SUMMARY

• 9+ years of professional experience as a Business Analyst in Healthcare Industry.
• Strong knowledge in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology and Medicaid Management Information System MMIS.
• Experience of EDI transactions and HIPAA ASC X12 Transaction sets: 834 (Benefit Enrolment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 820 (Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271 (Explanation of Benefits (EOB) /Response to EOB), 276/277 (Claim Status/Claim Status Response).
• Strong knowledge of Medicaid, Medicare (Part A, B, C, D), Procedural and Diagnostic codes and Claims Process.
• Knowledge and Experience on, Billing, Claims Payment Processing in relation to HIPAA, EDI, 834, 837,835, and 270, 271.
• Enhanced knowledge of HL7 Standards, HIX, EHR - Electronic Health Records, EMR - Electronic Medical Records, CMS regulations, Health Care Reform, EMTALA, PPO, POS and HMO.
• Firm grip of understanding in SDLC methodologies particularly RUP, AGILE-SCRUM, Waterfall.
• Expertise in conducting Rapid Application Development (RAD, Joint Requirement Planning (JRP) and Joint Application Development JAD sessions, interviews, workshops and requirement gathering sessions with business users, stakeholders and development team.
• Extensive experience in gathering requirements and authoring Business Requirement Documents (BRD), Software Requirement Specification (SRS), Functional Requirement Document (FRD) and maintaining Requirement Traceability Matrix (RTM).
• Possess strong PBM (Pharma and claims system background) experience.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, and HL7.
• Involved in developing business process models for projects and demonstrations at the Centers for Medicare and Medicaid (CMS) using business process model notation and enterprise architecture.
• Strong knowledge of Rational Unified Process (RUP); risk engineering, data modeling and mapping, and design using Unified Modeling Language (UML) and Visio.
• Experienced in creating Use Cases, Sequence Diagrams, Activity Diagrams, Collaboration Diagrams and Class Diagrams using Rational tools and Microsoft Visio.
• Experienced in conducting SWOT Analysis, Business Analysis, Risk Analysis and Gap Analysis.
• Good knowledge of PPACA (Patient Protection and Affordable Care Act).
• Strong knowledge of the Trizetto Facets.
• Extensive detailed knowledge about clinical trials, drug development and drug discovery cycle.
• Extensive Experience in Functional, Integration, Regression, MMIS, HL7, FRD, User Acceptance UAT, MITA, System.
• Experienced in preparing User Manuals documentation and Conducting training and support to the users and other stakeholders.
• Broad knowledge of Test plans, Test cases and test scripts and also Excellent communication and presentation skills.
• Excellent Client relationship management, analytical, and conflict resolving skills.
• Good control on MS Office suite, MS Visio and MS Project.
• Good knowledge of Oracle and SQL.
• Solid Change Management experience and also Skilled in validation and testing complex scenarios for the maintenance of quality standards in projects.

PROFESSIONAL EXPERIENCE

Confidential, Stanford, CA

Sr. Business Analyst

Responsibilities:

• Involved in developing business process models for projects and demonstrations at the Centers for Medicare and Medicaid (CMS) using business process model notation and enterprise architecture.
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility and billing essential.
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
• Experience in X12 EDI Transactions (834 enrollment, 820 payments, 270/271 eligibility/response, 837I and 837P institutional and professional claims, 835 Healthcare Claim Payment Advice, 277CA Claim Acknowledgement, 999 transactions).
• Experience with EDI HIPAA conversion and deep knowledge of healthcare business processes and EDI infrastructures.
• Experience working with EDI standards (e.g., ASC X12, NSF, HL7).
• Involved several working sessions and much 'offline' research/documentation with the key stakeholders and SME's from the Pharmacy department.
• Involved in generation and execution of SQL queries to understand the processes used by the pharmacy department.
• Experience in reviewing data to produce finance and market intelligence reports using PBM.
• Experienced in building and maintaining web applications using Adobes AEM CMS to include site architecture, custom components, workflow development, Digital Asset Management (DAM).
• Involved in developing HL7 messaging for bi-directional case and disease report exchange, in HTML and XML formats, in accordance with HL7 specifications.
• Performed Gap Analysis by identifying current technology, policies, and procedures, documenting the enhancements for the requirements, and analyzing new HIPAA compliance and developed an action plan for the migration process.
• Worked as a liaison between the business client and development team for the implementation in compliance with HIPAA standards.
• Involved in analyzing and understanding Business Epics.
• Clarifying requirements which are not clear with Business Analyst.
• Collecting test data for requirements to perform testing.
• Analyze requirements to ensure testability, report gaps and discrepancies.
• Creating and executing test cases for GUI, Sanity, Smoke, Functional and Regression testing.
• Performed Peer review for testing related documents Test cases, Test Plan and Release summary document.
• Executing test cases and log defects in JIRA.
• Retest the scenarios post defect fix.
• Adding scenarios, test data and screen shots used for testing to Test Ready User Stories in JIRA.
• Prepared and present weekly status reports to management.
• Played active role during daily scrum meeting and task planning as part of agile methodology.
• Interacted with offshore team to share & provide required information on planned work items for the sprint.
• Internal review of user stories with management for scenarios/test data/screen shots prior demo.
• Participated in Sprint Demo sessions with business.
• Performed Integration testing of ACMP application.
• Well versed with Microsoft SharePoint to manage project related documents.
• Involved in writing complex queries in SQL Server.
• Involved in Sprint retrospective meetings scheduled at the end of each sprint.
• Involved in UAT & SIT Concerns meetings.
• Involved in Planning & Product Backlog Grooming User Stories with Business Analyst and Team members.
• Participated in Defect Triage call to discuss open defects and Defect clarifications.
• Maintained Defect/Issues/Observations Tracking sheet.

Confidential, New York City, NY

Business Analyst

Responsibilities:

• Worked according to the activities/roles laid down in each phase of software development life cycle created using agile methodology.
• Analyzed and documented the system specifications, Business requirements and detail design of the software for full understanding of the business and used Requisite Pro for the requirement tracking and analyzing.
• Worked with various IT functional areas as well as regularly interacted with hospital personnel such as Clinical Informatics, hospital IT management, clinicians, physicians and senior management.
• Performed requirements analysis and design using Rational Rose and Requisite Pro.
• Conducted JAD sessions for communicating with all the project directors and stakeholders. Created process workflows, functional specifications and project initiation artifacts.
• Analyzed, documented and managed all project requirements and change to requirements throughout the software development lifecycle using Requisite Pro.
• Created Use-Cases, Sequence and Collaboration Diagrams to demonstrate software architecture and interaction of system components before prototyping. Used Rational Rose, Requisite-Pro for requirement traceability.
• Experience with data management, data modeling and also involved in data mapping from xml to facets
• Involved in GAP analysis around the identification of business rules, business and system process flows, user administration, requirements and assumptions.
• Developed test cases and scripts based on business requirements for the GUI, functional, User Acceptance & System Back-end testing.
• Conducted interviews with all users, internal department heads to elicit their requirements for the project.
• Created Use Cases diagrams using UML.
• Prepared Systems Requirement document (Functional, Non-functional) and Test Plan.
• Implemented RUP (Rational Unified Process) methodology for iterative and incremental development of the system.
• Prepared the Functional Specification Document (FSD) and Software Requirement Specifications (SRS) as per SEI CMM standards.
• Developed flowchart and process diagram using MS Visio.
• Conducted interviews with clients to analyze their data and gather requirements.
• Aided in building EDI’s 270, 271, 276, 277, 835, 837 and 834 transactions.
• Worked on improvement of Claims Reimbursement User Interface for a better experience and in corporate changes as per HIPAA guidelines using the gap analysis.
• Developed test cases and test plans on the basis of requirements and also did manual testing of the functionality of the application to ensure that the application is able to handle a lot of data.
• Used UML to create use case diagrams, sequence diagrams and activity diagrams.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Identified bugs during the test phase and reported them using ALM.
• Maintained Traceability Matrix throughout the project.
• Involved in the Rational Unified Process (RUP) to build the different phases of Software Development Life Cycle (SDLC).

Confidential, Jacksonville, FL.

Business Analyst

Responsibilities:

• Gathered, analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Used HIPAA transactions to support the analysisof current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes forHIPAA transaction processing EDI’s 837,835, 270, and 271.
• Troubleshooted file transmission problems and assisted customers in a call center environment with EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides (837P, 837I, 837D, 270/271).
• Produced Gap Analysis documents for HIPAA. Established questionnaires and resource leveling required for implementing HIPAA and upgrading diagnosis codes.
• Conducted user interviews and documented business and functional requirements. Performed Requirement Analysis and developed Use Cases, Activity Diagrams using Rational Rose.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data.
• Involved in supporting the oversight, coordination, and completion of business requirements, testing and readiness activities necessary to support client during a PBM transition.
• Completed the documentation of Claims Scenario’s for the source system. Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Involved in creating business processes and modeling diagrams using Rational Unified Process (RUP).
• Created use case scenarios and documented workflow and business process using Rational Rose.
• Involved in project management using MS Project. Documented requirements associated change requests with requirements and connected requirements with Use cases.
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Identified/documented data sources and transformation rules required populating and maintaining data warehouse content.
• Used Rational Clear case for version control. Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle.
• Served as conduit for managing system requirements between the business and the software development team.
• Queried database using SQL for backend testing.
• Used Rational clear quest for defect management.

Confidential, NYC, NY

Business Analyst

Responsibilities:

• Worked with the account managers, managements, and report requestors to gather requirements, get report requests.
• Involved in developing and conducted statewide HIPAA awareness program for all IDS staff in Assurant.
• Coordinated with the developer, on day-to-day basis, during the development process.
• Involved in architecting integrated HIPAA, Medicare solutions, Facets.
• Validated the following Transaction Processing: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan).
• Wrote Business Requirements, analyzed them and tested them.
• Interacted with the ETL team, developer(s), management, and account holders to get the requirements, document them, design templates, and write specifications.
• Generated report templates based on the requests by account managers and also designed Functional Specification Documents for the reports.
• Involved in designing and developing the project document templates based on SDLC methodology and helped with Data Mapping between the data mart and the Source Systems.
• Worked as a liaison between the Business and Technology Department. Enhanced communication lines between executives, managers, and peers.
• Worked in RUP environment using Rational Requisite Pro. Analyzed trading partner specifications and created EDI mapping guidelines.
• Extensive use of Excel to create Functional Specification Documents & Templates. Designed the process flow diagrams for flow of information and report creation process.
• Conducted JAD sessions for the report users, requestors, and the developers. Prepared Need Analysis Documents of the requirements gathered through JAD sessions.
• Used MS Visio to create Flow diagrams and Use Case Diagrams. Created presentations explaining the entire report development process, while drawing a comparison between the legacy & the new report.
• Used JavaScript for client-side validations extensively along with .NET validation controls. Used Rational Rose to model the process using UML to create behavioral and structural diagrams.
• Created Test Scripts & Test Scenarios to check report content, layout, and parameters. Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Documented the meeting minutes about issues discussed and solutions resolved also Identifying and mitigating the risks, applying creativity innovation to solve complex problems, building relationships and working collaboratively as well as developing and communicating a vision for system by providing the thought leadership, mentoring, effective verbal/written communication, preparing and delivering effective presentation.
• Migrated Data from MS Excel to SQL Server Reporting Service Using DTS and SQL loader utilities.
• Modified System flow diagrams using Visio. Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Closely involved in projects conducted with the help of teams to achieve deadlines timely and proficiently and worked on FACET claim processing system.
• Strong knowledge of the Merit-based Incentive Payment System (MIPS) which is a system for value-based reimbursement under the Quality Payment Program (QPP).

Confidential, Oklahoma City, OK

Sr. Business Analyst

Responsibilities:

• Involved in gathering business requirements, design and development for the BPA, EPSDT, EDMS, EDI, Claims, Financials, Recipient, Prior Authorization and Managed Care modules.
• Experience in developing Medicaid Account for changes for Benefit Plan Administration (BPA) Sub-system, Financials, Claims, Managed Care, Recipient, Prior Authorizations, EDI (Electronic Data Interchange), Reference, EDMS (Electronic Data Management System), and EPSDT (Early Periodic Screening Diagnosis and Treatment) system.
• Ensured all artifacts compiled with HIPAA policies and guidelines.
• Experience in analyzing medical and/or pharmacy claims including prior PBM.
• Worked on EDI transactions like 270,271,834,837 and 835.
• Gathering requirements and preparing functional documents for Facets 4.71. Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.
• Knowledge in gap analysis for HIPAA, 837P and 835 transactions.
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS. Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Assisting the project manager in creating the business case and project plan.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team.
• Involved in impact analysis of HIPAA, 835 and 837P transaction sets on different systems.
• Involved in forward mapping and backward mapping using GEMs and incorporated that into a Translator Tool.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Translated high level business / data requirements into Process, Workflow, and Data Flow Diagrams using MS Visio towards facilitating clear understanding of the business process.
• Responsible for documenting and delivering user Requirement Review Document (RRD), Business Requirement Document (BRD) documents, process flow diagrams.
• Experience in reviewing the High-Level Design Document (HLD) and Low-Level Technical Design (LLD) for Benefit Plan Administration, Financials, Claims Managed Care, EDI, EDMS, Recipient, EPSDT subsystems.
• Documented the meeting minutes about issues discussed and solutions resolved also Identifying and mitigating the risks, applying creativity innovation to solve complex problems, building relationships and working collaboratively as well as developing and communicating a vision for system by providing the thought leadership, mentoring, effective verbal/written communication, preparing and delivering effective presentation.
• Created, updated and reviewed business (BRD) and functional (FRD) requirements.
• Worked closely and collaboratively with client and member of delivery to facilitate analysis and trouble shooting and closure and resolution.
• Involved in analyzing and modifying the professional, inpatient, pharmacy and dental FFS and Encounter claims processing and adjustment claim processing for diagnosis and procedure codes.
• Involved in analyzing and processing codes for EDI files Inpatient, Professional, pharmacy and Dental claims through X12 formats.
• Worked and supported on EDI Translators to analyze EDI files submission for Professional, Inpatient, Outpatient, pharmacy claims and dental claims Errors.
• Involved in remediating financial fund code assignments and DRGs (Diagnosis Related Group) for inpatient, professional claims, and RA (Remittance Advice) reports, pay reject reports, adjustments report for diagnosis and procedure codes.
• Involved in analyzing and processing of claims with prior authorization for diagnosis and procedure codes.
• Involved in modifying the implementation of CMS416-EPSDT Annual Participation file, Health Check reports EPSDT system for diagnosis and procedure codes.
• Involved in analyzing and processing of the benefit plan administration business rules to enforce the state policies for diagnosis and procedure codes.
• Involved in analyzing and processing of table-driven benefit plan structure, recipient plan, and provider contract and reimbursement agreement business rules to process claims to pay, deny or suspend.
• Worked on Medicaid and CHIP program requirements, including complete end to end life cycle data flow of eligibility, enrollment, claims, encounters, payment and post-payment.
• Involved in analyzing and processing of managed care recipients and managed care participants (MCPs) associated with HH (Health Homes), SI (Supplemental Income) and CSP (Coordinated Service Program) plans processing.
• Involved in analyzing and modifying current system for managed care benefit enrollment process 834.
• Involved in managed care recipients for capitation changes and delivery payments changes 820 for international classification of disease diagnosis and procedure codes.
• Involved in reviewing, writing scenarios, reviewing scripts, helping data preparation, helping to execute the scripts and supported the component testing, system test, model office test (MOD) and user acceptance testing (UAT).

Confidential, New York City, NY

Business Analyst

Responsibilities:

• Worked according to the activities/roles laid down in each phase of software development life cycle created using agile methodology.
• Analyzed and documented the system specifications, Business requirements and detail design of the software for full understanding of the business and used Requisite Pro for the requirement tracking and analyzing.
• Worked with various IT functional areas as well as regularly interacted with hospital personnel such as Clinical Informatics, hospital IT management, clinicians, physicians and senior management.
• Performed requirements analysis and design using Rational Rose and Requisite Pro.
• Conducted JAD sessions for communicating with all the project directors and stakeholders. Created process workflows, functional specifications and project initiation artifacts.
• Analyzed, documented and managed all project requirements and change to requirements throughout the software development lifecycle using Requisite Pro.
• Created Use-Cases, Sequence and Collaboration Diagrams to demonstrate software architecture and interaction of system components before prototyping. Used Rational Rose, Requisite-Pro for requirement traceability.
• Experience with data management, data modeling and also involved in data mapping from xml to facets
• Involved in GAP analysis around the identification of business rules, business and system process flows, user administration, requirements and assumptions.
• Developed test cases and scripts based on business requirements for the GUI, functional, User Acceptance & System Back-end testing.
• Conducted interviews with all users, internal department heads to elicit their requirements for the project.
• Created Use Cases diagrams using UML.
• Prepared Systems Requirement document (Functional, Non-functional) and Test Plan.
• Implemented RUP (Rational Unified Process) methodology for iterative and incremental development of the system.
• Prepared the Functional Specification Document (FSD) and Software Requirement Specifications (SRS) as per SEI CMM standards.
• Developed flowchart and process diagram using MS Visio.
• Conducted interviews with clients to analyze their data and gather requirements.
• Aided in building EDI’s 270, 271, 276, 277, 835, 837 and 834 transactions.
• Worked on improvement of Claims Reimbursement User Interface for a better experience and in corporate changes as per HIPAA guidelines using the gap analysis.
• Developed test cases and test plans on the basis of requirements and also did manual testing of the functionality of the application to ensure that the application is able to handle a lot of data.
• Used UML to create use case diagrams, sequence diagrams and activity diagrams.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Identified bugs during the test phase and reported them using ALM.
• Maintained Traceability Matrix throughout the project.
• Involved in the Rational Unified Process (RUP) to build the different phases of Software Development Life Cycle (SDLC).

Confidential, Baton Rouge, LA

Business Analyst

Responsibilities:

• Created business and technical requirements, functional specs, gather and translate functional requirements into technical requirements and provide analytical support to the management team as needed.
• Utilized the RUP Software Development Methodology for the creation of the new operations system.
• Actively participated in all phases of SDLC, which is used as our practice-based methodology to effectively model the system.
• Followed standards according to Medicare (A, B, C, D) and Medicaid, HIPAA compliance and ANSI X12 837 formats.
• Used Rational Requisite Pro to collect requirements.
• Prepared Project requirements, User Specification documents, and UML diagrams to present detailed design of the system.
• Conducted JAD sessions for gathering requirements for the project.
• Proposed strategies to implement HIPAA in the new MMIS system and worked on planning and documentation
• Heavily involved in testing and reporting issues, as well as defining resolutions.
• Managed defect tracking and helped in the verification of the developed test cases.
• Generated traceability matrices for QA and test teams.
• Contributed knowledge and support to QA and UAT teams throughout the process of testing the applications workflow and functionality.
• Conducted risk analysis to analyze potential risk that could affect patients as a result of new functionality introduced into the system.
• Performed defect tracking and maintaining trailing history of bugs.
• Executed SQL queries to test data entry into the database and worked with the QA team to execute test cases.
• Provided weekly status updates to project stakeholders on the progress of project development.
• Created and presented reports on a weekly basis to keep the management up to date on the progress of the projects.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Gathered Requirements from different insurance companies and other stakeholders.
• Responsible for UAT testing team on HIPAA EDI 837 and 835.
• Used UML and RUP methodology to analyze and translate business requirements into system specifications.
• Involved in designing and developing project document templates based on SDLC methodology for marketing campaigns for Medicare A, B, C and D program.
• Designed and authored Business Requirement Documents, Functional Specifications, traceability matrices, and Use Cases.
• Wrote Supplemental specifications, business rules matrix for Medicare mail conversion to ensure ease of maintenance.
• Analyzed and wrote technical documentation for root cause analysis on customer support issues.