SUMMARY

• Scrum Certified Business Systems Analyst with more than 9 + years of experience in delivering business and systems solutions for leading providers of health Care Insurance.
• Highly accomplished professional with a proven track record of leading complex, cross functional and result - oriented.
• Extensive experience gathering, defining, business requirements (BRD) translating them into technical specifications and Functional Requirements (FRS) documents for the inbound and outbound EDI process for HIPPA compliant files.
• Experience in EDI automated first - pass claim adjudication, requiring through understanding of claim processing, both front and backend operation.
• Good Knowledge of Health Insurance plans (Medicare), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding.
• Experience with Medicare and Medicaid claims Encounter processing for provider/state claims payment issues.
• Strong healthcare and Medicaid business configuration experience with focused primarily on claims adjudication, pricing, provider, member, enrollment, and prior authorizations.
• Strong in defining scope of projects based on after gathering Business Requirements including Documentation of constraints, assumptions, business impacts, Project risks & scope exclusions.
• In-depth expertise in all aspects of software Development Life Cycle specializing in requirements solicitation and documentation.
• Strong project management skills including planning, scheduling, monitoring and budgeting with experience in requirement gathering, gap analysis and risk analysis.
• Experience with Medicare Advantage Programs, HIPAA 4010, HIPAA 5010 EDI transaction codes such as 270/271(inquire/response health care benefits), 276/277(Claim status), 834(Benefit enrolment), 835(Payment, 837(Health care claim).
• Knowledge of HIPAA, X12, and HL7 standards and Medicaid provider best practices.
• Proficient in MS Office, MS Access, Power Point, MS Visio.
• Excellent work ethics, self-motivated, quick learner, team player, and team oriented.

TECHNICAL SKILLS

Process/Modeling Tool: Software Development Life Cycle (SDLC), MS Visio, Rational Rose, Rational Requisite Pro, Rational Clear Quest, VSS.

Methodology: UML, RUP, Agile, Business Modeling

Databases: MS Access, SQL Server, OracleLanguages SQL, Java, XML and HTML, Mainframe, .NET

Operating Systems: MS-DOS, WINDOWS 98/2000/NT/XP

Office Tools: MS Office, Word, Excel, PowerPoint, Access

Project Management: MS Project

Testing tools: QTP, ALM, Quality Center

PROFESSIONAL EXPERIENCE

Confidential, Norfolk, VA

Sr. Business System Analyst

Responsibilities:

• Attained various Vendor & Provider calls and took meeting minutes, Created Documents, Process Flows, Presentations
• Interacted with business managers and other stakeholders to determine project scope thus defining key challenges and project deliverables.
• Conducted business requirement meetings with business unit teams to determine project goals and elicit Business requirements in accordance to SDLC deliverables.
• Attended meetings and participated in JAD sessions to ensure that legal and compliance deadlines are met.
• Gathered business requirements through discussion with stakeholders and SME’s.
• Translated requirement documents into technical specification documents for the development team to easily understand for use of design and coding enhancements and or modifications of the system.
• Analyze and observe system behaviors to attain precise system issues.
• Document all enhancements and modifications in Confluence for future team tracebacks.
• Develops the pricing Agreement Templates (PAT) for all provider reimbursement set up
• Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, research and resolved within established SLA timeframes.
• Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements.
• Maintained a working knowledge process of rules, state plan policy, contractual guidelines, and operational procedures to effectively provide technical expertise and business rules.
• Participate in encounter rejection reconciliation activities
• Conduct research to find solutions for system issues and present it to Business and stake holders for approval of modification.
• Refine User stories with business for future sprints and assign to team members. Participate in scrum ceremonies, sprint planning, daily standup, refinements, demos and retrospective.
• Ensure that proposed solution concepts are aligned with existing enterprise roadmap and objectives.
• Create and update the mapping document to ensure system mapping matches new system enhancements and modifications.
• Worked in release notes for any changes made in Facets 5.40 and 5.50 to ensure changes hasn’t impacted flows through encounters processing data system.
• Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers.
• Run queries in Microsoft SQL to identify root causes of claim denials, incorrect payments and claims that not correctly submitted for payment by state.
• Act as the resource to other markets by developing and managing work plans which document the status of key relationship issues and action items for high profile providers.
• Ensure ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits.
• Maintain tracing system of operational issues, progress and status.
• Properly develop test cases, test scripts, and test steps with the QA team to ensure the acceptance criterion is being met.

Confidential, NY

Sr. Business Analyst

Responsibilities:

• Interact with business managers and other stakeholders to determine project scope thus defining key challenges and project deliverables.
• Conduct business requirement meetings with Business unit teams to determine project goals and elicit Business requirements in accordance to SDLC deliverables.
• Attend meetings and participate in JAD sessions to ensure that legal and compliance deadlines of CMS(Centers for Medicare and Medicaid Services) and New York State of Health are met.
• Gather business requirements through discussion with stakeholders and SME’s
• Responsible for conducting Business Impact Analysis and Gap Analysis to assess the “AS IS” and “TO BE” scenarios.
• Liaise with stakeholders, business owners, end-users and develop business/system use cases.
• Manage Requirement Traceability Matrix (RTM) to trace and map Business requirements, Functional requirements, and System requirements.
• Create process flows diagrams for all “As IS” and “To Be” scenarios using MS Visio
• Involved in Business process redesign and its documentation.
• Involved in activities to make sure proper documentation and standards are being followed.
• Write Business Requirement Document inclusive of both high-level and detail level requirements after collecting requirements through conducting JAD sessions and brainstorming sessions.
• Prepare Use cases in accordance to the requirements which forms the basis for Functional and Technical specifications.
• Document and distribute the meeting minutes for requirements related meetings.
• Document and manage the Requirement Change Requests.
• Analyze TRD/General Design document to support the business in ensuring that what is requested is delivered.
• Provide direct support to different business units for various Adhoc reporting requirement needs.
• Be available to the developers, QA and business UAT teams for consultation/ clarifications related to the requirements.
• Participate in testing strategy and document it in a test plan which contains purpose, test types, schedule, scope, roles, entry, and exit criteria, defect workflow, test deliverables, risks, assumptions, constraints, & dependencies.
• Constantly involve in review meetings to ensure that testing is done based on the QA master plan and deadlines are met.
• Identify frequency, dependency on time, triggers for each risk and escalate the risk on time.

Confidential, PA

Sr. Business Analyst

Responsibilities:

• Analyzed Business Requirements and segregated them into high and low level Use Cases and Activity Diagrams using MS Visio.
• Performed GAP analysis involving the current state and proposed state.
• Worked closely with other BA’s and ETL Leads/Managers and was responsible to perform detailed data requirements analysis and create design specifications and operational documentation.
• Provided the ETL team with the Data mapping document and assisted them to create the mappings.
• Worked closely with the architects, database administrators and technical team during Data mapping and Data integration.
• Analyzed and presented the Business with information on Data anomalies, issues, input errors, field value ranges, data patterns, referential integrity gaps and the level of record incompleteness that is the source systems.
• Organized meetings with the SMEs and Data Owners to walk through the findings and determine the cleansing process.
• Developed the Epics and Themes for the scrum project.
• Devised and prioritized the product backlog by conducting requirement churning sessions with various Business/ Product teams.
• Used AGILE - Scrum methodology and worked in short Sprints to achieve goals.
• Mentored various teams on SCRUM methodology and helped the company transformation into and Agile Development Shoppe.
• Participated in Scrums and Scrum of Scrums and discussed the open issues and statues.
• Participated in Agile planning sessions and assumed the product Owner role for the agile initiative.
• Created and explained the User Stories to the Scrum Team and helped them design the Tasks.
• Designed acceptance criteria for validating the output of each Sprint.
• Reviewed Team Velocity on a frequent basis and advised Scrum Master at various stages.
• Participated in Sprint Planning and sprint review meetings for Finalizing the Sprint Backlogs and Verifying the sprint outputs respectively.
• Created Release Tracking Document in order to track the necessary changes.
• Participated in Business Demonstrations and Decisions for the Release of the Sprint Output to Production.

Confidential, Dayton, OH

Sr. Business System Analyst

Responsibilities:

• Interact with business users for better understanding of individual subject areas and modified specifications to reflect accurate user needs.
• Gathered user requirements by interviewing focus groups and brainstorming with SME’s, Business users and Product owners. Created targeted questionnaires for SME’s to refine requirements and translated into business rules.
• Attending status update meeting daily/weekly basis and work closely with Architects and Developers.
• Worked on HIPAA Transactions and Code Sets Standards such as 837 I & P Encounters.
• Validated and compared the Claims generated through E2E process with the claims from the existing system in backend executing SQL queries and comparison tool.
• Developed Data and Data mapping requirements for the reports.
• Provided detailed set of Input parameters and Report output Wireframes and Mock ups.
• Worked Extensively with HIPPA EDI 834 forms received from various Vendors, Partners, and Producers in validating the Data in Stage environments, Test running the formats and conducting issue analysis.
• Worked with HIPPA Edi 837 & 835 files for data validation and created Data mapping and ETL process requirements for loading data into the EDW.
• Address UAT issues to ensure proper action was taken based on priority and requirement.
• Participated in various sessions with Business to understand the business rules and to come up with naming conventions to standardize the data.
• Played a key role in the user acceptance testing (UAT), and implementation of system.

Confidential, Tallahassee, FL

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 Medicare/Medicaid claims processing in compliance with government compliant process.
• Adopted RUP methodology for the software development life cycle.
• Understood and defined various elements and objects used in Healthcare Medicaid management information systems MMIS & COT’s Product (County Billing, Third Party Liability and Miscellaneous).
• Ensured that the MMIS upgrades must be able to handle the new HIPAA transactions.
• Worked for the COB testing (Continuity of Business) for MMIS
• Gathered requirements and developed business requirement document for mulitiple enhancements and technology requests forms for sizing and planning the Healthcare Medicaid application for the state of New Hampshire.
• Provided training to over 20 users on the MMIS application.
• Facilitated JAD sessions to develop business solution that meets the business requirements, resolve open issues, and change requirements.
• Performed Data Analysis to see the variation in the as is system and to be system.
• Conducted GAP Analysis, and created Business rules and error Message catalogue for the version of MMIS.
• Created Traceability Matrix using IBM Req Web to trace the business rules and error messages to the business & functional requirements.
• Development of data migration map between MMIS to the IBM SOA.
• Automated several manual processes to ease the work of the user.
• Developed Use Cases, User interface documents and report specification documents for the MMIS application.
• Created various process Hierarchies, to define the logic of healthcare Medicaid modules.
• Developed understanding documents for the technical team to provide detail descriptions of the healthcare Medicaid modules.
• Worked closely with the offshore technical and testing team to make sure all the requirements were met and the functionality was developed as per the business requirements
• Developed learning manuals for IBM SOA and supplement power point slides to aid user’s knowledge.
• Worked constantly to be on the same page as the users and technical team.
• Maintained the Users distribution list and communicated whenever there was an issue with the system or if the system was down for maintenance or production release purposes.
• Have been closely working with the quality team to document the test results, also been a part of testing.
• Conducted UAT and documented the results as well as fixing bugs with the technical team.