SUMMARY

• Over 15 years of IT Experience with an emphasis on Business & System Analysis, Software Testing End to end, and Maintenance including 7 years of Operational experience in EDI application support.
• Expertise on Legacy systems, Client - Server and Web Applications.
• Extensive Experience in Commercial & MEDICAID Health care arena in following areas Fiscal Intermediary Shared Systems (FISS) Claims Processing, Common Edit Module (CEM) Front end edit processing including all HIPAA Transactions.
• Requirement's gathering with extensive analysis for both mid-scale to large scale system development projects.(Including but not limited to Gateway Reengineering).
• Proficient skills and noledge related to testing (System & Integration Testing, Regression Testing, UAT, Functional Testing and Volume Testing, Creation and execution of test matrix for both internal and external users).
• Extensive experience in EDIFECS/Specbuilder, Cognos, Informatica, Infosys CMS, FTP SFTP, Mercator, Amisys, Pro32, Quality Center (QC), SQL query Management Practice Systems (MPS), GP.Net, TSOG (IBM Mainframe applications).
• Proficient experience in handling On-Call support production support.
• Extensive noledge of HIPAA Standards and Security.
• Extensive noledge of 5010, ICD-10, Centers for Medicare Medicaid Health Benefit Exchange.
• Proficient experience with interacting with trading partners and creating standard specifications for various inbound and outbound transactions using ANSI X12 4010 and 5010 standards.
• Extensive experience in EDI transactions 837I/P, 835, 834, 820, 278, 270/271, 276/277, 999A/E, 277CA & TA 1.
• Experienced in Data Analysis Techniques & Data Management Tools (MS Excel, SQL & Relational Databases)
• Excellent root cause analysis, advised options, risks, cost benefit analysis and impact on other business processes and system priorities to clarify interdependencies, to ensure systems traceability of projects are accurate.
• Experience with CAQH certification
• Strong analysis, coding and design skills.
• Excellent documentation and PowerPoint presentation skills
• Highly advanced written and oral interpersonal communication skills, PC skills and problem-solving skills.
• Proficient experience as Client management liaison for Provider Services, Provider Contracting and Reimbursement, Project management functions, managing multiple projects simultaneously and working with Developers / Testers via onsite and or offshore business models.
• Over 15 years of consistent, excellent Customer Service/ Advocate Skills

PROFESSIONAL EXPERIENCE

Confidential

Sr. Core System Business Analyst

Responsibilities:

• Troubleshooting cose system (IDX) errors for Business Units (Claims, Benefits, Medical Management, Pharmacy)
• Testing specs for the systems that interface with IDX
• Modification, Updating, Adding Creating Rules for Rule Banks
• Modification, Updating, Adding Creating various Dictionaries
• Facilitating meetings with both internal/external customers
• Review current productions processes, and ensure documentation exist and is current with updates and versions.
• Review current manual process to automate by replacing manual touch points with job scripting and scheduling.
• Support business critical projects through the system development life cycle
• Modify and maintain rulebanks for IDX (GE Centricity)
• Maintain Dictionaries (Provider. Employer)
• Implementation of New Document Generation Solution (Napersoft)

Confidential

Sr. EDI & SharePoint Programmer Analyst

Responsibilities:

• Troubleshooting test and production issues for EDI and proprietary transactions
• Point of contact for Centers of Medicare/Medicaid (CMS) regarding the Edge Server
• Attend weekly CMS Edge server calls and work groups, communicating to upper management any issues that may require action
• Responsible for all Preferred Provider Group (PPG) onboarding and testing
• Requirements gathering for both internal and external customers relating to service requests
• Managed communications between application users and vendors reporting to provider representative as needed
• Review current productions processes, and ensure documentation exist and is current with updates and versions.
• Review current manual process to automate by replacing manual touch points with job scripting and scheduling.
• Support business critical projects through the system development life cycle
• Remediate EDI processes to send and receive X12 file formats which contain ICD10 codes by the compliance date 10/1/15. Complete testing with inbound and outbound trading partners. Support the enterprise ICD10 project

Confidential 

Sr. Enrollment Accounting EMPO Business Analyst 

Responsibilities:

• Create Business Requirement Documents (BRD's)specific to Medcaid/Medicare 834 (Enrollment)
• Create and update Test Case Scenarios specific to Market Place Exchange for several states including but not limited to OH, FL,MI,
• Gather and document Business requirements specific Subject matter Expert for Enrollment projects
• Facilitated project review walkthroughs
• Identified interfaces that need to be standardized and consolidated with timeline (immediate, future).
• Participated in weekly conference calls with corporate Business Intelligence team to improve reporting functions
• Gathered all impacted HL7 field information of each applications in to Impact Analysis document.
• Tested the Business test case scenarios specific to 834 transactions.
• Prepared GAP analysis, impact analysis, migration documents of the assigned application.
• Collected purchase orders from applications to halp remediate all project related activities and submitted it to the legal team for approval.
• Managed communications between application users and vendor and contacted application vendor as needed.
• Raised change request and participated in Change Management as required (To perform testing on the production).

Confidential

Senior EDI HIPAA 5010 CEM FISS Business Analyst

Responsibilities:

• Interpretation of CMS guidelines, mandates and quarterly updates for front end edits
• Subject Matter Expert for Common Edit Module (CEM)
• Analyze Medicare/ Medicaid requirements to effectively create ANSI 5010 transaction.
• Gathering business requirements, per CMS change requests for 837 me/P, 276/ CA
• Create test case scenarios that meet CMS guidelines as swell as creating fixes for code when issues arise.
• Troubleshooting CEM edit issues to resolution.
• Review and monitoring of test cases with in Quality Center.
• Review CMS requirements on a daily basis, including but no limited to monitoring ECHIMP for updates, changes, modifications to CR's (Change Requests).
• Participate in EIC or 3 and 5 day sessions, system related walkthroughs inquiring, documenting questions providing comments as needed.
• Determine appropriate level of testing needed for each CR.
• Perform CR analysis necessary to develop accurate, testable test scenarios.
• Develop and maintain High quality Test Scenarios within Quality Center.
• Work closely with seasoned testers for developing the detailed Test Procedures and Test Case Specifications.
• Develop and maintain test documentation including Test Scenario Specification, Test Plan, and Test Case Specification.
• Conduct BA/Tester meetings with Testers to present the test scenarios and answer questions.
• Support defect management life cycle resulting no unresolved issues before implementation.
• Attend (facilitate within STCCEM) POC review twice weekly including analysis and research of and distribution of POC drafts among delegated team members.
• Contribute towards internal Software Quality Assurance Processes.

Environment: FISS production and beta testing, Soap UI, Quality Center, Sharepoint, .