition.
• Experience in managing requirements from project inception through release.
• Experience in Medicaid Management Information System (MMIS)
• Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.
• Worked on several Data Migration projects and worked with the data team to create data mappings between the source and the target system
• Proficient in using and Implementing Six Sigma tools such as FMEA, SIPOC, ISHIKAWA, ANOVA and Regression Analysis( Single and Multiple)

TECHNICAL SKILLS

Methodologies: UML, RUP and SDLC

Languages: C, SQL

Database: MS Access, DB2, MS SQL Server 2005

Microsoft Applications: Excel, Word, Power Point, Share Point

Application Management Tools: Rational Rose, Requisite Pro

Workflow Application: MS Visio

PROFESSIONAL EXPERIENCE

Confidential, AL

Sr. Business Analyst, PMO

Responsibilities:

• Assisted project manager to communicate with various lines of business users to create business cases and documentation for requested efforts, enabling them to prioritize and position requests appropriately.
• Comprehended business objectives, challenges, strategic direction and technologies by working with Stakeholders and Users; gathered business requirements, defined the approach and drove the creation, review, and approval of business requirements, Use Cases, functional requirements, process models, conceptual models, and data business intelligence/analysis.
• Reconciled requirements, process models and data business intelligence/analysis needs with technology, architecture, risk management, industry standards, firm objectives.
• Assisted project manager and made sure that all analyses and deliverables are aligned with all known short and long-term objectives of projects and Project Management Methodology.
• Worked with Project Manager and Technical Analyst to understand project direction and structure in order to execute project objectives in support a supporting role and manage changes.
• Ensured that project tracks (Application Development and Quality Assurance teams) have awareness and a clear understanding of requirements and their impacts on their tracks.
• Participated in QA process of a project/product by validating reported defects/changes against requirements.
• Assisted in the negotiation and documentation of defects/changes with the business.
• Assist corporate testing team in identifying and documenting test cases, creating test data, writing test scripts, executing test scripts, and documented defects.
• Participated in the Deployment/Adoption of a project/product by acting as SME for the project/product.
• Participated in the definition of Support and Operations of a project/product by acting as SME for the project/product.
• Verified that technical efforts and project execution are in adherence to all requirements, process models and data business intelligence/analysis needs throughout the various phases of the project lifecycle.
• Made certain that issues are identified, tracked, reported on and resolved in a timely manner.

Confidential, MI

Sr. Business Analyst

Responsibilities:

• Prepared the inventory of the systems and business capabilities supported by the systems.
• Conducted the Interface analysis to identify the point to point interfacing between applications.
• Proposed the Enterprise service Bus (ESB) concept to remove the P2P interactions between the systems.
• Identified the data elements that are passing from one interface to another.
• Worked on NASCO & Local (Legacy) Membership and Billing System
• Collaborated with the Architecture team to provide technical solution
• Working knowledge of the NASCO ITS Blue card Claim system
• Worked on NASCO Bluebase Membership/Billing system 834 File
• Worked on MOS (Michigan Operating System) MTV Metavance Membership/Billing system 834 File
• Working knowledge of Benefits comparison chart, Groups Apps etc.
• Worked in the TPA environment and have a good understanding of the FACETS group structure
• Working knowledge of FACETS Group Enrollment & Billing System
• Conducted Data Analysis and created Data Mappings for back end systems
• Collaborated with the Architecture team to provide technical solution
• Worked on NASCO ITS Blue Card Claims, hand on experience with ITS Products & platform with all indicators (SF, RF) etc.
• Working knowledge on NASCO’s PDM (Project Data Manager)
• Worked as technical lead on Data Analysis, Data Profiling and Data Mapping on MOS Data store and other NASCO systems used to setup large Groups.
• Worked on Local Membership system Legacy/PRISM conducted Data Analysis on member level tables and group level tables
• Prepare Data Flow Diagram and help building architecture diagram for technical solutions
• Delivered many artifacts including RTM, Supplementary Specification Document, and Software Architecture Document
• Assist corporate testing team in identifying and documenting test cases, creating test data, writing test scripts, executing test scripts, and documenting defects.
• Created Test Use Cases for business for the purpose of UAT.

Confidential

Business Analyst

Responsibilities:

• Participated in the initial Project Planning and Resource requirement sessions with different stakeholders.
• Worked with Big 3 consulting firm to build out of a high level roadmap and time line to achieve compliance
• Worked with the Functional Specialists and SMEs to document high level workflows for the Claims processing, EDI, and Reporting
• Worked with HL7, EDI ANSI 4010 and 5010 Standards Knowledge of ICD 10
• Participated in HIPPA 4010 to 5010 upgrade JAD sessions and documented the outcomes as business requirements.
• Prepared 5010 GAP documents involved with 837, 835, and 278 transactions in collaboration with other team members.
• Performed impact analysis on 5010 upgrades and ICD-10 conversions.
• Done Impact Analysis on EDI 834 Enrollment interface for FACETS
• Analysis how to improve FIRST PASS RATE on 837 Claims for FACETS
• Participated in the initial Impact Analysis (ICD-10) for all the critical functions within BCBS, i.e., Claims Processing, Utilization Management, Medical Policy, Reporting, Vendor Management, etc and got exposure to NASCO.
• Participated in 1CD 9 to ICD 10 codes conversion requirement gathering sessions and created high level business requirement document.
• Defined ICD-9 to ICD-10 mapping process using GEMs (General Equivalency Mapping) crosswalk file
• Conducted Business Requirements walkthrough with the business owners as well as the Technical Stakeholders.
• Performed detailed analysis for the following functional areas that is going to impacted by ICD-10 codes

Confidential, New Mexico

Business Analyst

Responsibilities:

• Conducted GAP Analysis for current Medicaid Management Information System (MMIS) and federal mandate HIPAA 5010 / ICD-10.
• Assessed HIPAA 5010 requirements by creating Side By Side 4010-5010 Business Rule Comparison documents for State specific Interface Record Layers (IRL) using ASC X12 Standards 5010 implementation guide for all transaction.
• Briefed System Analysts about the changed/added/deleted Business Rules for HIPAA 5010 and project details.
• Analyzed System Impact including MMIS Tables, Windows, Reports and Interfaces to external entities.
• Analyzed Medicaid Eligibility Determination System for Children’s Health Insurance Program (CHIP) and enrollment transaction 834 submitted to program administrator for HIPAA 5010.
• Analyzed HIPAA 5010 impact on external Data Warehouse and data warehouse extract process and mapping of MMIS database and data warehouse.
• Analyzed RRI/Viking Subsystem (an external system off the state, dealing with conversion of paper claims to electronic claims) and recommended changes for HIPAA 5010.s passed and failed.