SUMMARY

• 9+ years of experience as a Healthcare Business Analyst with solid understanding of Business Requirement gathering, Business Process flow, Business Process Modeling, Data Analysis, Data Mapping and Business Analysis.
• A thorough understanding of the Software Development Life Cycle (SDLC) including but not limited to the various concepts such as Requirement Gathering. Proficient in Requirement Management, including gathering, analyzing, detailing and tracking requirements.
• Extensive experience in gathering Business/Functional user requirements, creating Use Cases as per user requirements, developing/designing diagrams such as Activity, Class, and or Sequence diagrams, and in addition to creating Business Requirements Document (BRD)
• Thorough understanding of consistently developing and maintaining the health care industry databases, health care insurance and health care industry related aspects. Experienced in HIPAA compliance.
• Strong understanding of information technology capabilities and dependencies, including platforms, content management, e - document strategies and process mapping..
• Assisted Project Manager in Planning/scheduling Meetings (MS project).
• Performed Batch, Integration, System, and End-to-End testing
• Experience with data migration (ETL development), document data manipulation processes
• Experience working on HIPAA,EDI 837I, 837P, 999, 276/277 and 835.
• Strong knowledge of EDI Claims, member enrollment, billing transactions, claims management process, Medicaid and Medicare Services
• Knowledge of Medicaid Management Information Systems (MMIS).
• Knowledge of claim and encounter processing and data validation requirements mandated by CMS ( (Center for Medicare and Medicaid Services)
• Sound knowledge of HIPPA privacy requirements
• Experience working in Medicare and Medicaid projects.
• Proficient in Technical and Business Writing, Business Process Flow, Business Process Modeling, Business Analysis and Testing various methodologies.
• Strong knowledge of coordinating and performing various Testing techniques such as Smoke Testing, Sanity Testing, and Functional Testing by creating Test-Cases, Test Scenarios and analyzing/reviewing Bugs/Defects, closely work with Development and QA Teams to ensure bugs were fixed
• Experience in conducting User Training and writing User manuals.

TECHNICAL SKILLS

Project methodologies: Rapid Action Development (RAD), Joint Application Development (JAD, Rational Unified Process (RUP), System Development Life Cycle (SDLC), Agile, Waterfall, Gap Analysis, Scrum, V-shape modeling.

Change Management Tools: Rational Clear Quest, Rational Clear Case.

Model Diagrams: Process Flow Diagrams, Activity Diagrams, Data Flow Diagrams, Context Diagrams, Use Case diagrams, Sequence Diagrams, Business Process Model Notations.

QA/Testing and Defect/Change Tracking Tools: Rational Clear Quest, Test Manager, HP Quality Center, Quick Test Professional, LoadRunner.

Business Modeling & Versioning Tools: Rational Rose, Rational Requisite Pro, Rational Clear Case, SharePoint, Microsoft Office Suite (Excel, Access, PowerPoint, Project, Visio, outlook), Enterprise Architect, Test Director, Erwin Data Modeler, Toad Data Modeler.

Programming Languages: Structured Query Language (SQL), Unified Modeling Language (UML)

Operating System: Windows NT/98/2000/XP, MS Dos, Note ++

Databases: MS Access, DB2, MS SQL Server 2000

Other tools: IBM Tivoli, Enterprise Manager.

Claims coding and formats: CPT, HCPCS, Revenue Codes, CMS, 837, 999, 277CA, 835

PROFESSIONAL EXPERIENCE

Confidential, Washington DC

Application Analyst Consultant

Responsibilities:

• Created a data mapping document for outbound 837 data elements
• Created reporting requirement for 837, 999,277 and inbound 835 files.
• Created encounter log to track each file and report received from the DHFC based on the error reports.
• Worked with the development team to fix the errors reported on encounter
• Created process for the resubmission of denied encounters by The District Of Columbia department of healthcare Finance (DHFC)
• Review the 999 acknowledgement error report to check on the denied claims reason.
• Identified and documented discrepancies during the reconciliation process of outbound 837,999 acknowledge response, 277CA acknowledge response and inbound 835 responses.
• Documented policies and procedure for submitting adjustments for encounter data.
• Documented process for identifying and resubmitting denied encounters
• Documented procedure for reviewing and analyzing denied encounters, correcting denied encounter and resubmitting denied encounters.
• Responsible for monitoring and tracking all the encounter data submission process on timely and accurately to the State.
• Coordinate between the development team and the higher level management about the reports and status of the encounters.
• Documented business rules for submitting encounters based on the CMS guidelines and EDI companion guide.

Environment: MS Office, MS Visio,, Mainframe, EDI, Note++, Microsoft excel, HTML, ANSI X12, Center for Medicare and Medicaid services (CMS), HIPPA standards, ICD 9-ICD10

Confidential, Harrisburg, Pennsylvania

Application Analyst Consultant

Responsibilities:

• Locate the 837 ANSI X12 transactions, understanding loops segments, elements and structure and validate the data in the transactions.
• Tracking each outbound 837 encounter EDI file and reporting 999 acknowledgement, 277CA acknowledgement and 835 status
• Extensively worked on verifying EDI file format against ANSI standards
• Plan and analyze activities related to the processing of encounter data and data validation
• Knowledge of Understanding data transfer from MCO to state systems and potential problems that may arise.
• Organize and coordinate services and communication among administrative departments for the purpose of identifying, resolving and monitoring encounter, data validation and management issues.
• Interpret various administrative rules, regulations, policies and procedure pertaining to encounter data collection.
• Knowledge of CPT,HCPCS, revenue and other typical medical billing codes, as well as standard claim formats, such as the X12
• Understanding privacy rules under the Health Insurance Portability and Accountability Act (HIPPA), standards data release rules, and industry-accepted data security practices to enable protection of confidential patient information while allowing state entities to utilize the data.
• Strong written and oral communications skills to provide clear instructions to team through Encounter Data companion Guide, and to have productive conversations with plans when data issues arise.
• Documented procedure for submitting encounter data to the Department of Healthcare Finance (DHFC)
• Documented reconciliation process following from the EDI translator from the encounter data submitted as accepted/rejected transaction file, 999 reports and 999 Error reports.
• Documented reconciliation process following from the EDI translator from the encounter data submitted as accepted/rejected transaction file, 277CA reports and 277 rejected encounters.
• Analyze and identified what processed are automated and what processes are manual for submitting encounters.
• Identified discrepancies during the reconciliation process of outbound 837,999 acknowledge response, 277CA acknowledge response and inbound 835 responses.
• Documented policies and procedure for submitting adjustments for encounter data.
• Documented process for identifying and resubmitting denied encounters
• Documented procedure for reviewing and analyzing denied encounters, correcting denied encounter and resubmitting denied encounters.
• Responsible for monitoring and tracking all the encounter data submission process on timely and accurately to the State.
• Responsible for creating Encounter Metrics and Encounter Data certification reports for the State.
• Review and analyze the Claim Adjustment Reason Codes and the remittance Remark codes received in the inbound 835 in reference to particular claim or services.
• Responsible for tracking each denial, repairable and non-repairable denied encounters.

Environment: MS Office, MS Visio,, Mainframe, EDI, Note++, Microsoft excel, HTML, ANSI X12, Center for Medicare and Medicaid services (CMS), HIPPA standards, ICD 9-ICD10

Confidential, New Jersey

Business Analyst

Responsibilities:

• Gather necessary information to document the business requirements, technical requirement, identifying solutions and translate the business needs to a functional specification that is turned over to development.
• Conducted meetings to gather requirements from Business Managers, Supervisors, stakeholders, Data Governance Team and subject matter experts to gain knowledge about needs of the system.
• Worked on HIPAA ANSI X-12 EDI series such as 270/271, 276/277, 278, 834, 835, 837 and version 5010 of this transaction
• Ensured that project followed Business Rules and was compliant with HIPAA rules to display minimum benefit information.
• Updated EDI transactions with the HIPAA 4010 to HIPAA 5010 changes and for that participated in full life cycle implementations (SDLC) from project initiation to final deployment
• Responsible for ensuring that privacy and security environments of healthcare data remained intact.
• Effectively conduct JAD sessions and Business Requirement review sessions with teams to complete project documentation and work with the business to gain approval/sign-off.
• Document functional requirements, system design specification use cases, workflow diagram, screen and interface designs.
• Communicate Business process, business solutions and status update to IT managers and upper Business during Status meeting.
• Data cleansing, data migration, and data mapping were used to and validation of database structure in the OLAP.
• Work with the business to analyse business process and system issues and turn them into actionable system changes that benefits the business.
• Created Data Structure and data mapping to increase efficiency of data usage for transactional and analytical processes
• Work on Data Analysis in terms of Data Type and Data Length of each back-end system and map to one another.
• Review and provide final approvals to SIT Test Scenarios, Test Cases.
• Highly involved during the reviewing and validating System Testing Defects/bugs in IBM ( Clear Quest (CQ) and closely work with development team and QA team to provide fixes
• Work closely with the development team to coordinate the system change, work closely with QA team to ensure appropriate system testing.
• Create UAT Test Scenarios, UAT Test cases and participate in UAT testing with business.

Environment: MS Office, MS Visio, Rational Requisite Pro, Rational Rose, Rational Clear Case, Rational Clear Quest, Quality Centre, Requisite Pro, RUP Methodology, Oracle Pl/SQL, EDI, Enterprise Architect.

Confidential, Kennett Square PA

Business Analyst

Responsibilities:

• Functioned as the primary link between business line, operations and the technical areas throughout the project.
• Facilitated JAD sessions, user meetings, interviews and Requirement Elicitation Sessions to extract business requirements and to confirm that those requirements are in alignment with up gradation of existing system to 5010.
• Conducted meetings to gather requirements from Business Managers, Supervisors, stakeholders, Data Governance Team and subject matter experts to gain knowledge about needs of the system.
• Extensive use of MS Project to maintain record of recommendations, communications, activities, schedules and to monitor progress of project in real time.
• Worked on HIPAA ANSI X-12 EDI series such as 270/271, 276/277, 278, 834, 835, 837 and version 5010 of this transaction.
• Conducted GAP analysis to identify and document gaps between existing 4010 compliant system and proposed 5010 compliant system.
• Thorough use of UML and MS Visio to develop Use Cases, Activity Diagrams, Sequence Diagrams.
• Identified, researched, investigated, analyzed and documented business processes and use case scenarios.
• Designed strategy for up gradation of system and implementing user interfaces to be 5010 compliant.
• Ensured that project followed Business Rules and was compliant with HIPAA rules to display minimum benefit information.
• Responsible for ensuring that privacy and security environments of healthcare data remained intact.
• Prepared Business Process Reengineering (BPR) documents by interacting with SMEs.
• Interacted effectively with internal and external parties and worked closely with project manager in handling the whole and project.

Environment: MS Project, SQL, Rational Unified Process (RUP), Rational Requisite Pro, Rational Rose, Clear Quest, Microsoft Visio, Windows Vista/XP, MS Visio, ETL, SQL, DB2, Office Suite (Word, Excel, Power Point).

Confidential, Downers Grove, IL

Business/ Systems Analyst

Responsibilities:

• Worked on analysis of the Facets claims processing application in order to gather requirements to comply with HIPAA 5010 requirements.
• Analyzed HIPAA 4010 and HIPAA 5010 standards for 837P, 837I and 835 transactions and prepared gap analysis document for each transaction.
• Utilized RUP methodology during the project life cycle and worked together with RUP mentors at the location.
• Wrote high level and low level business requirements for the project.
• Analyzed the existing data model and provided suggestions and recommendations
• Worked with the solution architect in order to understand the existing data model and modify the data model to accommodate the required 5010 changes.
• Dealt with data mapping issues between various source systems and staging area and data marts
• Worked with data mapping team to create data maps for data integration task i.e. transformations.
• Utilized Mercator as an EDI mapping tool to map the claims data that passes through the EDI gateway to the Facets claims processing application.
• Conducted meeting with the EDI team and other stakeholders team members to discuss the requirements
• Did analysis for the ICD 9 to 10 conversion project along with various SMEs and Stakeholders and investigated the work to be done in order to do the transition from ICD-9 to ICD-10.
• Responsible for 5010 EDI Transactions and possess knowledge of HIPAA Companion Guides
• Involved in meetings with product manager, project manager, onsite and offshore team members to resolve issues and roadblocks during the project.
• Used Rational Requisite Pro for overall Requirements Management and to build the Requirements Traceability Matrix.
• Involved in identifying the integration points within the organization as required for the project, involved in preparing test cases and UAT.
• Provided business and technical suggestions and recommendations during the project life cycle.
• Worked closely with the business team, development team and the quality assurance team to ensure that requirements are understood as intended in order to achieve the desired output.
• Involved in performing several database tuning tasks and built reports using PL/SQL.
• Extracted large volumes of data from legacy systems and uploaded into the Oracle database using SQL*Loader and PL/SQL.
• Ran SQL queries to check the results of the involved database.

Environment: MS Visio, Excel, MS office, Rational Rose, Dreamweaver, Rational Unified Process (RUP), ETL, Agile, SQL Server, Informatica.

Confidential, Waltham, MA

Business Analyst

Responsibilities:

• Acted as a liaison between stakeholders and software development team to gather requirements
• Interviewedclient employees for two projects to gather information, understand the users need, define requirements and develop specifications.
• Facilitated(JAD) Joint Application Development sessions to identify business rules and requirements and then documented them in a format that can be reviewed and understood by both business personnel and technical personnel.
• Analyzed gaps for training purposes between existing application and after integration of the new one.
• Extensive documentation of use cases
• Assisted in the development of quality assurance artifacts including: Quality Assurance Plan, Test Plan and Test Cases
• Conducted functional walkthroughs, User Acceptance Testing (UAT) sessions, and assisted the development of User Guides and Manuals for customers.
• Worked with IT Team for development, testing, implementation and user acceptance
• Coordinated with offshore Testing team members on deliverables, defects, and defect resolution.
• Organizing weekly Project status meetings with business users and updating project plan and status reports
• Project tracking and Status Reporting to business users/management.
• Collecting sign offs and approvals from business users and keeping them in MS SharePoint controlled environment.
• Raising tickets for Change Management and making sure change management processes are being followed for deployment.

Confidential

Business Analyst

Responsibilities:

• Worked with team of 15 business analysts, 20 SMEs and around 30 programmers to finalize information requirements and develop a potential design for the system.
• Extensively used Microsoft Project to plan and create project timelines and phases.
• Developed wire-frames for User Interfaces for the workflow.
• Utilized Rational Rose, Microsoft Visio to develop UML diagrams, Use Case diagrams and Process Flow diagrams.
• Conducted back-end testing by developing SQL queries.
• Monitored and tracked customer complaints with the online trading software.
• Collaborated with the business users for resolving requirement gaps, enhancements, defects and UAT cycle.
• Extensively used Rational RequisitePro and Rational Clear Quest for requirements management and defect tracking.
• Conducted extensive black box testing to assess the stability of the system.
• Deployed as an onsite component of testing team to use the management information system (MIS) for a banking branch on a pilot basis.