PROFILE:

• A Business Analyst with 8 plus years of experience in the field of Healthcare, Business Analysis, Data Warehouse and Project management.
• A highly motivated professional. Very detail-oriented, result-oriented, positive communicator, analytical and have great leadership skills.
• Has a creative bend of mind.
• Believes that customer should grow as company grows.
• Highly passionate about growth and success of customers.
• Expertise in Business Analysis, Portfolio management, Fixed income securities, and have a strong knowledge of Project Management tools such as CPM, PERT, and GANTT charts.
• Strong foundation and experience working with business modeling tools such as UML, RUP, SQL, SDLC, and have a substantial knowledge of quality tools such as six sigma and CMM.
• Expertise in performing GAP Analysis of business rules, business and system process flows, user administration, and requirements.
• Strong experience at formulating Use Cases, Test Plans, Test Cases, GANTT charts, Requirement Traceability Matrices.
• Experience at developing Use case diagrams, Activity diagrams, Sequence diagrams.
• Involved in executing test plans, test cases, test results analysis with the testing team and reporting defect management and test status matrices.
• Developed Test Cases for Unit Testing, Regression Testing and User Acceptance Testing (UAT).
• Has high standards for quality, and always strives for perfection.
• Good understanding of software development methodologies such as Agile, RUP, JAD, RAD and hands on experience in formulating JAD sessions.
• Good communication and presentation skills with capability to drive ones decision in most cases.
• Expertise at using MS Visio, MS Project, MS Excel, PowerPoint, and SharePoint.
• Expertise in web services Simple Object Access Protocol (SOAP), WSDL, XMK, and REST.
• Broad understanding on Medicare, Medicaid and CMS.
• Extensive knowledge of Patient Protection and Affordable Care Act (PPACA) and HIX (Health Insurance Exchange).
• In depth knowledge on Confidential Compliance (Title I & Title II), ICD9/ICD10, HL7, EDI transactions, 4010/5010 versions and Healthcare Information Technology (HIT) Standards.
• Worked on different EDI healthcare transactions like 837, 835, 834,, 270,271, 276, 277 and 278 .
• Experience in Electronic Medical and Health Records (EMR & EHR)/Automated Health Care Systems.
• Experienced in Risk and Compliance, Document management, and Data Integration.
• Organized Requirement Gathering Sessions (RGS) and interviewed Subject Matter Experts (SME’s) gathered detailed functionality aspects of business process to update requirements.
• Involved in preparing GAP analysis, SWOT analysis, Cost benefit analysis, Risk analysis, business refinement process including checking and validation of requirements in conjunction with the stakeholders.
• Exceptional analytical skills in understanding the business process (AS-IS and TO-BE), understanding the functional requirements and translating them to system requirement specifications.
• Experience in relational database, writing SQL queries for Data Analysis and generating reports.
• Skilled in developing Test Plan and Test Cases as per the business process requirements.
• Good understanding of using testing tools, such as QTP, Test Director and performing a variety of software testing including User Acceptance, Performance, Load, Stress, Sanity, Parallel, Black Box, Grey Box, White Box, Positive, and Negative Testing.
• Adept at preparing Use Cases, UML diagrams, Functional Requirement Specifications (FRS) and implemented processes, procedures, guidelines and policies for the Development and QA Teams.
• Well versed with Rational Suite including Rational Rose, Requisite Pro and Clear Quest.
• Familiar with industry standards such as Six Sigma, ISO 9000 and CMM levels.
• Highly trained in networking skills like DHCP, SSL, DNS, TCP/IP, and Load Balancing.
• Excellent organizational, interpersonal skills, written skills and leadership skills.
• Diligent worker, self-starter and consistent performer.
• Ability to work effectively, independently and in a team.
• Expert level skills in MS Office products like, MS Project, MS Word, MS Excel, MS PowerPoint and MS Visio.

TECHNICAL SKILLS:

Operating Systems: Windows 95/98/NT/XP/Vista and Windows 7

Languages: SQL, PL/SQL, HTML, UML.

Database: Oracle, MS Access.

Methodologies: Rapid Action Development (RAD), Joint Application Development (JAD), Unified Modeling Language (UML), System Development Life Cycle (SDLC), Agile, CMM, Six Sigma, Business Modeling, Process Modeling and Data Modeling

Documentation Tools: MS – Office Suite (Word/Excel/Power Point).

Business modeling Tools: Rational Rose, Requisite Pro, MS Visio, MS Project, Clear Quest, Adobe Photoshop.

Testing: Quick Test Pro (QTP), Test Director, Mercury Quality Center.

PROFESSIONAL EXPERIENCE:

Confidential, Columbus OH

Business Systems Analyst / UAT

Confidential formerly known as Ohio Department of Job and Family Services (ODJFS). Launched in July 2013 as an independent state agency, the Confidential (ODM) is Ohio’s first Executive-level Medicaid agency. With a network of more than 70,000 active providers, ODM delivers health care coverage to nearly 2.4 million residents of Ohio on a daily basis.

Project 1 – Medicaid Management Information System – Claim Adjudication, Pricing, Reference, Medicaid Information Technology System (MMIS - MITS) – Recipient Data Maintenance, Integrated Eligibility

The scope of this project was to test the data movement and the production conversion implementation from the current Legacy system to the new MITS. MITS accepts multiple, unique data feeds from different agencies and applies that data according to ODJFS-specific business rules. Because the recipient data comes from a variety of sources, MITS weaves this information together to form a cohesive repository of recipient eligibility and demographic information.

Responsibilities

• Methodical testing of new application enhancements and production defects.
• Identified risks, problems, concerns and suggested improvement to the business users.
• Trained and coached new hires regarding CRIS-E and MITS interface .
• Prepared Data Flow Diagrams and Use case models using MS-Visio where required.
• Created a Test Plan and executed them in Quality Center.
• Conducted user interviews, attended JAD (Joint Application Development) sessions, and documented analysis.
• Represented the client in various process improvement discussions.
• Was involved extensively in claim adjudication, and processing
• Worked on EDI as well as portal
• Involved in Claims pricing logic, and edits/audit testing
• ICD-10 testing, core team member for Claim adjudication team, worked extensively for DRG testing, pricing logic, claim adjudication functionality
• Was involved in vigorously testing all interface files.
• Leaded various projects as a claim adjudication team lead, mainly related to edit and audits
• Gained in depth knowledge about hospital claims

Environment: MS Project, Scrum-Hybrid, MS Visual Studio 2003, HP Quality Center, QTP, XML, SQL Server, MS Office Suite (MS Word, MS Excel, MS PowerPoint, MS Visio), iTrace, e-Room.

Confidential, Deerfield, IL
Business Systems Analyst

Confidential is a national organization dedicated to the delivery of quality health care plans and products working together with its customers, consultants, brokers, providers and employers. Providing managed care and specialty health care services throughout the United States. Confidential Life & Health Insurance Company is a subsidiary of WellPoint.

Project Description: This project was aimed at developing software for auto-adjudication of claims process to improve the efficiency in processing claims. The system primarily aimed at handling Medicare / Medicaid insurance claims and process exceptions.

Responsibilities:

• Requirements Elicitation from Business Managers, Supervisors, stakeholders and the subject matter experts through meetings to understand needs of the system.
• Completed a Business and Technical Requirement Document (BTRD).
• Perform the validation of implemented business scenarios.
• Wrote multiple Test-Cases for multiple transactions include 837, 835, 276, 277, 270 271 - (both inbound and outbound) transactions.
• Worked with Facets Team for Confidential Claims Validation and Verification Process (Pre-Adjudication).
• Worked on insurance data related to Medicare, Medicaid, and Insurance claims
• Developed current ‘AS-IS’ and ‘TO-BE’ business processes and use case documents in compliance with Confidential policies and procedures using MS Visio.
• Involved with project management team in developing project plan.
• Prepared business flow and data flow diagrams.
• Involved in Black box testing using decision testing and use case testing.
• Created Use case diagrams, Activity, Sequence and Collaboration diagrams using UML.
• Worked directly with quality resources to ensure testing activities are in line with the defined business requirements.
• Coordinated with QA team and performed user acceptance testing.
• Maintained a record of recommendations, communications, activities, and schedules to monitor the progress of project in real time using MS Project.
• Interacted with Subject Matter Experts (SME) and end users and established a business analysis around AGILE methodology.
• Organized user acceptance test (UAT) results between users and development team and provided recommendations for Application change requests (ACR).
• Performed the Gap analysis on the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.

Environment: Agile methodology, MS Visio, MS Project, UML, QualityCenter, Microsoft Office.

Confidential, Richmond, VA

Business Analyst

Confidential has a continuum of health management solutions to help improve customer’s overall health, prevent illness, and optimize their care dollars. This comprehensive suite of health and wellness programs touches people in every stage of health. This program helps those in good health stay healthy and prevents disease, offers one-on-one support for people dealing with chronic conditions, or severe and complex illnesses, provides for member’s health needs to be integrated throughout the entire continuum of services to ensure coordination of care.

Responsibilities:

• Gathered requirements from Business Managers, Supervisors, stakeholders, Data Governance Team and the subject matter experts through meetings to understand needs of the system.
• Used the guidelines and artifacts of the Rational Unified Process (RUP) to strategize the Implementation of Rational Unified Process effort in different iterations and phases (Inception, Elaboration, Construction and Transition) of the Systems Life Cycle methodologies. Prepared various artifacts for all the phases of RUP.
• Led JAD sessions with stakeholders to analyze system needs and integrate requirement to develop a consistent navigation structure
• Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non functional requirements.
• Involved in up-gradation of Confidential X12 4010 transaction to Confidential X12 5010
• Responsible for business analysis, requirement specifications, project planning and identifying the resources and implementation of the project.
• Performed the Gap analyses of the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.
• Worked with the QA (Quality Assurance) team for designing Test Plan and Test Cases for the User Acceptance testing- Defined test cases, creating test scripts, analyzing bugs, interacting with QA / development teams in fixing errors and User Acceptance Testing (UAT).
• Created functional flow diagrams, context diagrams and other high level diagrams for documenting the functionality of separate modules using MS-Visio and UML.
• Worked on different modules of MMIS and MITA.
• Implemented Traceability Matrix and Business Requirement Specification Document verified the functionality coverage.
• Used MS Project to maintain the project schedule and track its status.
• Responsibilities involved interface with end-users, obtaining approval, identifying information, procedures and decision flows, evaluating existing procedures, methods and technical documentation.

Environment: UML, RUP, MS-Sharepoint, MS-Project 2000, MS-VISIO, CMMI, Quality Center, windows 2000, EDI, Confidential compliances.

Confidential, Moon Township, PA

Business Analyst

Confidential is a diversified national insurer in the United States. Based in Bethesda, Maryland, Coventry operates health plans, insurance companies, network rental and workers’ compensation services companies. It is currently ranked the third most successful prescription drug plan service in the United States.

Project Description:

The project involved Claims Management for Healthcare Payers solutions streamline claims processing, speed access to customer information, and ensure the security of private medical information. The overall goal was to reduce the labor costs associated with processing covered live claims, utilize a single platform for all incoming data sources, automatically route claims for review and approval, and increase the accuracy and timeliness of payments. Shrink paper storage and document retrieval costs while complying with regulatory standards including Confidential .

Responsibilities:

• Worked extensively with the users and with different levels of management to identify requirements, use cases and to develop functional specifications.
• Assisted the UI architect in developing a new UI for the claims reimbursement process.
• Created Data Flow Diagrams (DFD), ER diagrams for data modeling and Web-page mock-ups using MS Visio for acceptance from end users.
• Worked on claim processing module which involved Receipt and Verification of Claim Forms (837) and Claims Attachments (275), Claims Enquiry and Response (276/277), Adjudication, Healthcare Claim Payment/Advice (835) as per Confidential guidelines.
• Involved in the day-to-day implementation of the Rational Unified Process (RUP) methodology of application development with its various work flows and artifacts.
• Prepared Business Flow diagrams, UML Activity diagrams and Use Case diagrams.
• Performed GAP analysis and documented business and system level use cases to derive the requirements illustrating the functional behavior.
• Organized use case documents and developed RTM using Rational Requisite Pro.
• Submitted change requests and worked with change request records in Clear Quest.
• Participated in entering, tracking system defects in Rational Clear Quest.
• Actively participated in the weekly defect status meetings to review and prioritize the defects within a functional area.
• Involved in the different phases of test effort like Black Box testing, User Acceptance testing, Regression testing, and Back End testing.

Environment: MS SQL, C++, Windows, Rational Rose, Rational Requisite Pro, QualityCenter, Clear Case, UML, Rational Suite, MS Visio, MS Project, MS Office.

Confidential, Tampa, Florida

Business System Analyst

Confidential is the nation's leading provider of comprehensive home health services. Gentiva serves patients through more than 350 direct service delivery units within approximately 250 locations in 35 states. Gentiva Health Plan is a community-accountable health plan that serves nearly 800,000 residents through four free or low-cost health insurance programs: Medi-Cal, Healthy Families, Gentiva’s Healthy Kids. Coordination of Benefits (COB) is a Health Care Financing Administration (HCFA) Program undertaken by Gentiva. Medicare Coordination of Benefits is the process for ensuring that payment of Medicare beneficiaries' claims is properly shared among insurers when the beneficiary is covered by private insurance in addition to Medicare. By coordinating benefits, the COBC assists Medicare in paying claims more accurately the first time, which saves costly follow up and mistaken payments.

Responsibilities:

• Assisted in gathering requirements and prepared business requirement documents (BRD).
• Translated BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models.
• Defined Use cases from requirements and helped convert them into software specifications.
• Involved in Confidential /EDI Medical Claims Analysis, Design, Implementation and Documentation.
• Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Written multiple Use Cases for multiple transactions include 837I, 837P, 835, 276, 277, 270, 271(both inbound and outbound) transactions.
• Maintained Requirement Traceability Matrix (RTM).
• Use Case development and UML modeling using modeling tools like Rational Rose/MS Visio.
• Presented the nursing outcomes to C-Level executives in Gentiva Nursing and Data Management group using Crystal Reports XI.
• Expertise in building applications using SQL and Oracle.
• Analyzed business needs, created and developed new functionality to meet real time data integration that facilitated decision-making.
• Created product documentation, printed user manual and training materials.
• Developed queries using SQL to automate the weekly and monthly “Meds Update Reports” and FCO reports.
• Coordinated Regression Testing and created test scenarios for User Acceptance Testing (UAT).
• Maintained documents for change request and implemented procedures for testing changes.

Environment: Rational Rose, Rational ClearCase, RUP, MS Visio, MS Project 2000, UML, HTML, Qualitycenter, SQL Server, MS Office (Word, Excel, PowerPoint), Load Runner, OO Modeling.