SUMMARY

• Overall 6+ years’ experience as a Health Care Business Analyst.
• Extensive experience in Clinical Data Management, data analysis and generated CRT tables, reports, graphs for FDA submission according to protocol.
• Experienced in payer rules, requirements, governmental regulations and HIPAA compliance. Interacted with claims payment and enrollment to review, analyze and document business processes.
• Experience with healthcare system, Medicaid and with prime focus on claims adjudication, provider, eligibility and prior authorization.
• Expertise in developing Software Test Plans, Test Case Design, Test Scripts based on User Requirements Specification (URS),System Requirements documents(SRS), Functional Requirement Specification Documents(FRS)
• Exposed to SOX, HIPAA / EDI transaction code include (270, 271, 276, 277, 278, 834, 835 and 837).
• Strong experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases. Expertise in designing and developing Test Plans and Test Scripts
• Data Processing experience in designing and implementing Data Mart applications, mainly transformation processes using ETL tool DataStage
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Experience using MS Visio, Rational Unified Process (RUP), Rational Rose, Requisite Pro, Advanced MS Excel.
• Experienced in SQL Server Reporting Service (SSRS), Executing Queries and Running Store Procedures.
• Experience in using the guidelines and artifacts of the Rational Unified Process (RUP) to strategize the implementation of RUP effort in different phases of the project.
• Experience with System Life Cycle (SLC) and Medidata RAVE application.
• Exceptional Documentation skills for writing use cases, business requirement documents and functional requirement documents as well as for creating Use Case diagrams based on UML Methodology and business process flow diagrams using EA, Requisite Pro and MS Visio
• Excellent analytical, problem-solving and interpersonal skills and Effective verbal and written communication skills
• Solid team player with initiative, adept at building relationships with colleagues and customers.

TECHNICAL SKILLS

EDI transactions: 270,271,276,278,810,820,835 and 837(P, I & D)

Healthcare Management: HIPAA, HL7, ISO 9000, Six Sigma and TQM.

Healthcare Claims Systems: NASCO

Operating Systems: Windows XP, Windows 2000

Languages: UML, SQL, PL/SQL and Client/Server architecture. .

Database Analysis: Oracle 8, MS Access, SPSS and

Process/Model tools: Rational Suite and MS Visio

Testing Tools: Win Runner and Test Director.

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

PROFESSIONAL EXPERIENCE

Confidential, NY, NY

Sr. Business Data Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Responsible for writing Functional Requirement Specifications (FRS) and User Requirement Specification (URS).
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Developed straightforward DBMS queries, knowledge of HL7 and xml interface messaging.
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Designed and developed ETL processes using DataStage designer to load data from Oracle, MS SQL, Flat Files (Fixed Width) and XML files to staging database and from staging to the target Data Warehouse database.
• Assisted the database development team in data modeling, data structure and data table layouts required for consolidation of incongruent databases,
• Involved in integration of various Customer Data Sources and provided Data Mapping from various sources like CCD, LPCD, DCD into the target centralized customer data source.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology
• Established a RUP (Rational Unified Process) centric business analysis methodology.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Used DataStage stages namely Hash file, Sequential file, Transformer, Aggregate, Sort, Datasets, Join, Lookup, Change Capture, Funnel, Peek, Row Generator stages in accomplishing the ETL Coding.
• Coordinating and Developing QA activities.
• Actively involved in developing, executing and managing User Acceptance Testing (UAT).
• Conducted phase planning and requirements gathering session with project team, clinical staff and physicians to customize EMR system.
• Developed test plans with QA team and helped test every scenario using Mercury Test Director Tool for system testing
• Assigned tasks among development team, monitored and tracked progress of project following Agile methodology.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Wrote Test Cases and performed User Acceptance Testing, documented the in detail defects using the Defect Tracking report.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created Use cases, activity report, logical components and deployment views to extract business process flows and workflows involved in the project. Carried out defect tracking using Clear Quest
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.

Environment: Requisite Pro, Rational Rose, Agile, HL7Interfaces, UNIX, PL/SQL, HTML, MS Office, MS Visio, EDI, UML.

Confidential

Business Analyst

Responsibilities:

• Worked on EDI transactions processing: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Experience with EMR implementation and post-implementation support.
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
• Conducted user interviews, gathered requirements, and analyzed the requirements using Rational Rose & Requisite Pro - RUP in Clinical Phases I, II, III
• Developed modules for extracting encounter data from multiple systems, converted to common format, and loaded into a regional Health Information Exchange for regional patient care management and clinical decision support.
• Documented ETL test plans, test cases, test scripts, and validations based on design specifications for unit testing, system testing, functional testing, prepared test data for testing, error handling and analysis.
• Performed In-Death analysis of systems and business processes of Medicare Part D as per CMS rules and procedures.
• Involved in testing the Pharmacy Claims adjudication and Billing processing is done through PBM (Health Trans) and Claims Accumulation and Adjudication is done through Diamond.
• Worked with X12 standard SME for 834 and 837 transaction sets requirements with HL7.
• Developed plan for data feeds and data mappings with the use of HL7 for integration between various systems, to follow ICD 9/ICD 10 Code set and ANSI X12 5010 formats
• Researched the existing client processes and guided the team in aligning with the HIPAA rules and regulations for the systems for all the EDI transaction sets.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Working within a growing knowledge of X12 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid.
• Troubleshoot file transmission problems and assisted customers in a call center environment with EDI and Medicaid Insurance claim related inquiries explained and enforced guidelines in the X12 Implementation guides (837P, 837I, 837D, 270/271).
• Used Quality Stage to check the data quality of the source system prior to ETL process.
• Design and review of various documents including the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM) and testing documents
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI Transaction, Code set and Identifier aspects of HIPAA.
• Used Test Director and Mercury Quality Center for updating the status of all the Test Cases & Test Scripts that are executed during testing process.
• Used MS Visio for Process modeling, Process mapping and Business Process flow diagrams.
• Performed UAT and exposure to User Certification Testing (UCT) and Operational Readiness Testing (ORT)
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access. Produce performance reports and implement changes for improved reporting.
• Used Rational Tools for creating use cases, version control and defect tracking, monitoring. Use Rational Unified Process (RUP) methodology in all areas of the software development life cycle (SDLC).
• Performed source data profiling to verify that data meets the business requirements.
• Facilitated Deign/Development (technical design) review’s and ensured that business and system requirements are met.
• Played major role in writing lower level and upper level Use case.

Environment: Technical Analyst, Share Point, C#, Java, NET, SQL, PL/SQL, UML, MS Office Suite (Word, Excel, Access, PowerPoint, and Outlook, MS-Project, Visio), Requisite Pro.

Confidential

Business Analyst

Responsibilities:

• Worked according to the activities/roles laid down in each phase of software development life cycle created using Rational Unified Process.
• Working within a growing knowledge of X10 4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, 278, EDI, Privacy, Security, and Medicaid.
• Responsible for developing Front end edits for claimsadjudication
• Develop MITA Maturity Model (MMM) & Business Capability Matrix (BCM) to identify the maturity level of SD Medicaid Enterprise.
• Involved in creating specifications for ETL processes, finalized requirements and prepared specification document.
• Involved in performance testing of Medicaid client server claims processing system, Medicaid MCC / MCO and Medicaid Management Information System (MMIS)
• Worked on EDI transaction 835 to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Authored test plans, test cases for various test scenarios and helped testing team to better understand the test scripts.
• Applied RUP methodology with its various workflows, artifacts and activities to manage life cycle from Inception to Transition phase.
• Extracted the Business Requirements from the end users keeping in mind their need for the application and prepared Business Requirement Documents (BRD) using Rational RequisitePro.
• Prepared a Project Charter and a detailed Business Requirements Documents (BRD).
• Defined, developed specs for federal reporting specific to Medicare Advantage
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access. Produce performance reports and implement changes for improved reporting.
• Developed Use Cases in Microsoft Visio along with Activity Diagram to present the workflow in a visual form.
• Performed task decomposition, delegated tasks and monitored project milestones using MS Project.
• Developed test cases and scripts based on business requirements for the functional, User Acceptance, Performance, Integration testing, System Back-end Testing and End-To-End testing.
• Interacted with the users and logged any defects, enhancements from the UAT and communicated them to the development team

Environment: RUP, UML, Word, Excel, PowerPoint, SQL, Project, Visio, SharePoint, ADR, IBM Web sphere, J2EE, Mercury Test Director, Lotus Notes

Confidential

Business Analyst

Responsibilities:

• Helped in defining Change Management Process for Release Management Team.
• Prepared Business Object / Business Process Models that included modeling of all the activities of business from conceptual to procedural level.
• Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Used DataStage as an ETL tool to extract data from sources systems, loaded the data into the SQL Server database.
• Validated the following: 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response), 834 (Enrollment/Dis-enrollment to a health plan)
• Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, business process flows, and prototypes and management reporting requirements
• Created the business process model using MS Visio for better understanding of the system and presented it to Project Manager and other team members for validation.
• Performed the requirement analysis and documented the requirements using Rational Requisite Pro.
• Assisted the Project Manager to develop both high-level and detailed application architecture to meet user requests and business needs.
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access.
• Created and segregated SQL views and stored procedures for obtaining meaningful set of data.
• Planned and defined system requirements to Wire Frame with Use Case, Use Case Scenario and Use Case Narrative using the UML (Unified Modeling Language) methodologies.
• Sound understanding of Object Oriented Analysis and Design OOAD and proficient in documentation of as-is and To-be business processes.
• Led and conducted JAD sessions for requirements gathering, analysis and design of the system.
• Created context and workflow models, information and business rule models, Use Case and Object Models during the analysis using rational tools.
• Designed and developed project document templates based on SDLC methodology
• Established RUP (Rational Unified Process) methodology and provided assistance in developing Use cases and project plans.
• Analyze business requirements and segregated them into Use Case Diagrams, Activity Diagrams, Sequence Diagrams, and OOD using Borland Together according to UML methodology thus defining the Data Process Models.
• Documented Requirements for Management Reporting out of Clear Quest using Crystal Reports.

Environment: Requisite Pro, Rational Rose, Agile, PL/SQL, Oracle, HTML, MS Office, MS Visio, EDI, Rational Clear Quest, Rational Clear Case, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.

Confidential - Chicago, IL

Business Analyst

Responsibilities:

• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests.
• Established a Business Analysis methodology around the Rational Unified Process.
• Facilitated preliminary sessions with the client SMEs for the upcoming 5010 transaction sets on Claims and Payment. Identified needed modifications for upcoming ICD9/ICD10 directives from the then available documents from World Health Organization, and CMS.
• Researched the various steps in the lifecycle and then constructed the system in a way that the high risk customers would be easily identified and monitored.
• Performed ETL coding using Hash file, Sequential file, Transformer, Sort, Merge, Aggregator stages compiled, debugged and tested. Extensively used stages available to redesign DataStage jobs for performing the required integration.
• Interaction with underwriters to understand multiple data points. Prepared data flow diagrams using MS Visio for better clarity and to ensure documented process
• Met with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business requirement Document.
• Ensured that all Lines of Business specifications were consistent in form and function to the Diamond Base System.
• Provide implementation assessment, strategy, and mentoring services for Rational Rose, UML and RUP.
• Installed, authored, and managed reports using SQL Server 2005 Reporting Services.
• Developed project plans and managed project scope.
• Gather requirements by conducting meetings and brainstorming sessions with end users and SME and document them using Requisite Pro - the documentation tool offered by Rational.
• Managing personnel allocation and SDLC process for systems projects enhancements
• Worked extensively with MS Excel and MS access
• Defining test cases, creating test scripts, analyzing bugs, interacting with QA / dev teams in fixing errors, SIT and (UAT)
• Created the SQL scripts for demonstrating the prototypes and for verifying the result sets
• Teamed up with both internal and external software development groups to provide functional requirements specifications in form of use cases, business process flows, and prototypes and management reporting requirements
• Ensured that project/requirement(s) are properly tracked and documented as per Project Manager’s needs
• Involved in project management using MS Project
• Designedand implementedaweb service to support the outsourcing of clinical trial disclosure.
• Assisted in building a Business Analysis Process Model using Rational Rose and Visio.
• Performed extensive Requirement analysis and developed use cases and workflows.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, and OOD
• Performed usability analysis and testing including user interface design throughout the development life cycle, provided Client meetings, Artifacts and end-user training on application usage and General IT knowledge.
• Worked with Siebel users and co ordinate with the teams involved in testing the user interface and backend testing
• Gather final requirement and draft the BRD and Business Data Flow Diagrams
• Conducted JAD sessions for communicating with Stakeholders and Project directors.
• Developed business requirement specification documents as well as high-level project plan.
• Responsible for all risk assessment and management activities including business continuity, disaster recovery planning and physical and information security.
• Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models that includes modeling of all the activities of the business from the conceptual to procedural level. Followed top down, levelled technique for building Business Process Models.

Environment: SQL Server, Oracle, Rose, MS Word, MS Excel, MS Visio, LoadRunner, WinRunner