SUMMARY

• Highly skilled and professional Sr. Business System Analyst with 7+ years of specific experience in the field of Healthcare
• Extensive knowledge of all phases of Software Development Life Cycle methodologies like Agile, Iterative Software Development andWaterfall Processes.
• Extensively worked on Pharmacy Benefit Management and Switch Vendors in the pharmacy claims cycle.
• Efficiently managed CDM to ensure correct billing and reimbursement
• Experience in Requirements Elicitation: BRD, FRD, Use Cases, User Stories,EPICS, Acceptance Criteria and Data Scenarios.
• Serves as liaison between the client and Development Team.
• Responsible for gathering, analyzing, and documenting Business and Functional Requirements Documents in compliance with HIPAA and FDA mandates.
• Thorough knowledge of object oriented analysis and design using UML diagrams such as Use Cases, Class Diagrams, State Diagrams and Flow Chart Diagrams.
• Experience withcompliant (e.g. HIPAA, 21 CRF Part 11) processes and operations development, Medicare and Medicaid
• Experiencedin conducting and facilitating interviews, shadowing, brainstorming and JointApplication Development (JAD), Joint Application Requirement Capturing(JAR) sessions for Requirement Analysis, AS IS, Risk analysis, Adaptability and Feasibility Studies with various stakeholders to identify business critical and high - risk areas of the application.
• Experience in verifying EDI raw data of 837 transactions as per HIPAA based transactional 5010 formats and mandate.
• Excellent working skills in FACETS and Claims Adjudications
• Extensive experience in Gap analysis of HIPAA 4010 to HIPAA 5010 conversion using the implementation guide and companion guide of EDI transactions (EDI 837, EDI 835, EDI 834, EDI 820, EDI 270/271)
• Good knowledge of ICD 9- CM, ICD 10-CM structures and differences
• Sound experience in conducting Impact Analysis to migrate from ICD-9 to ICD 10 on the key business process and key application system like Claim Processing, Payments, and Reporting in the healthcare industry
• Goaloriented professional with superior analytical, communication,presentation skills, excited and motivated to learn new technologies

TECHNICAL SKILLS:

• Business Modeling Tools
• MS Visio/Visible Analyst, PBM
• Processes
• BPMN, Agile, Waterfall.
• Requirements Management
• IBM DOORS, JIRA
• Data Modeling
• UML, DOORS, JIRA.
• Change Management
• Management
• Rational ClearQuest
• MS Office Suite, MS Project, Excel
• Databases
• SQL Server
• Data Quality
• IBM Infosphere
• Testing
• Claims Adjudication
• ALM/QC,ClarEDI, Qualys
• Facets

PROFESSIONAL EXPERIENCE

Confidential, Newark DE

Business System Analyst/EDI Analyst

Responsibilities:

• Developed the scope and the vision document to define the primary goals, objectives & scope of theproject(Hesnson Pharmacy Claim Process System)
• Efficiently process CDM requests received from Managed Care and Patient Accounts, researching references and regulations to ensure correct coding/charging through the CDM.
• Maintains and monitors CDM so that it does not go out of date and does contain current procedures, services and products to efficient billing system.
• Effectively review/identify/analyze necessary CPT changes related to quarterly and annual AMA CPT updates and regulatory changes by timelines set.
• Performed Gap Analysis, requirements analysis, impact analysis and validate requirements.
• Extensively interacted with key stakeholders, SMEs, Development teams to finalize Business Requirement Document as in conjunction with CMS and FDA compliance and HIPAA regulations
• Ensure the CDM is accurate and compliant with federal, state, and payer regulations. Managing time effectively, performing tasks accurately and meeting set timelines.
• Enhanced the Pharmacy Billing and Claims processing through PBM and Switch vendors and POS services for claim adjudication
• Performed Data Mapping and tested HIPAA EDI 5010 X12 mapping formats (such as 837,277,999, 835, and 834) as well as other industry standard and custom formats using ETL tools.
• Processed Claim Life Cycle with FACETS to facilitate,validate and expedite claims adjudication.
• Worked on HIPAA 5010and maintain all ANSI X12 formats (277, 837, 835, etc.) in the EHR to ensure billing and cash posting is correct.
• Created and managed Business Requirement Document(BRD), Functional Requirement(FRD) User Stories and Use Cases from requirement elicitations(Interviews, Brainstorming, Shadowing and JAD)
• Responded to inquiries regarding EDI, DAW and POCissues with enrollment, claims, payments, and/or clearinghouse activities.
• Conducted analysis of EDI transactions and documented reports after FACETS encounter processes provided adhoc queries for reports
• Performed research and analytical role related to the claims adjudication system and internal processes.
• Worked on Medicare Advantage(ABC) Medicare part D, Medicaid Options (Under 65 and over 65) Managed Care(Diseaseand CaseManagement,Insurance Regulations and Claims Processing and Claim Scrubbing in HMO, PPO, Medicare and Medicaid)
• Ensure that CMS Revaluations are compiled and HCPCS Coding verification requirements modifiers are adequately applied to eliminate claim denials during adjudication
• Documented the Business and Functional requirements for designing the Billing System e.g. Cash management, Point of Sale (POS) module to enhance the encrypting standards that are required for the application
• Performed complete reconciliation of Explanation of Benefit (EOB) and Explanation of Payment (EOP) and check remittances received from Managed Care contracts and send ICD-997/999 Functional Acknowledgment.
• Validate the Business- to-Business(B2B) data exchanges between partners and validate the internal processing of Maintenance Management Information System(MMIS) or other transaction processing system through NCPDP Telecommunication VD.0 (835), PBM and Switch Vendors based on FDA approval.
• Managed, owned the BRD and track development processes through Requirement Traceability Matrix.
• Worked as an Interface between business users, testers and application development teams so that all users understood business needs and value
• Involved in Incident Reporting and Change Control procedures to track changes during the development phase of the project

Environment: Waterfall/Agile, SQL Server 2012, MS Office (Word, PowerPoint, Excel), MS Visio, SharePoint, HP ALM/QC, JIRA

Confidential, Newark DE

Business System Analyst

Responsibilities:

• Performed Gap Analysis to evaluate the current state and future state and offer solutions to bridge the gap.
• Assisted in the definition of done and the roll out of product roadmap (Spring Goal) across multiple releases by working with Product Owners and Development teams.
• Planed and facilitated internal functional design sessions involving both business and technical resources through wireframes, documenting business rules and created high-level interface designs.
• Serves as an escalation point to research and resolve data anomalies and mapping them to company requirements.
• Led Sprint review sessions with both internal and external stakeholders and critically evaluate the Incrementfrom multiple sources to develop logical recommendations.
• Assisted Product Owner to create and prioritize User Stories to create value for users.
• Often times serve as coordinator within the team as a Scrum Master Certified. (SMC)
• Led User Acceptance Test (UAT) before the go-live of the product
• Coordinated in conjunction with the Product Owner the overall timeline and operational readiness tasks for Sprint releases

Environment: Agile/Scrum, Waterfall, SQL Server 2012, MS Office (Word, PowerPoint, Excel), MS Visio, SharePoint, HP ALM/QC, JIRA

Confidential, MD

Program Planning and Evaluation Manager

Responsibilities:

• Spearheaded development of county diabetes registry to facilitate disease management and surveillance
• Promote healthy lifestyles by researching, creating and leading numerous programs across diverse population.
• Identify and increase participation of target minority ethnic populations for diabetes management from 30% to 55% within 3 months of engagement.
• Worked and coordinated care management system to streamlining workflows, prioritizing daily tasks for care team members in a predictive way, and steering activity to the areas that positively influence the patient lives in the most efficient way.
• Worked in conjunction with Clinical Application System to monitor patient recovery and movement within Provider Facilities( HL7 & ADT messages, Passport, LYNZ E-Point, LYNZ I-Point)
• Assisted in the implementation of Medicaid/Medicare and Dental enrolment services
• Engaged in HIPAA implementation and auditing of healthcare claim adjudication.(EDI- 837, 835, 834, 270/271)
• Researched diabetes health related problems and formulated pragmatic policies to address them.
• Promoted smoking cessation outreach programs from 20% to 50% within 6 months of engagement. among cross-functional demographics.
• Developed diverse outreach materials for health promotions such as flyers, brochures and PowerPoint presentation for tobacco cessation programs.
• Gathered primary data, reviewed and analyzed child fatalities in Washington County within 1 month for the Fatality Review Committee.
• Monitored and evaluated outcomes of the diabetes registry and recommendations for its adoption by the Health Council of Washington County.
• Developed and implemented Individual Personal Goals, counseling services for behavior modification and community integration plans for physically and mentally challenged residents.
• Delivered health education on issues of safe sex, smoking cessation physical activities and behavioral risk factors.
• Offered crisis interventions management to vulnerable clients to prevent intentional harm and ensure residence safety for DDA programs.
• Provided strategies and awareness among the staff for teamwork, efficient communication channels and good work ethics.

Environment: Waterfall, Agile/Scrum, SQL Server 2008, MS Office (Word, PowerPoint, Excel)