SUMMARY

• Extensive experience in strategic planning, product development and technology implementation.Demonstrated ability to make immediate improvements relating to internal and external reporting, efficiency and internal controls.
• Led and worked with diverse teams of business and technology professionals to design workflows, networks, system protocols and capacity planning equations.
• Thrive on complex projects with tight deadlines. Strong troubleshooting, and follow through qualifications with ability to manage and prioritize a variety of projects.
• 7+ years of extensive experience as a business analyst with strong experience in Healthcare Insurance claims and Insurance claims with a solid understanding of Business Process Flows, and Business Analysis. Detail - oriented and good documentation and process management skills
• Extensive practical knowledge of various SDLC methodologies like Waterfall, Rational Unified Process, Agile and Scrum.
• Extensive experience in gathering Business and Functional Requirements, performing Gap Analysis and Impact Analysis.
• Experience in developing UML use case diagrams, Work Flow Diagrams using tools like MS Visio.
• Excellent Business writing skills in creating Business Requirement Document (BRD), Use Case Specifications, Functional Requirement Document (FRD), and System Requirements Specifications (SRS).
• Effective problem solving skills - ability to think out of box and give solutions that are feasible under given circumstances.
• Created and managed change requests using Change Management Process and conducted feasibility analysis for those changes.
• Experience working with HIPAA ANSI X 12 4010/ 5010 270/271 , 276/277, 834, 835, 837 for institutional, professional and commercial claims, and up-gradation of ANSI 4010 to ANSI 5010.
• Excellent understanding of ICD 9, ICD 10, HCPCS, and CPT Codes.
• Functional experienced in Claim Life Cycle and Health Care Payer domain process along with various line of health insurance system like PPO, HMO, POS.
• Strong work experience of Medicaidand Medicare Part A, B, C and D (Medicare Prescription Plan).
• Gained extensive knowledge and understanding of PPACA, MITA, MMIS, Electronic Medical Health Record (EMHR) and Pharmacy Benefit Management (PBM).
• Experience working on Web Portal Projects and worked with Facets team on different modules like Claims processing, Claim Pricing, Provider network management and Reporting.
• Proficient in Developing and executing Test Plans, performing functional, usability testing and ensuring that the software meets the system Requirement.
• Experienced in working with QA testing teams, while interacting with business users and gathering user’s requirements to develop necessary Test plans, Test Cases, Test script and assisted the QA team in UAT.
• Performed Data mapping in XML, performed data analysis with SQL Queries

PROFESSIONAL EXPERIENCE

Confidential, Milwaukee, WI

Sr. HIX Business Consultant/Sr. Business Analyst

Responsibilities:

• Facilitating the Enrollee Satisfaction Survey Vendor Contracting Oversight, Health care issuer Accrediting Entity Management, Health Plan Issuer Accrediting Verification for the FFE Quality Team
• Developing Health Plan Issuer Accreditation Mapping to Qualified Health Plan (QHP)
• Participating in workshops and update meetings with Insurance carriers
• Facilitating the requirements sprints for the FFE Financial Management Team and Advance Premium Tax Credit (APTC).
• Conducting Claim/Encounter Management, claim data collection, claim quality check, and filter claims for Risk Adjustment.
• Facilitating Cost Sharing Reduction (CSR) Reconciliation and reporting, Federal Exchange, Qualified Health Plan (QHP) User Fee, Risk Adjustment Claims processing, Risk Adjustment Factor calculation, Risk Adjustment Annual Issuer Charge and Payment, Risk Adjustment reporting, Risk Adjustment User Fee, Reinsurance Contribution (Issuer, State and TPA), Reinsurance Quarterly payment calculation and reporting.
• Conducting Stakeholder Analysis.
• Facilitating Health Insurance Form Filing requirement sessions.
• Developing Preliminary Business Object Model for Health Insurance Form Filing, Requirement Document for Health Insurance Form Filing and Preliminary Business Process Model for Medical Loss Ratio (MLR) CD Administration.
• Write and maintain project requirements, facilitated meetings, built business and system flows, managed defects and wrote test scripts and use cases.
• Responsible for providing Business Requirement Document (BRD) and Functional Requirement Document (FRD)
• Creating of Business Process Workflow Diagrams with Stakeholders throughout the Business System Development Life Cycle (SDLC), to create the provider portal which allows providers to access patient information to increase convenience.
• Involved inrequirements gathering sessionswith Business Analysts and Architects tounderstand requirements in terms of business change.
• Successfully using Scrum Analysis Model (Agile) for gathering requirements by facilitating Use Case Workshops and sessions.
• Providing subject matter expertise for the implementation of Health Exchange Business Process with a special focus on Medicaid Integrated Eligibility, Plan Management, SHOP/SHOPPING, and Financial Management Business domains.
• Following the Agile scrum SDLC (System Development Lifecycle) methodology, Validated QHP Benefits, Rates, Network Adequacy, Essential Community Providers, Prescription Drugs and Service area Information with their templates for data submission by insures.
• Validating system requirements for the Certifications, Accreditations and Attestations of Insurance Carriers and system integrations with the Department of Insurance (DOI). The SERFF system and the CMS-HHS Federal Hubs.

Environment: Share Point 2010, Industry Print 5, MS Visio 2010, SQL

Confidential, Atlanta, GA

Sr. Systems Analyst

Responsibilities:

• Gathered requirements from claimsbusinessarea,
• Identified the scope, business objective and documented the functional requirements for each release
• Gather requirements at JAD sessions with the purpose of defining the functional business and system requirements.
• Wrote clear, concise and detailed System Requirements Specification (SRS)documents and user documentation in accordance to guidelines and standards of a level where developers can interpret and design and develop the application with minimum guidance
• Prepared process flows and diagrams for the project.
• Performed gap analysis for HIPAA 4010/4010A - 5010 conversion - Involved in the documentation of HIPAA 5010 changes to EDI 837/835transaction.
• Performed gap analysis ofICD9toICD10conversion for procedure and diagnosis codes in accordance with the HIPAA compliant.
• Developed cross-walk for understanding major changes from ICD-9 to ICD-10 versions. Some of the changes included in Loop 1000A (Submitters contact information), Loop 2000A (billing), Loop 2000B (Claim filing Indicator code) etc.
• Followed Agile methodology concepts,responsible for writing user stories for requirements and discussed release sprints withbusinessand obtained sign offs on the documents.
• Worked with Database team, involved in writing SQL queries, extracting data, creating modifying tables, functions procedures.Reviewed primary objects like Views, Indexes, Store procedures, Functions based onbusinessrequirements and physical constraints.
• Extensively worked with SME to better understand the existing claim processing
• Planned, Planned, prepared, facilitated, documented and assessed meetings with the management and the development team to better understand the Business Requirement such that the project can be completed quantitatively and qualitatively.
• Worked alongside with HIPAA-5010 change management team to analyze and define changes which supported the process of developing business and technical requirements within and across transactions.
• Directly involved in process improvement Plans and implementing business change, creating and managing Project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Used MS-Visio to create Data Flow Diagrams as a Structured Analysis tool.
• Created and assisted in creation of Business flow diagrams, Activity/State diagramsandSequence diagramsso that the development team and other stake holders can understand the business process..
• Worked alongside the QA team and Developer to establish traceability matrix to ensure the completeness of the enrollment procedure.
• Guided QA team to write test cases and test scripts to confirm the displayed information and also tested to print the image in the paper.
• Performedfunctional testingof the application as per the 5010 changes.
• Documented and analyzed all defects using Quality Center and tracked them to completion by communicating with the team every day.
• Supported development and Installation team.
• Performed Unit and Integration Testing.
• Implemented Alpha Test in order to confirm the functionality of recent conversion.

Environment: MS Office, Windows 2000, .NET, MS Visio, MS SharePoint, TFS, MS Project, MS Visio, SQL, Oracle, SOA, HTML.

Confidential, Rye Brook, NY

Business Systems Analyst

Responsibilities:

• Responsible for the requirementsgathering phase and prepared BRD and FRD..
• Responsible for requirements analysis, design and developing technical requirements.
• Created and tested scripts for premium calculations and claims limits and deductibles (claims calculations).
• Developed complex forecasting tools using Access.
• Responsible for verifying the eligibility of beneficiaries for providers and to process Medicare part D claims.
• Responsible for the investigating the then existing businessproblems and helpedIT development staff to complete systematic analysis of these problems to determine their impact on other work.
• Involved in processing Health Care Claim Transaction set EDI i.e. 837.
• Responsible for mapping XML data into EDI X12 using Extreme translator.
• Designed and developed integration solutions end-end.
• Responsible for capturing and managing all types of change requests throughout the development lifecycle using RationalClearQuest.
• Designed an application for the management to analyze the market trends, behavior, habits etc by collecting relevant data at various points and organizing the data into appropriate data warehouses and data marts and through the processing the data into various statistical reports (ad-hoc/canned for strategic management decision making) by utilizing SAS.
• Responsible for requirements management usingRequisite Pro
• Developed Base line scripts for testing the future releases of the application
• Applied the SQL scripts to the test database and execution of the scripts on the database
• Worked with business representatives to understand data marts requirements, data models, data flows, Facets on-line, priorities and ensured that IT work is appropriately aligned.
• Responsible for creating business work flows and processes, design documentation, project plan documentation and creating management reports based on the analysis.
• Conducted joint discussion sessions (JAD) with business users, stakeholders to understand the requirements in more detail.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements were covered in scripts and tested properly.
• Maintained Test Matrix with the test results obtained.
• Followed the UML based methods using Rational Rose to create use cases, activity diagram, sequence diagram, collaboration diagram that included functional and non-functional specifications for the development teams.
• Used the Agile methodology to build the different phases of Software Development Life Cycle.
• Participated in enforcing the rules of Scrum, removing impediments from the team while promoting self-management and constantly improving the standard of work.
• Interacted regularly with the business users and the IT team for understanding the requirements.
• Came up with test cases for various reports on the data marts and identified that the test case documents are updated timely.
• Analyzed defects and performed bug testing by using Rational ClearQuest, configuration management and version control with Clear Case.
• Reviewed high-level design documents and low level designs of classes and sequence diagrams.
• Conducted training and provided end-user supportby providing tools training.

Environment: RUP, UML, HP Quality centre, Win Runner, Rational Clear Quest, Windows, MS Office, XML, TOAD, Ultra Edit.

Confidential, Austin, TX

Business Analyst

Responsibilities:

• Interacted with the client and the technical team for requirement gathering and translation of Business Requirements to Technical specifications
• Worked closely with project manager in handling the entire project
• Conducted JAD sessions with business units and stakeholders to define project scope and deliverables and constantly worked with the project team to design the application that will support the business and meet the constraints of time
• Used Requisite Pro for creating the requirement documents and prepared Business Process Models that included modeling of all the activities of the business from the conceptual to procedural level
• Met with client groups to determine requirements and goals
• Identified and documented the dependencies between the business processes
• Documented the Use Cases and prepared the Use Case, Activity, and Sequence diagrams and Logical views using MS Visio and MS Office for a clear understanding of the requirements
• Used MS Project for various planning and budgeting activities
• Created and maintained Use Cases, visual models, including activity diagrams, logical Business process models, and sequence diagrams using UML
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles
• Participated in testing and liaised with the QA teams to complete testing and ensures test results meets requirements

Environment: MS Office, Quality Center, SQL Server, Facets, MS Project, Server, MS Visio, Unix, J2ee, Java, XML, Mainframes and Rational ClearQuest, ClearCase, Windows XP

Confidential, Iselin, NJ

Business Systems Analyst

Responsibilities:

• Conducted user interviews and JAD sessions with end users, stake holders and developers to gather functional and non-functional requirements of the system, and creation of user stories.
• Involved in developing the business model for expediting the claim settlement process.
• Performed document analysis involving creation of Use Cases and Use Case narrations using Microsoft Visio, in order to present the efficiency of the gathered requirements.
• Defined frameworks for the application development and analyzed the areas of improvement.
• Highly interacted with the development team and claim settlement experts making sure that the development of the project is meeting the business requirements.
• Involved in the analysis of the functional, technical specifications, data mapping document and conceptual diagrams.
• Identified critical areas of business risk and modified the business process to reduce the same.
• Wrote business requirements specification (BRS) and functional requirements specification (FRS) documents as per the business requirements and process flow.
• Used SCRUM methodology in supporting system development cycle.
• Jointly responsible for monitoring the progress of the system development by preparing status reports, charting out schedules, allocating and managing technical and human resources using MS Excel and MS Project
• Conducted daily interaction with both the development team and stake holders
• Analyzed the security implementation of the application with respect to users perspective
• Documented user stories and modeled use case diagrams by utilizing MS Visio
• Prepared test data for the functional test cases.
• Evaluated test results and prepared test summary reports
• Interacted with developers & various members of my team to discuss and resolve defects and their priorities
• Investigating the bugs using SCRUM methodology by creating the test cases to fix bugs and interacting with the developers to resolve technical issues.
• Performed bug tracking using Clear Quest.

Environment: SCRUM, Windows Vista / NT, UNIX, Oracle, Java, HTML, JavaScript, MS Office, MS Visio, MS Project, Rational Enterprise Suite and Mercury Suite of Testing Tool, MS Excel

Confidential, Nashville, TN

Business Systems Analyst

Responsibilities:

• Interacted with Business owners and Stakeholders to understand their needs and documented what system changes are required to support those needs.
• Utilized Agile methodology and gathered high level requirements from the business, created User Stories and prioritized the product backlog with Scrum Master.
• Documented the proposed additional extension to the existing HIPAA application.
• Facilitated Joint Application Development (JAD) sessions with the Management, Mainframe and HIPAA team to make sure everyone are in sync with the business requirement processes and for clarification of requirements
• Worked on HIPAA Transactions 270, 271, 276, 277,834, 835 and 997.
• Used MS Visio to create Use Cases and Sequence Diagrams.
• Liaised and Coordinated in resolving EDI mapping issues arising from data transfer process from EWM to ACAS and third party systems.
• Analyzed mandatory and the situational fields and compared with the users manuals for EDI.
• Worked closely with the host (Main frames support person) and helped him understanding the process and in the creation of the match, input and the delete files.
• Created and Maintained the Requirement Traceability Matrix (RTM).
• Initiated Test Plans, developed and executed test cases and scenarios, worked with users to develop specific acceptance criteria and prepare test exhibits.
• Facilitated XML configurations to accurately parse EDI, EDIFACT, CSV, and Excel data files into the Oracle database.
• Writing Standard SQL queries and optimizing existing SQL Queries
• Conducted User Acceptance Testing (UAT) sessions with business users and prepared document for enhancements and bug fixes.
• Used Test Director and Mercury Quality Center to report any bugs and communicate to the developers and product support team.
• Analyzed and evaluated User Interface Designs, Technical Design Documents and Quality Assurance Test condition the performance of the application from various dimensions

Environment: MS Visio, MS Project, Windows, HIPAA, Microsoft Office Suite, Quality Center, Agile