SUMMARY

• Over 7 years of experience in the IT field as a Business/System Analyst with a thorough knowledge of Software Development Life Cycle (SDLC) and RUP including requirement capture, analysis, design and development.
• In - depth knowledge of business processes in Healthcare industries.
• Experienced in Business Requirements gathering and managing, Risk Analysis, Gap Analysis, Feasibility Studies, and UML Modeling.
• A result oriented enthusiast, with highly developed planning, analytical, technical communication, decision-making and leadership skills, driven with the ability to multitask and deliver effectively, in a fast-paced environment.
• Served as Product Owner developing and prioritizing User Stories in SCRUM.
• 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)
• Six Sigma Green Belt Certified (SSGBC).
• Managed Product Backlog and provided guidance and information as required for completion of Sprints, and jointly managed Burn Down Charts with SCRUM Master.
• Coordinated and documented SCRUM Reviews and Retrospectives.
• Strong knowledge of managed claims management process, Knowledge of Medicaid and Medicare Services. CMS, Health Assessment Systems, Hl7 Standards, HIPAA, PPACA(Patient Protection and Affordable Care Act), Compliance issues, LO INC and SNOMED Mapping, HL7 Message Validation, ICD 9, Electronic Health Records, Electronic Medical Records.
• Extensive experience in GAP analysis of 4010-5010 conversion using implementation guides and companion guides.
• Worked on various projects that included enhancements from QNXT 4.8 to QNXT 5.0.
• Worked on configuration of QNXT 5.0 for New Line of Business.
• Extensive experience in identifying core business process, identifying risks, creating systems requirements specifications. Ability to comprehend and document business process in models and documents using Rational Tool Suite and other documentation/modeling tools.
• Worked on all the environments of QNXT which includes the Test Environment, Development Environment and Production Environment.
• Strong working experience with Data Warehousing tools like SSIS, SSRS, Informatica and Cognos.
• In depth knowledge of ICD-9-CM, ICD-10-CM/PCS structures and format and the differences between them.
• Involved in JAD, walkthroughs and various meetings with the stakeholders of the project including technical users in order to design complete and detailed documents such as Business Requirement Documents, Functional Requirement Documents, Use Case Diagrams and Activity Diagrams.
• Experience inExtracting, Transforming and Loading (ETL)data from Excel, Flat file, Oracle to MS SQL Server by usingBCP utility, DTS and SSIS services.
• Evaluated and analyzed the current business models of a company; performed GAP Analysis; generated “AS IS” and “TO BE” process flows.
• Clear understanding of testing concepts and hands on experience writing test cases, test plans and planning test strategy using testing tools like Quality Center.
• Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI) in 4010 and 5010 formats.
• Involved in claims submission and payment (remittance) retrievals and used HIPAA X12N 820 for the inbound premium payments.
• Expertise in creating SQL Queries for business analysis.
• Experience in using requirement management tools, such as IBM Requisite Pro, HP Quality Center.
• Excellent communication and analytical skills with strong problem-solving capabilities to interface with end users, business representatives and development teams.

TECHNICAL SKILLS

Requirement Management Tools: Test Director (Quality Center), Requisite Pro

Business Modeling Tools: Rational Rose, MS Visio

Programming languages: C, SQL, UNIX shell scripting, VB Script

RDBMS/Data base: ORACLE 9i/10g, MS Access

Operating Systems: Windows 2000/XP/ME/VISTA

Management skill: Risk management, SDLC, UML

PROFESSIONAL EXPERIENCE

Confidential, Phoenix, AZ

Sr. Facets Solution / Business Systems Analyst

Responsibilities:

• Involved in configuration of FACETS Subscriber/Member application.
• Worked on FACETS Data tables and created audit reports using queries. Manually loaded data in FACETS and have good knowledge on FACETS business rules.
• Performed data mapping and data modeling and used canonical data model to map data from X12 834 transactions.
• Did the forward and backward data mapping between the fields in mainframe and FACETS.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Tested the changes for the front-end screens in FACETS related to following modules, test the FACETS batches (membership).
• Re-engineering and capturing of transactions with legacy systems Enrollment -834 .
• 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 (Amysis) to FACETS (Client Server based system).
• Provided support to full Software Development Life Cycle, testing, training and implementation.
• Analyzed the functional details of various modules in mainframe and did the GAP analysis with the new system.
• Developed logical & physical modeling as per business requirements.
• Responsible for working with the State to review and modify process flows to increase productivity and effectively utilize FACETS features not provided by the legacy systems.
• Assisted QA team in Preparing Test cases.
• Conducted Integration tests and User Acceptance Tests.
• Organized, managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 - 834 formats to meet HIPAA requirements set forth by the federal government

Confidential, Tampa, FL

Sr. Business Analyst

Responsibilities:

• Experience in EDI (270,271,835,834,837) transactions.
• Create back end data loads through Access to upload tables into Facets system.
• Working on two state base exchanges that are Kentucky and Idaho. For KY I am the point of contact from Confidential .
• Managing membership with these two states.
• Wrote requirement documents like BRDs, FSDs, process flow, and inbound/outbound 834,820 and 864 and Gorman mapping.
• Research Confidential system, inbound/outbound 834,820,864 EDI files in case of any issue/discrepancy with one or multiple members.
• Worked with Agile methodology.
• Involved in testing Membership Enrollment in QNXT.
• Touch base with state point of contacts if we need any information/confirmation from State Exchange.
• Working on recon process for membership from state exchanges of KY and ID.
• Define and document EDI business process requirements
• Map flat files to X12 documents using ProEDI.
• Involved in Logical & Physical Data Modeling. Database Schema design and modification of Triggers, Scripts, and Stored Procedures in Sybase Database Servers.
• Reduced costs of labor by implementing QNXT.
• Developed an implementation guide for Partners for EDI X12 transactions such as 834, 835,837,270 and 271.
• Worked on data modeling and produced data mapping and data definition documentation.
• Involved in testing claims/Financial management in QNXT.
• Prepare test Data sets and performed data testing using the PL/SQL scripts. Also used MS excel for data mining, data cleansing, data mapping, and data dictionary and data analysis.
• Performed data analysis on the existing data warehouse's of AFS, ACBS and info lease.

Environment: QNXT, SQL Server, .NET, Cognos, Windows XP, Rational Rose, Rational Requisite Pro, Clear Case, Clear Quest, UML, Rational Suite, Java, MS Visio, MS Project, MS Office MS Access, XML.

Confidential

Sr. Business / EDI Analyst

Responsibilities:

• Analyzed and optimized the process. Converted Business Requirements into Functional Specifications and Technical Specifications using Rational Requisite Pro.
• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Involved in configuration of FACETSSubscriber/Memberapplication.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA 5010 code sets, ICD-9, ICD 10 coding and HL7.
• Authored functional specifications for different HL7 system interfaces: ADT (registration), SIU (scheduling), OMG (rad order entry), and ORP/RDS (Rx processing).
• Designed, developed, and implemented innovative & sustainableTableau reports. Supported effective rollout of reports, including training collateral.
• Experience with Trizetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Worked on HIPAA Transactions 270, 271, 276, 277,834, 835 and 997.
• Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Tested, Cleaned and Standardized Data meeting the business standards usingFuzzy /exact lookupsusingSSIStransformations.
• 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 (Amysis) toFACETS(Client Server based system).
• Responsible for Back-End Testing Using SQL Commands using TOAD.
• 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).
• Responsible for positioning and delivering QlikView projects and cross building applications into new and existing customer base.
• Developed gap analysis and risk assessments for theFACETSupgrade project including effects on internally developed extensions and third-party software for pricing and contract configuration.
• Understanding of Trizetto’s core Facets product and knowledge of using Facets Data Dictionary.

Confidential, Phoenix, AZ

Business / EDI Analyst

Responsibilities:

• Data mapping on Enrollment Module (EDI 834) ofFACETS.
• Strong knowledge of Affordable Care Act (ACA) and Detail understanding of ICD9/ANSI/HL7 to ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of thehealthcareindustry.
• Verifying, validating and routing the X12 834, 5010 enrollments, confirmation/effectuation, cancellation, and termination information from the enrollment systems to the exchanges in the format required by the recipient system.
• Gathered the Requirements for Medicare, Medicaid Systems as part of Patient Protection Affordable Care Act (PPACA).
• Configured and maintained of Facets and other application software products, such as Claim check,Facets
• Workedwith different lines of business to understand theACAand HIXpolicies and developed a process to implement them from IT perspective by developing necessary artifacts.
• Expertise in iterative approach of AGILE development with all the team’s members.
• Experienced in testing EDI and HIPAA Transactions 837, 835, 820, 276, 277, 278,270.271 code sets testing in Health Insurance.
• Involved in all phases of Software development life cycle (SDLC) using Agile Scrum methodology.
• Facilitated User Acceptance Testing (UAT) with the stakeholders and the business users, and the errors discovered were fixed and then verified via regression testing.
• Involved in Change Control Management and Configuration Management.
• Cancellation and termination for On-Exchange and Off-Exchange using Edifecs Transaction Manager.
• Validated EDI X12 files for Conjecture (CNX) and Center for Medicare System (CMS) using IngenixClaredi and manually edited and fixed the errors to make it error free and ready for processing.
• Thoroughly analyzed EDI raw data for transactions (834) in the 5010 formats to verify the changes as per the 5010 formats.