SUMMARY

• Business/EDI Analyst with over 6+ years of experience in Health Care domain with Claim adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs. Good knowledge of FACETS Member, Provider and Claim module involving Configuration, Customization, Reporting, Analysis and Enhancement.
• Created Business Requirement Document (BRD) and Functional Requirement Document (FRD) through various JAD sessions, interviews and meetings with business users, SMEs and development team.
• Comprehensive experience in different SDLC methodologies: Waterfall, Agile and Rational Unified Process.
• Designed Use case, Sequence and Activity diagram using Unified Modeling Language.
• Conducted GAP analysis and Impact analysis.
• Wrote Test cases and Conducted different integration and regression testing. Involved with UAT team in user acceptance testing.
• Skilled in mapping business requirements to test cases, maintaining traceability matrix.
• Earned good knowledge in RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administrator, SQL Enterprise manager, data analysis and reporting.
• Involved in analysis and configuration of data flow models.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange), transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD - 9, ICD-10 coding.
• Sound knowledge in the HealthCare transactions: Eligibility Request/Response (270/271), Claim Status Request/Response (276/277), Benefit Enrollment (834), Payment Order/Remittance Advice (820) Health Care Services Request (278), Payment/Advise (835) and Health Care Claims (837).
• Provided analytical solution to the customers for Facets Production Issues.
• Through system analysis and documentation experience with HIPAA compliance.
• Worked on different modules within health care: Membership, Providers, Claims, Enrollment.
• Performed the data analysis and data mapping for different source system including mainframe system, data warehouse and database to target system, database, and allocation for the Medicare part D - Prescription Drug claim.
• Good knowledge of Pharmacy Benefit Management (PBM) adjudication and PDE reporting.
• Thorough knowledge of Medication Therapy Management program and application.
• Experience with EDI X12, HIPAA 4010 and 5010 standards and ICD-9 to ICD-10 conversion.
• Experience withICD9/ICD10, NDC, DRG, CPT, NCPDP codes and NSF formats for interfaces & images to clearing house / trading partner’s applications.
• In-depth knowledge and extensive experience in Health care systems: FACETS, QNXT, Medicare part A, B, C, D and Medicaid system.

TECHNICAL SKILLS

Methodologies: Waterfall, RUP, Agile

Project Management: MS project, Lotus Quickr, Mantis

Version control: Rational Clear case, Visual Source Safe, CVS

Change management: Rational RequisitePro, Clear Quest, Test Director, Mantis

Testing: Quality Center, Test Director, QTP, Win-runner, Mantis bug Tracker

Language: C, C++, Java, .Net, UML, XML, HTML

Database: SQL Server, Oracle, Data Studio, MS Access, DB2, TAOD interface

Reporting tools: Crystal report XI, SAS,COGNOS

Modeling Tools: MS Visio, Rational Rose

PROFESSIONAL EXPERIENCE

Confidential, Washington, DC

Business/EDI Analyst

Environment: FACETS, Agile, SQL, SQL server, .NET, JAVA, COBOL, PEGA, MS Office Tools, MS Visio, SAS 9.2, UML, HP Quality Center

Responsibilities:

• Worked with diverse team of Business users to gather requirement and prepared BRD and FRD.
• Conducted numerous JAD sessions with Business users, developer and SMEs.
• Performed the Gap Analysis to find the existing gap between the HIPAA 4010 to HIPAA 5010 EDI transactions and ICD 9 to ICD 10.
• Prepared several use cases and designed use case diagram, activity diagram and sequence diagram.
• Worked on requirements of the 835, 276,277, 837, and HIPAA transaction across the enterprise.
• Initiated with a comparison report of migration of . 270 Eligibility, coverage and benefit inquiry (V4010X092A1) Vs. 270 (V5010X279).
• Used General Equivalence Mapping to convert ICD 9 to ICD 10. Involved in both forward mapping and backward mapping.
• Responsible for imparting domain knowledge on HIPAAX12transactions and how it is used as HIPAA 837 transactions.
• Created Project management plans for managing on time delivery using MS Project along with writing test cases, unit and systems integration test plans in Quality Center.
• Wrote test cases for testing migration of EDI and the processing of member enrollment and benefits, batch jobs corresponding to the enrollment (834) and real time transaction like 270, 271, 276, and 277.
• Created process flows for HIPAA EDI transactions such as 270, 271, 276, 277 and 820.
• Facilitated the User Acceptance Testing (UAT) with Pega System Administrators and Business Users, documented any issues or defects and eventually got sign off from the right parties.
• Involved inclaim adjudication processoffacetsapplication.
• Experienced onFacets data model.
• Reviewed Test Plans developed by the testing team for testing the application.
• Assisted the QA personnel in the creation of Test Cases using Rational Test Manager.
• Engaged on theloading EDI 834-file toFacetsthroughMembership module.
• Performed gap analysis for ICD 9 to ICD 10.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems.
• Worked on developing the business requirement and use cases for FACETS batch process, automating the billing entities and commission process.
• Troubleshoot any problems found within FACETS and when testing the SQL data database while validating the business rule.
• Involved in configuration of Member and Provider Module in FACETS.
• Analyzed data and created reports using SQL queries.

Confidential, Blue Bell, PA

Business/EDI Analyst

Environment: MS Office, Snag IT, MS Lync, FACETS, Agile, Toad, SQL server, .NET, JAVA, COBOL, MS Office Tools, MS Visio, HP Quality Center

Responsibilities:

• Involved in discussion with subject matter experts during gap analysis sessions to identify the areas of impact toGateway, Backend Systems and Front end Systems for the 5010 remediation.
• Conducted gap analysis and impact analysisof transition from HIPAA 4010 to HIPAA 5010 on EDI transactions 837 (I, P & D) 1, 834, and 835.
• Conducted and facilitated interviews, user meetings,JAD sessions, and Requirement Elicitation Sessions to extract the Business Requirements related to the upgrading
• Constructed the Business Requirement Document and the Functional Requirement Document for Inbound (837-I, P, D, 270, and 834) and Outbound (835, 271) transactions.
• Worked closely withTrading Partnersto ensure that requirements were met.
• Contributed in the writing of5010 Implementation, Companion Guides for all ANSI X12transactions.
• Extensively involved in Database testing by writing SQL queries.
• Involved in claims submission and payment (remittance) retrievals by using ASCX12N 820 for the In- bound premium payments; ASC x12N 834 for the Inbound
• Appointed as the point of contact in theHIPAA 5010core team for responding to any queries.
• Involved concurrently in enhancement of HIPAA X124010transaction to HIPAA X125010andICD 9-CM (Clinical modification)toICD-10-CM/PCS(Clinical modification/procedure coding system).
• Performed impact analysis for conversion ofICD-10.
• Involved with the quality assurance team to develop and design test plan and test cases.
• Involved in resolving and documenting issues related to these EDI transactions including 834 transactions, 837 transactions using Test Director.
• Worked on FACETS Pre-pricing process - Subscriber/member eligibility, Plan benefits, Check
• Worked on Coordination of Benefits - Calculations using Total charges, Facets allowed,
• Worked on Claims Payment and Adjustments - Claims inquiry, Remittance, Explanation of Benefits, Discounts, Interest calculations, Split payment etc
• Conducted business validations, covering the following deliverables: FACETS Providers, Facets Claims and Facets Membership and Operational reports
• Used GEM for forward and backward mapping to convert ICD 9 codes to ICD 10 codes and vice versa.
• Reviewing all codes and appropriately applying them.
• Assist in preparing the context diagram.
• CreatedEDImapping guidelines.
• Determined technical parameters forEDI by working with the development team for communication, security, and privacy.
• Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 835, 837-(I, P, & D), 835.
• Acknowledged HIPAA rules and regulations duringElectronic Data Interchange (EDI) and also ensured that the development team kept up with it.
• Used MS Project regularly to monitor activities, schedules and communication during the project.

Confidential, MA

Business Analyst

Environment: Agile, IBM AS/400, IBM DB2, aXes data explorer (SQL), C++, MS Office Tools, MS Visio, Share point, Mantis BT, UML, COGNOS, Decision Stream

Responsibilities:

• Worked with business representatives to understand requirements and priorities and ensure that software development work is appropriately aligned
• Involved in the meeting with Business Process Owners, SME (Subject Matter Experts) and Health Center users for Requirement gathering in Definition Stage using Rational Requisite Pro
• Facilitated Joint Application Development (JAD) Sessions, as well as weekly client & team meetings
• Interacted with the Subject Matter Experts (SME) and stakeholders to get a better understanding of client business processes and gather business requirements.
• Performed Gap Analysis to identify the deficiencies of the current system and to identify the requirements for the change in the proposed system.
• Wrote complex SQL queries to perform the Back End Testing of the Oracle database using SQL and UNIX.
• Worked on Unix Platform and experienced in back end testing by executing SQL Queries.
• Participated in user meetings, gathered Business requirements for the Data- warehouse design.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the CMS Compliances/Regulations and HIPAA Regulations 4010 and 5010
• Created Use cases for 835 (Claim Payment/Advice transaction set) and also performed impact analysis for the 835 transaction 5010 changes.
• Converted the Business Process Requirements (BPR) into System Specification Requirements
• Created various Use Cases and workflow diagrams, sequence diagrams, and Class diagrams using MS Visio and used UML methodology to define the Data Flow Diagrams (DFD.)
• Developed user stories, project backlog, and prioritization for timely & smooth execution of the project.
• Maintained Traceability Matrix in Excel.
• Used IBM Rational Clear Quest as Version Control/Change Management Tools.

Confidential, Little Rock, AR

Business Analyst

Environment: .Net,MS Visio, MS Project, UML Modeling tool, SQL, Microsoft Word, Microsoft Excel, Microsoft PowerPoint,Rational Requisite Pro, Rational Rose, Quality Center, Crystal report XI and Window XP.

Responsibilities:

• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to followANSI X12 4010formats including270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and encounter,to meet andexceed HIPAA requirements set forth by the federal government.
• Extracted theBusinessRequirementsfrom the Business Users and documented it for the developers following theHIPAA guidelines by conductingJADsessions and Interviews.
• Worked Extensively with Inbound837I and837 P and835(Out bounds) claims processing systems
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Implemented data access, storage and validation routines on the database server using Procedural Language/Structured Query Language (PL/SQL).
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Developed schemas for extraction, transaction, and loading (ETL) using Solonde Warehouse Workbench to expedite data integration between systems.
• Worked with various teams and data-architects to come up with processes in dev/qa/prod for Extraction, Transformation and Loading data into the Datamarts.
• Hands on experience in Data Manipulation, Defining Components and in writing SQL queries
• Conducted Web Meetings with Off-Shore team members to ensure that everybody is on the same page.
• Collected weekly status reports to ensure that all deliverables are met on time and on schedule.
• ConductedJAD sessionwith management, senior management executives, and other stakeholders for open and pending issues on the development of the project.
• CreatedUse Casesfrom the list of requirements and prepared use case diagrams using Rational Rose.