SUMMARY

• Over Six years of experience as Business Analyst in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Documentation: BRD (Business Requirement Document), FRD (Functional Requirement Document) and Non - functional Requirement Document.
• Experience in developing detailed functional specs through JAD sessions, interviews, on site meetings with business users & development team.
• Experience in interviewing Business users & SME providing recommendations to resolve issues for various business/technical groups & defining strategic solutions to business problems in a multiple project environment.
• Analysis & Design (Use Case, Sequence and Activity diagrams).
• Test Case writing (manual/automated test cases) and Conducting Tests (Integration testing, Regression testing), Black Box/White Box testing, UAT (User Acceptance Testing).
• Writing Manuals (System guides, training material for business users and Deployment guides).
• User training on the changes being released and conducting post production activities like getting feedback from users. In case of any issues - doing Root Cause Analysis, prioritizing tasks with business users.
• Experience with data analysis, data mapping and dimensional modeling experience in decision support systems (data marts) using Star Schema.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Good knowledge and extensively used RDBMS, Oracle, SQL, and PL/SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• Well versed in translating business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML) diagrams using MS Visio and Rational Rose.
• Good knowledge on different modules within healthcare (Membership, billing, enrollment, claims, capitation, providers).
• Good knowledge on different modules within healthcare (Membership, billing, enrollment, claims, capitation, providers).
• Experience with HIPAA compliance and Healthcare systems.
• Experience handling HIPAA ANSI X12 (270/271, 834, 835, 837, 276/277), ICD9/10, NDC, DRG codes.
• Experience providing primary analysis for business processes running on the EDI (Electronic Data Interchange) standard.
• Experience with health care Systems: FACETS, QNXT, and Medicare Part D and Medicaid systems, Mainframe System

TECHNICAL SKILLS

Product Methodology: SDLC, RUP, Agile, UML, Spiral model and Prototyping

Project Management: Microsoft Project, Microsoft Office

Business Modeling Tool: MS Visio, Rational Rose, Quality Center

Version Control Systems: Rational Clear Case

Change Management Tools: Requisite Pro, Clear Quest, Test Director & ERWIN

Databases: MS Access, MS SQL Server, Oracle

Operating Systems: Windows Family, Familiar with UNIX and LINUX

Reporting tools: SSRS, Business Objects

PROFESSIONAL EXPERIENCE

Confidential, New York, New York

Business Analyst

Responsibilities:

• Provide technical and procedural support for User Acceptance Testing (UAT)
• Prioritizing and Communicating open issues and project risk/mitigation plans to UAT teams
• Prepared detailed test cases by analyzing technical requirements
• Handle responsibilities of analyzing test results and troubleshooting environment issues
• Coordinating with UAT team to facilitate testing strategies.
• Check test files and production files in Medical Claim Mainframe System for Step Up Step down Project
• Performing Impact analysis for readiness of ICD-10 conversion.
• Performed business analysis for denial claims to find out the root cause of rejection. Once acknowledged all kick out codes were processed correctly and an explanation report was created and delivered to all key stakeholders
• Researches complex claims inquires and communicate response to adjudication department to insure accuracy of ICD-9 and CPT codes
• Effectively communicated user acceptance results between teams.
• Conducted JAD sessions for user interviews to gather requirements.
• GatheredBusinessRequirements from theSubject Matter Experts (SMEs)and documented the requirements in theBRD.
• Performed risk analysis of the requirements to identify key business areas for the project.
• Developing test strategies, test scenarios and test cases
• Executing and reviewing test runs
• Developed and executed SQL queries on claim records to validate reporting
• Submitted change requests and worked with change request records in Clear Quest.
• Designed and documented Test Cases according to the application requirements using Quality Center
• Implemented Unified Modeling Language (UML) methodologies for process modeling and developing use cases.
• Assigned the tasks of creating bug reports and performing tracking testing of systems
• Performed data validation and mainframe testing in interactive mainframe environment

Confidential, Nashville, TN

Business System Analyst

Responsibilities:

• Worked on Member Management, Eligibility, Claims, and Provider modules within FACETS
• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, premium billing, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system to FACETS.
• 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.
• Used MS SQL Manager Studio 2008 to query the MS SQL database.
• Involved in documenting the business process by identifying the requirements and also involved in finding the system requirements
• Worked in creating interfaces for various external vendors
• Created Technical Specifications for the 835 and 837 I and P files with their changed and new contents to create 5010 complaint files.
• Facilitated Joint Application Development (JAD) sessions with all IT group members for communicating & managing expectations and to discuss various means for integrations with current system using an adoption through execution strategy
• Performed the analysis of the earlier systems, generated a detailed requirements document describing new system architecture through use cases diagrams and activity diagrams using MS Visio
• Identified and documented the requirements for 5010 conversion.
• Collected the information related to ongoing application upgrade and their impact on ICD-10 implementation and impact, benefits and risks of ICD-10 code application.
• Re-Organized the collected data and prepared documentation for implementation.
• Facilitated data mapping activities and helped with the expansion of membership and provider data model
• Created workflow diagrams, process flow and data flow diagrams
• Assisted team with Data Mapping and Data Extracting Strategies for data migration.
• Involved in creating use case diagrams for the purpose of the team to understand the workflow of the system.
• Analyzing the business needs for the reports and documenting the requirements in SSRS forms.
• Facilitated JAD sessions and captured meeting minutes
• Analyzed EDI ANSI X12 file mapping and reported in analysis spreadsheet. Performed validation of 837 (P, I) & 835 format files
• Effectively communicated user acceptance test results between users and development team and provided recommendations for change control requests (CCR).

Environment: Facets 4.8, MS Visio, Word Excel, PowerPoint, Rational Rose, Requisite Pro, SQL.

Confidential, Downers Grove, IL

Business Analyst

Responsibilities:

• GatheredBusinessRequirements from theSubject Matter Experts (SMEs)and documented the requirements in theBRD. Utilized data flow diagrams, use case diagrams and process flow diagrams to represent information provided by the Business Owners.
• Performed Analysis ofICD9 Procedure and Diagnosis Codesin accordance withICD 10 CM and ICD 10 PCS Conversion Compliances.
• Organizedmeetings and ledJAD sessionsto ensure legal and compliance deadlines ofCMS(Centers for Medicare and Medicaid Services) are met.
• HIPAA Conversion Analysis - Involved in the documentation of HIPAA 5010 changes toEDI 837, 834, 835, 276, 277 Transactions.
• 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
• Documented theUAT Planfor the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Worked with Business Owners ofIDX, the claims adjudication system,and documented updates and enhancements to the application.
• Effectively elaborated theCurrent processand gave a clear picture of the proposed process for the projects in the organization.
• Vendor Management - Worked as a facilitator for Testing Efforts and New Requirements between theHealthcareCompany and its various Vendors.
• Maintained the Traceability Matrix Table to uniquely trace the identified business requirements to general design to testing as proof that requirements requested have been developed into a solution and that it has been tested and tracked.

Environment: IDX, MS Visio, Word Excel, PowerPoint, Rational Rose, Requisite Pro, SQL, and Oracle.

Confidential, Newton, MA

Business Analyst

Responsibilities:

• Understanding business requirements for Medicare Part D file required for CMS (Risk Management, RAPS and suspect management).
• Worked on developing the business requirements and use cases for FACETS batch processes.
• Worked on customization screens/reports related to Member, Enrollments, and Providers in FACETS.
• Responsibilities spanned through all phase of the project life cycle from inception through post-implementation.
• Conducted one-to-one interviews and group meetings with the Subject Matter Experts (SME’s) to gather the business requirements.
• Created Entity Relationship diagram (ERD’s) and process flow using UML and Microsoft Visio to clearly communicate the business requirements.
• Translated the business needs, wants and objectives into requirement and created Business Requirement Document (BRD) and Functional Requirements Documents (FRD) using Requisite Pro.
• Developed Requirements Traceability Matrix (RTM) to track requirements against test cases during the QA Phase.
• Facilitated formal defect review meetings with project teams and developers to report, demonstrate, prioritized and suggest resolution of issues discovered during testing.
• Played a key role in the planning, testing, and implementation of system enhancements and conversions.

Environment: MS Office Tools, Windows XP, Oracle, SQL, Rational Clear Quest, Rational Clear Case, ERWIN, Requisite pro, Microsoft Visio, FACETS 4.21

Confidential, Cleveland, OH

Business Analyst

Responsibilities:

• Engaged in different phases of SDLC of the project executing RUP methodology of iterative software development from Inception to Transition phase. Performed the role of a liaison between Business Units and Technical Solution Developers.
• Understand and articulate Business Requirements from SME interviews and workshops and translate requirements into Business Requirement Specifications (BRS). Involved in conducting JAD with SMEs, Developers, Project Managers and Quality Analysts to discuss business requirements, test planning, resource utilization, and defect tracking sessions as a facilitator to gather requirements from the business area.
• Implemented Unified Modeling Language (UML) methodologies for process modeling and developing use cases. Developed Use Cases, Sequence diagram, State diagram, and Activity diagram.
• Involved in implementing Six Sigma practices to systematically improve processes and standards and by eliminating defects.
• Analyzed EDI ANSI X12 file mapping and reported in analysis spreadsheet. Performed validation of 837 (P, I, D) & 835 format files according to the EDIFECS engine.

Environment: Windows NT/2000, MS SQL Server, Rational Unified Process (RUP), UML, Rational Rose, Mercury Test Director, MS Office Tools.

Confidential, Middletown, NY

Business Analyst

Responsibilities:

• Responsible for interacting with client for requirements gathering, analyzing requirements, and creating detailed specifications
• Analyzed plan requirements and then contributed further defining the plan requirements with their Project Manager. Observed the compliance of the requirements with federal and state government regulations Medicaid, Medicare, and accreditation body requirements
• Successfully refined and implemented new and inherited projects for specialties or practices where the NextGen KBM could not meet the client's needs or workflow
• Designed, test, and customized EMR templates, documents and crystal reports
• Created documents using Documents Builder for templates
• Edit/Add new information using File Maintenance
• Recommended changes for system design, methods, procedures, policies and workflows affecting Medicare/Medicaid claims processing in compliance with government compliant processes like HIPAA(4010)/ EDI formats and accredited standards like ANSI
• Researched EDI claims and claims adjustments data to determine root causes of data errors
• Developed and executed SQL queries on claim records to validate reporting data
• Designed and documented Test Cases according to the application requirements using Quality Center
• Coordinated and attended meetings to review these specifications with the Quality Assurance Manager, Business System Analysts, RUP Engineers, Project Manager & others on the team
• Reviewed Test Cases from Use cases for EDI transactions and executed them in Quality Center testing environment
• Participated in the bug review meetings, updated requirement documents as per business user feedback and change in functionality of the application
• Assisted client in developing content and training materials; recommended enhancements and identified new business requirements ensuring appropriate documentation

Environment: Windows 95/98/NT, UML, Use Case diagrams, Rational Rose, MS Visio, MS Project, SQL Server, HTML, Win Runner, Test Director