SUMMARY

• Dynamic Business/Systems Analyst with over 8 years of professional experience in Software Development Lifecycle (SDLC) and business reengineering process, offering extensive experience in healthcare domain: particularly in private health insurance and managed care industry, Affordable Care Act, Medicare and Medicaid programs.
• An award winning analyst with proven track record of expertise in multi - disciplinary areas including business analysis, systems analysis, project management, cross-platform migration, implementation, systems enhancement, operations of enrollment and claims adjudication.
• Subject matter expert on enrollment audits, HIPAA EDI 5010 implementation, ICD 10, ANSI X12 EDI mapping (complete in/out), enrollment (834) management, Claim Adjudication, Benefit Configuration, provider management, and design, development and operations of enrollment/customer facing portals.
• Hands-on experience in working with government contracts at Confidential (CMS). Accomplishments include successful design, development and operational support, implementation, migration and delivery of over 100 projects.

PROFESSIONAL EXPERIENCE

Confidential, Owings Mills, MD

Sr. Business Analyst

Responsibilities:

• Account Management: Serve as an enrollment account manager for over 30 large group accounts serving over 500,000 insurance beneficiaries.
• Lead project initiatives, ensuring quality controls and measures, reviewing and approving level of efforts (LOE) and advising clients and implementation partners on innovative solutions and approaches to drive project cost down and increase efficiency.
• Lead projects: Lead, assess, plan, design and implement new groups, automation, cross-platform migration, open enrollment, systems enhancement and benefits change projects from start to finish.
• Responsible for identifying stakeholders, gathering and writing requirements. Conduct presentation, review and walkthrough, prepare EDI mapping, coordinate implementation calls, and work with technical resources, clients, vendors and implementation partners to automate enrollments.
• Open Enrollment: Coordinate, lead and implement open enrollment projects for accounts. Work with clients, vendors, implementation partners and internal departments to set up Open Enrollment schedules, set target production go live date, test, analyze, review and approve production files, resolve systems and file issues. Implement all annual renewals and special enrollment projects.
• Responsible for systems enhancements and new implementation OF SDLC initiatives for customer facing enrollment portals such as CareFirst Connect (CFC).
• Change management: Review and approve changes on benefits and work with group/vendors to implement changes. Update benefit structure and codes to enhance enrollment systems and files, work with implementation parts to set up/enhance enrollment portals, test enrollment files received on EDI 834 and other business formats, set release/implementation timelines and coordinate user training and go live events.
• Audits: Conduct pre and post-OE enrollment audits, and quarterly enrollment audits for all accounts; resolve enrollment discrepancies; and update enrollment.
• Day-to-day operational support: Resolve issues and problems relating to all large group automated enrollment; implement benefit changes; resolve system and file issues and provide member enrollment and billing support to internal and external customers.
• Work with third party carriers such as ExpressScript, Delta, CVS Pharmacy and Davis Vision to ensure vision, pharmacy and dental benefits are executed accurately.
• System design, enhancements, set up and operations: Plan, design and lead all enrollment project initiatives. Define requirement, rules, regulations such as rules resulting from ACA and the Supreme Court ruling on same sex marriage are captured on enhancements.
• Ensure benefits options, plan, package codes, coverage levels, department codes, COBRA and Medicare qualifications and Heal Saving benefits (HSA) are configured correctly according to the contracts.
• Customer Service: Respond to phone and email inquiries from the internal and external customers. Lead, moderate and participate in calls and provide solutions to the customers.
• Research and Analysis: Investigate complex system enhancements and automation processes; and analyze, define and interpret business needs and issues by gathering, analyzing, documenting and validating technical, functional and non-functional requirements. This includes review of inbound and outbound 834 files, reviewing TRMS and BAM reports, reviewing 999’s and TA1’s, researching the data source files and updating enrollment on Trizetto Facets, Nasco Member’s Edge, WebClient for PCP issues and other external systems.(THIS IS ALREADY MENTIONED ABOVE..SEE UNDELINED)

Confidential, Baltimore, MD

X12 EDI SME/Sr. Healthcare Business Analyst

Responsibilities:

• Responsible for providing EDI FLAT FILE development/maintenance support for 28+ different interfaces/projects for CMS HIGLAS project.
• As a EDI FLAT FILE POC for the CMS, provide on-going maintenance/new development EDI FLAT FILE support to Shared Systems Maintainers (FISS/MCS), SRA, IBM, CMS staff, and Medicare contractors (25+) throughout the nation.
• Develop EDI FLAT FILE mapping for FEPS-HIGLAs integration interfaces and provide EDI FLAT FILE/X12 EDI support to CMS CCIIO, CMS OIS, CMS FMSG and other contractors/stakeholders such as CGI, QSSI, Genova etc..
• Conduct CMS-HIGLAS Quarterly Flat File Rendering (EDI FLAT FILE) Review Calls for Shared Systems and other HIGLAS project releases involving 150+ participants from CMS, solution delivery contractors and Medicare contractors (MAC’s) throughout the country.
• Attend HCR, LOE’s, WG sessions, Solutions Walkthrough and CR review meetings, and provide EDI X12 functional solutions.
• Run large off-cycle EDI FLAT FILEs review calls as required.
• Provide EDI Interpretation, solution recommendations, trainings, EDI FLAT FILE walkthrough and other need based support to CMS staff, IBM/SRA consultants, HIGLAS system maintainers and Medicare contractors across the nation that include (NGS, Novitas, TailBlazzer, HP EDC etc.)
• Maintain version control of EDI FLAT FILE mapping documents for the Shared Systems, NTDO, ReMAS, DCIA and FEPS interfaces; upload them to eRoom repository; maintain data integrity and consistency.
• Review CMS Change Request (CR)/HCR documents resulting from Federal or State level legislations or Trading Partner requirements, and provide solutions recommendations.
• Review functional and technical specifications, master test plan, test scripts/results documents.
• Provide EDI FLAT FILE and EDI X12 training as requested by CMS.
• Build a solid understanding of Oracle Federal Financial Software (i11); assist Oracle function teams in writing BR100, Business Rules and Scenarios (BSR) etc.
• Work on GL, AP and AR Oracle functional areas as required.
• Provide functional/technical solutions to health insurance related interfaces including EDI 837 (claims), 274 (provider), 835 (payment), 271 (benefits), 811, 810 (non-claim invoice), and other transactions sets related to Debt Collection Act (Treasury, IRS), and 824 (file notification), Recovery Management and Accounting Systems (ReMAS), Medicare Secondary Payer Recovery Contractor (MSPRC), and Treasury Offset Program (TOP).
• Develop new EDI FLAT FILEs - for new systems joining HIGLAS (i.e. ReMAS, FEPS- Health insurance Exchange per Affordable Care Act 2010) as needed.
• Keep updated with HIPAA compliance, rules changes, version changes (4010/5010), codes (ICD 9/ICD 10), and other healthcare related laws including Confidential t Protection and Affordable Care Act 2010 that impacts healthcare transactions such as claims, payments, beneficiaries, vendor/customer information for the Confidential .

Confidential, Windsor, CT

EDI Business Analyst

Responsibilities:

• Document Trading Partner Migration Process Flow from HIPAA 4010A to 5010; create process flow diagrams and presentation materials; and monitor production and release events.
• Interpret Systems Architect and Logical Diagrams to business users and other stakeholders, and assist with change requirements elicitation.
• Assist in writing business requirements and system specification documents.
• Extensively work on EDI transactions 834, 835, 837I, 837P, 820, 270/271, 276/277, and 999.
• Responsible for interpreting ASC X12 Original and Errata version documents such as X12 220, 221A1, 222A2, 222, & 224A2 to business and technical users including the developers.
• Research, track, parse and interpret EDI files 999, Transaction Acknowledgement records, and enrollment and claims files in EDIFECS data repository and UNIX server and analyze them according to the request.
• Conduct operational and implementation assessment of project tasks and prepare budget estimate documents for change request using standard templates.
• Conduct ICD-9/ICD-10 conversion analysis through ICD 9 and ICD 10 proposed mapping documents and HIPAA 5010 system capabilities of EDIFECS tools. Update mapping documents as required for version upgrade and change requests.
• Work as a liaison between HP and Confidential and responsible for all the Cross Functional Communication.
• Monitor various files transfer events and repository records for claims, enrollment, remittance and status inquiry records in Trading Partner Gateway (HIPAA Gateway), transactional, operational and mainframe data repositories.
• Perform AS IS and To BE analysis for EDIFECS Standards- HIPAA 5010 Database Setup for new version releases. Documented proposed changes and coordinated development, testing and production release environments, including end-to-end testing.
• Validating the Log Files (999, X12) for 834/820, 277CA, 837IB and 835 Transactions in UNIX and HTM (Healthcare Transaction Manager).
• Responsible for preparing and presenting technical reports and documents to stakeholders in client facing environments. Moderate teleconferences and JAD sessions.
• Extensively use Quality Center to manage defects, change request and pre-uploaded requirements and mapping documents.

Confidential, Philadelphia, PA

Business Analyst

Responsibilities:

• Gathered requirements from subject matter experts (SMEs) and documented the BRDs; constantly communicated risks/contingencies to project managers and consulted with technical development staff to clarify business requirements from the business users.
• Interviewed business users and SMEs to elicit requirements. Worked on developing the functional requirement documents (FRD) and Use Cases for FACETS batch process; automating the billing entity, commission process and Medicare enrollment.
• Conducted HIPAA Conversion Analysis - contribute in the documentation of HIPAA 5010 changes toEDI 837, 834, 835, 276, 277transactions sets.
• Performed Analysis ofICD 9 Procedure and Diagnosis Codesin accordance withICD 10-CM and ICD 10 PCS Conversion Compliances using GEM.
• PerformedGAP analysis toassess“AS IS”and“TO BE”scenarios between HIPAA 4010 and HIPAA 5010 and conversions of codes from ICD 9 to ICD 10.
• Worked inFACETS Configuration, Data Element Definition and Usage, and completed configuringFACETSApplications such as Related Entity, Parent Group, Group, Subgroup, and Member/Subscriber.
• Formulatedsystem design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes such asHIPAA/ EDIformats and accredited standards.
• Extensively worked in customization and configuration ofClaims Processingapplications inFACETS 4.71. Involved in reconfiguration ofFACETSin functional areas, including Membership, Claims, Provider, Enrollment and Service Modules.
• Coordinated the upgrade of EDI Transaction Sets 837, 835 and 834 to HIPAA compliance. Work on EDI 834-file load in Facets through MMS (Membership maintenance sub-system).
• Vendor Management - Worked as a facilitator and point of contact person for Testing Efforts and New Requirements between theHealthcareCompany and its various Vendors.
• Maintained theTraceability Matrix to ensure accuracy and consistency of project success. Deal with data mapping issues between various source systems, staging area and data marts.
• Worked with theUAT and QAteams to conduct an assessment and determine how effective UAT and QA guidelines can help the company achieve timely completion of projects.
• Analyzed dataand create reports usingSQLqueries for all issued Action Items.

Confidential, Dallas, TX

Jr. Business Analyst

Environment: NASCO, RUP, Rational Requisite Pro, Rational Rose, Crystal Reports, BizTalk Server, Oracle, MS Office, MS Access, MS PM, PL/SQL and Visio

Responsibilities:

• Gathered requirements using various elicitation techniques such as JAD sessions, interviews, document analysis, requirement workshops and site visits. Conduct task and workflow analysis.
• Prepared Business Requirement Document (BRD) and specific functional requirement document (FRD) for the enhancement of existing products and services.
• ReviewedTRDswith stakeholders and comment on them to get them updated from the Implementation Vendor the requirements to reflect thebusiness need of the stakeholders.
• Conducted ICD 10 Impact Assessment of thevarious streams such as Health Care Management systems, including HEDIS Specifications; Benefits, Mandates and Medical Policy; Claim Processing (NASCO & ITS) & Data Storage; Provider Contracting; and Reimbursement.
• Designed Use Cases, Sequence and Activity Diagrams using MS Visio; work as aUAT Testing Lead; and coordinate with Sees in defining, designing, conducting and evaluating results.
• Created Mapping Document forICD-9-CM toICD-10-CM/PCS, Clinical Modifications and Procedural Codes using GEM (general equivalence mapping).