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Facets Configuration Analyst Resume

Schenectady, NY

SUMMARY

  • Sr. Business Analyst with 8+ Years experience in IT and software projects in web/windows application environment with various relational database systems. Involved in various projects like Reporting, Integration, Migration/Conversion and Configuration from legacy application. Worked extensively in Business Analysis (Enterprise Analysis, Requirements Elicitation, Requirements Analysis & Documentation, Communications, Solution Assessment and Validation).
  • Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
  • Extensive exposure to unified modeling language (UML) tools such as MS Visio, Rational Rose and Requirement Management tools such as Rational RequisitePro.
  • Significant practical experience using the Rational Unified Process (RUP) methodology - workflow and Implementation.
  • Worked on the MMIS (Medicaid Management Information Systems) for State governments.
  • Experience in Software Development Life Cycle (SDLC)-Waterfall, V-Model, Prototype 89and Spiral model. Knowledge of reporting tools (Cognos, Crystal Reports & Microsoft Reporting Services).
  • Integrated between various systems, including XML, to follow ICD 10 Code set, ANSI X12 and HIPAA 5010 formats.
  • Extensive work with various Rational tools like RequisitePro- Requirement gathering/maintenance, Use Case document maintenance, ClearCase- version control and ClearQuest/TestDirector for bug tracking, Rational Rose for Use case diagrams, Sequence diagrams and activity diagrams.
  • Experience with data mappings including ANSI 4010A1 835, 837I, P, 276/277, 278, 270, 997, 850, 834 for institutional, professional, and commercial.
  • Efficient in MS Project/MS Excel for planning/status reporting/writing test scenarios.
  • Experience with HIPAA/EDI UB-82, UB-92 and HCFA 1500 claims, and HEDI information.
  • HIPAA Business Workflow Analyst / EDI x12N Consultant for MMIS (Medicaid Managed Care System).
  • Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats
  • Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS (Texas, Maryland, Illinois and Virginia).
  • Experience with Health Level Seven (HL 7) data exchange models.
  • Experience with TriZetto Facets 4.51/4.71 and TriZetto HIPAA Gateway 4.11 - supported new business requirements by extending the functionality of the core Facets system using the Facets extensibility architecture feature.
  • Experience with TriZettos Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
  • Experience with Bluecross, Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12 formats including 270/271, 276/277, 820, 834, 835, 837 to third part vendor applications including NEIC, SSI, ESI, Bluecross, Medicare, and several others using COBOL, Metafile, Visual Basic, Unix, DOS, Assembler, C, FTP, Windows, Novell, and various other communication packages.

TECHNICAL SKILLS

Process/Modeling Tool: Software Development Life Cycle (SDLC), MS Visio, Rational Rose, Rational RequisitePro, Rational ClearQuest, VSS.

Methodology: UML, RUP, Agile, Business Modeling

Databases: MS Access, SQL Server, OracleStandard and Codes HIPAA 4010A1/5010, ICD-10, ICD-9, ANSI X12, HL7, CPT and CMS

Languages: SQL, Java, XML and HTML, Mainframe, .NET

Operating Systems: MS-DOS, WINDOWS 98/2000/NT/XP

Office Tools: MS Office 2003/2000, Word, Excel, PowerPoint, Access

Project Management: MS Project 2000/2003

Testing tools: QTP, Test directorUS Healthcare Claims Processing system Trizetto QNXT, Facets 4.51/4.71

PROFESSIONAL EXPERIENCE

Confidential, Schenectady, NY

Facets Configuration Analyst

Responsibilities:

  • Utilized SDLC Methodology to configure and develop process, standards and procedure
  • Responsible for creating Customized Transaction set using ECM tool
  • Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business workflows & task analysis, and determine whether any current or proposed systems are impacted by the new development efforts
  • Developed and prepared EDI documentation for 834 (Benefit & Enrollment Maintenance) for client processing the 834 transaction.
  • Lead Business Intelligence reports development efforts by working closely with Microstrategy, Teradata, and ETL teams.
  • Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), reporing managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
  • Exposed to using ICD 9/ICD 10/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, reimbursement methodology.
  • Design, development, implementation and roll-out of Microstrategy Business Intelligence applications
  • Paradigm, Chordiant ECM, CRM, Foundation server and workflows, Chordiant Decision
  • Coordinated with various IT teams related to various backends(WGS, Facets, Nasco etc) for Test Data Setup in SIT & UAT environments
  • Designed Test Plans, Scripts after analyzing various scenarios/requirements & performed defect tracking using Test Director & Clear Quest
  • Design EDI Dashboard for encounter data to identify and report errors in terms of graphical representation for accepted and rejected claims.
  • Dealt with ICD 9 encryption to verify and confirm the validity of the incoming claims and documented them by saving it in the database.
  • Performed User Acceptance testing & End to End testing in interaction with Offshore QA/dev teams for various system releases & pushed them to production
  • Provided Production support, documented System Release/deployment issues & SOX documentation for Business Signoff.
  • Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance. Responsibilities include the
  • Analysis of inbound and outbound interfaces and extensions to Erisco FACETS claims processing system
  • Completed Data Mapping for Group and detail Product analysis and report writing
  • Analysis and Design of the Erisco FACETS data model to ensure optimal system performance and tuning
  • Configured facets modules such as Claims, Membership, Billing, Benefit and plan
  • Work closely with EDI to ensure accuracy in data transmissions and shared processes. Transaction sets processed (837P, 835, 834)
  • Involved in claim adjudication process of facets application
  • Responsible for writing the Test Cases and Test Scenarios based on the Functional Specification and technical Specification and documented in Mercury Quality Center.
  • Responsible for Back-End Testing Using SQL Commands using TOAD.
  • Developed SQL queries, functions, stored procedures and triggers to perform the backend testing of the data

Confidential, Boise, ID

Sr. Business Analyst

Responsibilities:

  • Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus.
  • Participated in review and analysis of business requirements, adding additional cases as needed, insuring they are complete and testable.
  • Worked on the requirements Gathering and management of the Medicaid Third Party Health Insurance Feed project.
  • Perform system testing on all EDI transactions both inbound and outbound.
  • While working on requirements of the 835 HIPAA project, jumped half way in the 820 report project, continued working on 835 7 and HIPAA EDI Transactions across enterprise, meanwhile new project initiation of migration began.
  • Initiated with a comparison report of migration of . 270 Eligibility, Coverage or Benefit Inquiry (V4010X092A1) vs.270 Eligibility, Coverage or Benefit Inquiry(V5010X279)
  • Tested the ANSI X12 Version 4010 / EDI transactions (HIPAA) like 270, 271, 276, 277, 837P, 837I, 837D, 835 remittances)
  • Built automated testing routines for the EDI system for NEHEN gateway, SFTP and FTP.
  • Wrote Test scenarios and test cases for testing the migration of EDI and the processing of member enrollment and benefits, batch jobs corresponding to the claims(837) and real time transactions like 270/271/276/277
  • Did the forward and reverse data mapping between the fields in mainframe and QNXT.
  • Tested the changes for the front end screens in QNXT related to following modules, test the QNXT batches (member load, Billing, Provider, etc).
  • Worked with HIPAA Team for RIMS Companion Guide of X12 ANSI 270/271 and 276/277 Companion guides for Professional and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving 837 HIPAA compliance and 835 Remittance Advice.
  • Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
  • Analyzed the front end Customization requirements on QNXT applications(Member, Group/Subgroup application, Member maintenance, etc)
  • Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, plan codes, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system (AIM) to QNXT.
  • Did gap analysis for HIPAA P and 835 transactions and HIPAA P and 835
  • Involved in impact analysis of HIPAA and 837P transaction sets on different systems
  • Performed GUI testing, Integration testing, Regression testing, Ad -hoc testing, Negative testing, End to End testing, Smoke testing Load testing, User Acceptance testing and Pilot testing
  • Wrote Test Scenarios, Test cases in excel sheet and imported them to Rational Manual Tester/Test Manager
  • Logged defects in Rational Clear Quest, re-tested defects, analyzed defect with Users and Developers.

Confidential, Phoenix, AZ

Sr. Business Analyst

Environment: Test Director, Sharepoint, Oracle 9i, Java/J2EE, MS Visio, Toad, DataStage, cognos, facets 4.31.

Responsibilities:

  • Used the Agile methodology to build the different phases of Software development life cycle.(SDLC)
  • Experience with Health Insurance Packaged Application like Facets. Providing US Health Insurance domain and TriZetto’s FACETS (version 4.31) and QNXT 3.2 system training and mentoring to other internal Business Analysts and Entry level fresher’s including knowledge of conversation from earlier versions of FACETS to version 4.31. Extensively worked with Trizetto QNXT QConnect.
  • Came up with methods to reduce risks of releasing new upgrade to the system in production by doing a controlled of new features (upgrades).
  • Met with users and stakeholders to understand the problem domain, gathered customer requirements through interviews (group and one-on-one) along with JAD sessions.
  • Identified the issues and done gap analysis with existing and current RDS Extract system for Reconciliation process. Dealt resolving issues with member attributes, enabling multiple rules associated with member lookup process in QNXT.
  • Responsible for working with the State to review and modify process flows to increase productivity and effectively utilize QNXT features not provided by the legacy systems.
  • Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in QNXT.
  • Resolved issues like member duplicated in file, dealing with dependent transaction if subscriber is not found, failures in submissions in QNXT.
  • Researched the CMS website and helped business team in formulating business rules.
  • Developed BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional using RequisitePro and Rational Rose to create/maintain: Use Cases, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams.
  • Worked with EDI team, developers and production support team at various stages of the project.
  • Worked with Claims, enrollment, eligibility verification for members and providers, benefits setup, and backend payment cycle in facets.
  • Data mapping, logical data modeling, used SQL queries to filter data within the Oracle database tables
  • Experience with HIPAA compliance and CFR Part 11 electronic exchange guidelines.
  • Experience with 21CFR Part II code of federal regulation, which deals with electronic records and electronic signatures along with HIPAA compliances.
  • Analyzed and tested various Common Eligibility Outbound Interface Process and other Inbound/Outbound Facets interfaces.
  • Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application.

Confidential, Groton, CT

Sr. Business Analyst

Environment: MS Office Tools, MS Vizio, Oracle Analytics, Siebel Clinical, Java, JSP/Servlet, Requisite Pro, Rational Rose, ClearCase, Business Objects 6.5, System Architecture, Brio 6.

Responsibilities:

  • Studied the old base and new Oracle Analytics data elements and provide a mapping from the existing legacy system.
  • Used the Agile methodology to build the different phases of Software development life cycle.
  • Met with report users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews (group and one-on-one) along with JAD sessions.
  • Involved in understanding the current business process, defining scope of the project along with position statement.
  • Responsible for creating business work flows and processes and creating management reports based on the analysis.
  • Validated business rules and all artifacts with users, approval and sign off.
  • Wrote Use Cases, prepared use case diagrams (using Rational Rose & UML) and followed Agile at every stage of the process
  • Applied Unified Modeling Language (UML) methodology to create use case diagrams and sequence diagrams in Rational Rose.
  • Produced functional specifications and led weekly meetings with developers and business units to discuss outstanding technical issues and deadlines that had to be met.
  • Created use-case scenarios and storyboards in MS Word and MS PowerPoint for better visualization of the application.
  • Assisted Design Team in preparing SRS, Software Design Document (SDD), User Interface Design, designing of Application Architecture & Database Modeling. Followed the UML based methods using ReqisitePro and Rational Rose to create/maintain: Use Cases, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams.
  • Coordinated with data architects and ETL team to understand/drill down on the datamart requirements. Came up with the plan to roll out datamart development efforts in different phases, coordinated efforts to analyze the datamart requirements between teams responsible for various source systems, scoped out the work required on behalf of different teams to adhere to the interface documents to provide data to the data-marts.
  • Led the testing efforts of the datamarts in development, coordinated moving/setting up of processes in dev/production. Worked with QA team and UAT team to go over the various test scenarios for different types of loads in the datamarts.
  • Documented the evaluation of various reporting tools like Oracle Analytics/Business Objects, made recommendations about the product depending on the reporting requirements.
  • Worked with the reporting team to understand the capabilities of Business Objects. Demonstrated these capabilities to the business users, conducted one-on-one and group sessions to educate the business users on various reporting capabilities of Business Objects. Worked with vendor teams like Oracle/Business Objects to resolve various issues with being faced by development teams.
  • Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.

Confidential, Atlanta, GA

Business Analyst

Environment: Java, JSP/Servlet, Oracle 9i, MS Office Tools, Windows XP, MS Project, RequisitePro, Rational Rose, ClearCase, MS Powerpoint, MS-SharePoint, MS-Word, MS-Excel, Business Objects 5.1/6.5, Informatica 7.1, IBM Process Modeler, Siebel CRM, Facets 4.21/4.31

Responsibilities:

  • Utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
  • Met with report users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews (group and one-on-one) along with JAD sessions.
  • Involved in understanding the current business process, defining scope of the project along with position statement.
  • Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional requirement.
  • Implemented automated COB processing of Medicare claims into Facets
  • Validated business rules and all artifacts with users, got approval and sign off.
  • Followed Unified Modeling Language (UML) methodology using ReqisitePro and Rational Rose to create/maintain: Use Cases, Activity Diagrams, Sequence Diagrams, and Collaboration Diagrams.
  • Tested and delivered Inbound/Outbound Facets interfaces.
  • Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
  • Assisted Design Team in preparing SRS, Software Design Document (SDD), User Interface Design, Application Architecture & Database Modeling.
  • Helped in project testing efforts for doing integration tests, regression tests and user acceptance tests.
  • Worked on Data mapping, logical data modeling, used SQL queries to filter data within the Oracle database tables.
  • Made sure that the systems complied with the rules of HIPAA and CFR Part 11.
  • Documented the dimensional models of ETL system.
  • Led the testing efforts of the datamarts in development, coordinated moving/setting up of processes in dev/qa/production. Worked with QA team and UAT team to go over the various test scenarios for different types of loads in the datamarts.
  • Used SQL to test various reports and ETL load jobs in development, QA and production environment

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