SUMMARY

• Healthcare Business Analyst with 7+ years of experience in the HealthCare Insurance Industry.
• Expertise in all the phases of the Software Development Life Cycle (SDLC), Agile/ Scrum Development and RUP methodology.
• Expert in creating User Stories, Case Diagrams, Class Diagrams, Sequence Flows using MS Visio and Rational Rose using UML concepts.
• Expertise in documenting the Business Requirements Document (BRD), generating the UAT Plan, maintaining the Traceability Matrix and assisting in Post Implementation activities.
• Experience in Forward Mapping and Backward Mapping analysis of ICD 9 - ICD 10 Conversion for CM (Diagnosis Codes) and PCS (Procedure Codes).
• Worked on one full lifecycle project on ICD 9 to ICD 10 Conversion. Documented Stakeholder Analysis, BRD, SRS, Test Plan, Test Plan Approvals doc, User code and Map lookup and Use Cases.
• Expertise in EDI HIPAA 4010 - 5010 Project to convert EDI X12 Healthcare 4010 transactions into 5010 Compliance transactions.
• Knowledge and expertise in working with Claims, Provider Relations, Enrollment, Finance, Benefits Administration, and Vendor Relations' Business Areas.
• Vendor Management - Worked as a facilitator for Testing Efforts and New Requirements between the Healthcare Company and its various Vendors.
• Worked on PBM projects involving Benefit Base Plan changes and Configuration changes to ensure the accurate processing of claims. Determined dependencies between enrollment and benefits processes and ensured each Business Areas delivered their tasks on the projected target dates.
• EDI Claims processing - documented enhancements to the EDI Claims Processes (EDI 820, 837, 835, 276, 277) to ensure accurate processing of claims.
• Eligibility File and Membership File - Ensured accurate transmission of the eligibility file and membership file to Vendors and Delegates as a result of the annual Benefit Changes.
• Mercury Test Director - Expert in all phases of the web based application. Expert in building test plans and test cases and navigating through the test lab.
• Defect Management - Fully involved in the process of defect identification and resolution using Test Director.
• Excellent Experience in web Based application of E-Commerce.
• Familiar with FACETS & HIPAA Compliance Standards.
• Implemented various HIPAA codes (270 and 276) used for Claims Enquiry and Eligibility purposes of patient records.
• SME for Oracle Letter generation based on the HIPAA guidelines involved in protecting the patients information.
• Intermediate level working knowledge on the functional aspects of ERP using SAP Materials Management (SAP MM)

TECHNICAL SKILLS

Modeling Methodologies: Agile (Scrum), Rational Unified Process (RUP) and Waterfall

Process/ Modeling Tools: Requisite Pro, MS Visio, Axure

Databases: MS Access, SQL Server

Quality Management: HIPAA, CMMI, CMM

Languages: C, C++, SQL, PL/SQL HTML, VB scripts

Operating System: Windows XP/ME/2000/NT/98/95, MS-DOS

Office Tools: MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, SharePoint

Testing/Tracking Tools: WinRunner7.01, Test Director 7.01/HP Quality Center

PROFESSIONAL EXPERIENCE

Confidential, Minnesota

Encounter/Claims Business Analyst

Roles and Responsibilities:

• Worked on HTHP State of WI 5010 Encounter Reporting Implementation Test Planning.
• Draft the Business Requirement Document (BRD) and Functional Requirement Document (FRD) for the Project.
• Drafting and implementing Test Cases and Test Plans for the project while in production.
• Ensure working on testing the Institutional and Professional Claims/encounters for 837 5010 & ASC X12 formats that meets HIPAA Compliance and State of Wisconsin DHS Requirements.
• Communicating with Trizetto (Application Vendor), HTHP (Client) and Internal Confidential staff for resolving the issues/errors from the files submitted to Wisconsin DHS.
• Leading efforts with business partners and technical teams to perform analysis, define requirements, and present innovative solutions that solve business problems, or that meet business project and service request needs.
• Partnering with IS management and business teams to define project direction, create project plans, and leads project meetings with technical, business and project management staff.
• Leading key project activities. Drives project efforts and facilitates project related meetings.
• Gathering and translating business requirements and works with technical staff to translate tactical business requirements in to functional requirements, thus driving technical improvements, enhancements, and/or creation of new applications.
• Worked on forward and backward mapping ICD 9 to ICD 10.
• Led ICD 9 - ICD 10 Conversion project implementation from start till end. Documented Stakeholder Analysis, BRD, SRS, Test Plan, Test Plan Approvals doc, User code and Map lookup and Use Cases.
• Negotiating and manages project scope, progress, and client expectations.
• Following the project life cycle process including writing Business Requirements documents (BRD)
• Communicating project updates as necessary to management, business, and technology teams.
• To stay in current with all available technical options, development procedures and innovative solutions for key business initiatives.

Environment: Microsoft Visio, Microsoft Project, Microsoft Office Suite, Axure RP Pro 6.0.

Confidential, Bloomington, MN

Sr. Business Analyst & Project Lead

Roles & Responsibilities:

• Provided strategic analytic and reporting support for the design of future benefit plans as well as the support of product sales, benefit plan operations, “Proof-Point” performance reporting of those plans, and mandatory reporting for state and federal exchanges.
• Strong experience and a good knowledge of the individual market product (opposition of buying healthcare through a group policy or your employer company).
• Leading stakeholder analysis and documentation of interdependent processes with other business units.
• Led discovery activities with business and information services staff at all levels to understand business objectives, assumptions, and constraints related to a solution delivery.
• Consulting several business units and diverse project teams to gather and document enterprise level requirements.
• Worked in planning and development efforts for BUSINESS side of a new "Individual Market" Product.
• Gathered reporting requirements utilizing business artifacts and interviews with Subject Matter Expert’s, Stakeholders, and Management.
• Developed Scope Document at the enterprise level, which provided project clarity and definition to all impacted partners.
• Documented project artifacts such as Charter, Scope, Idea Creation Request, Project Plan, Stakeholder Analysis, and Resource Plan.
• Drafted Current State Inventory and Analysis Document, Process Flow Diagrams, GAP Analysis and Functional Requirements Specification Document for deliverables from Enterprise Reporting and Analytics Perspective.
• Worked on documenting Standard Operating Procedures, Risk Analysis, Project Roadmaps, and Report Asset Catalogs.
• Organized and led product success and performance reporting efforts.

Environment: Microsoft Visio, Microsoft Project, Microsoft Office Suite, Axure RP Pro 6.0.

Confidential, New York, NY

Business Analyst

Roles & Responsibilities:

• Lead Business Analyst involved in documenting changes to the Benefits Administration, Enrollment Processing and Claims Processing Systems based on the Medicare Plan Changes initiative.
• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD. Utilized data flow diagrams, user story/ use case diagrams and process flow diagrams to represent information provided by the Business Owners.
• Organized meetings and led JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met. .
• Worked with Business Owners of Market Prominence, the Enrollment Processing System, to ensure that the enrollment process for the new members is updated with changes.
• Worked with the UAT and QA teams to conduct an assessment and determine how effective UAT and QA guidelines can help the company achieve timely completion of projects.
• Worked with Business Owners of Quality Care, the Claims Adjudication Process, and documented updates and enhancements.
• Effectively elaborated the current process and gave a clear picture of the proposed process for the projects in the organization. Worked aggressively towards timely completion of High Priority Tasks.
• Vendors and Delegates - Worked with Business Owners and Relationship Managers for Vendors and Delegates, e.g. Davis Vision, Montefiore, HCP, to ensure that Eligibility and Membership File exchanged on daily and weekly basis is updated with the Medicare changes.
• Change Control Process - Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Worked with Development Team to resolve issues and clarify Business Requirements from the Business Owners.
• Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Maintained the Traceability Matrix table to track the Business Requirements to the design to the testing keeping track of all requirements in the BRD.

Environment: Web Portal: Heads Down & PEPs, QCARE, MS Access, ORACLE,MS Word, Excel, and PowerPoint.

Confidential, Cincinnati, OH

Business Analyst

Roles & Responsibilities:

• Gathered requirements and documented User Stories for the applications that used SSN and DOB as unique identifiers.
• Updated displays of YOGI (Patient Screen) to include masked SSN & DOB Information.
• Claims Process Expert – Developed Claims Matching Scenarios upon which millions of Claim records were matched daily based on Patient's Information.
• Claims Process Cleanup – Involved in cleaning out the previous data and updating applications to accept new format of Claimants Information.
• Created Requirements Document for all the affected processes due to the truncation of the SSN and DOB fields of the Claimants' Information.
• Responsible for handling new conversions for the company so that Claims can be matched and billing records should not create mismatched records despite belonging to the same patient.
• YOGI application (Patient Screen) – Duplicate Claim Number project – Updated the YOGI application to include duplicate Claim Numbers in the system.
• Analyzed Business Requirements, developing tracking and enhancing them into functional requirements using Rational Requisite Pro as a requirements tool.
• Participated in Scrum meetings and used Sprint methodology as SDLC.
• User Acceptance Testing (UAT) – Carried out UAT activities associated with each project and presented the results to the Business Stakeholders.

Environment: CMMI (Level-3), Rational Rose, Rational Requisite Pro, RUP, Test Director, Win Runner, MSOffice2000, UML, Java.

Confidential, NJ

Business Analyst

Responsibilities:

• Involved in the quality planning and testing of a web based ordering solution of the pharmaceutical company.
• Facilitated test plans and user acceptance tests and regression analysis as well.
• Defined the scope and implemented business rules of the project, gathering business requirements and documentation.
• Order Process Management – Designed techniques to implement a new Billing and Inventory Management Tool to better track the expanding business' products.
• Software and Product Development for the healthcare industry products.
• Created User Stories, activity report, logical components, and deployment views to extract business process flows and workflows involved in the project.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Analyzed Business Requirements and developed User Stories, Activity Diagrams and State Chart Diagrams using Rational Rose according to UML methodology thereby defining the Data Process Models.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams, and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Facilitated JAD sessions with management, development team, users, and other stakeholders to refine functional requirements.
• Conducted presentations of the implementation results with analysis to the stakeholders and users and documented modifications and requirements.
• Worked with the QA team lead and QA standards to ensure compliance with all regulatory requirements.
• Effectively communicated user acceptance test results between users and development team and provided recommendations for change control requests (CCR).
• The Internet serves as a platform for e-commerce transactions for sale of CVS Products.

Environment: HTML, Rational Rose, SQL server, Microsoft Visio, Microsoft Project, Microsoft Office, Java

Confidential, Chicago, IL

Business Analyst

Responsibilities:

• Worked for the EPMO department at Health N0et as Business Analyst.
• Participated in full life cycle implementation00s (SDLC) from project initiation to final deployment.
• Worked with various Business Areas like Enrollment, Claims, Finance, Providers and Benefits Admin.
• Gathered Business Requirements for the Claims Business Area and updated EDI Transactions like EDI 837, 835, 277 and 276 with the HIPAA 5010 Changes.
• Involved in the documentation of ICD 9 – 10 Conversion's Impact Analysis of the Diagnosis and Procedure Codes.
• Experienced in development of Web Portals in the Healthcare Industry.
• Developed a Referral Web Portal that was used by providers and members to view their referral information.
• Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD.
• Knowledge of the Diagnosis and Procedural Code changes for Healthcare Entities like Payers, Employer Groups and Providers.
• Web Portal Development – worked as a Business Analyst gathering requirements to develop a referral portal. Documented Current State vs. Future State for a Referral Web Portal.
• Testing - Developed Test Scripts using Test Director and coordinated with developers to quickly resolve the defects associated with them.
• Analyzed and evaluated User Interface Designs, Technical Design Documents, and Quality Assurance Test Conditions the performance of the application from various dimensions.
• Created Business Requirement Documents and Technical Requirement Documents as a result of meetings with the Business Areas. Obtained business sign offs on the documents after reviewing the final documents with them.
• Change Control Process – Led the Change Control Process for changes submitted for the BRD once the document was submitted to IT department.
• Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Maintained the Traceability Matrix table to uniquely trace the identified business requirements to general design to testing as proof that requirements requested have been developed into a solution and that it has been tested and tracked.

Environment: MS Visio, Word, Excel, PowerPoint, CMMI, Rational Rose, Requisite Pro, Clear Case, Clear Quest, SQL, Oracle, J2EE technology, Java