PROFESSIONAL SUMMARY:

• 7+ years of experience as a Business Analyst in Health Care, and Banking industry
• Strong knowledge of the Scrum Methodologies and Software Development Life Cycle methodologies like Agile and Waterfall models.
• Proficient with E-commerce Content Management requirements
• Experienced with Iterative approach for Software Development as per Rational Unified Process (RUP). Involved in inception, elaboration, construction & transition phases using rational tools like Requisite Pro, Clear Case and Clear Quest during various phases of RUP.
• Experienced in interacting with business users to identify their needs, gathering requirements and authoring Business Requirement Documents (BRD), Functional Requirement Document (FRD) and Software Requirement Specification (SRS) across the deliverables of a project.
• Experienced in facilitating Joint Application Development (JAD), Rapid Application Development (RAD) and Joint Requirement Planning (JRP)sessions, interviews, workshops and requirement elicitation sessions with end-users, clients, stakeholders and development team.
• Experienced in Business Analysis, SWOT Analysis, Gap Analysis, Risk Analysis, Disaster Recovery Planning, Testing and Project Planning.
• Extensive knowledge of Medicaid, Medicare, Procedural and Diagnostic codes and Claims Process.
• Expertise in EDI and HIPAA Testing Privacy with multiple transactions exposure such as Inbound Claims 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions and testing in Client Server systems and Mainframe Applications
• Experience in Conversion of HIPAA X12 4010 codes to X12 5010 codesand ICD 9 codes to ICD 10 codes
• Experienced in analyzing and documenting business requirements and system functional specifications including Use Cases
• Strong Knowledge of UML, RUP, Rational Tools, E-commerce and EDI
• Proficient in creating Sequence Diagrams, Collaboration diagrams, Activity Diagrams, Class Diagrams using Rational tools and Microsoft Visio
• Experienced in Share Point
• Strong knowledge of Business Process Modeling, Business Intelligence and Business Architecture.
• Experienced in writing Test Plans and executing Test Cases
• Skilled in validation and testing complex scenarios for the maintenance of quality standards in projects
• Experienced in creating User Manuals and providing training to users.
• Creative and Aggressive person capable of forming and maintaining positive and productive team environments with integrative thinking skills.
• Perform data mining activities of gathering and compiling data to make a thorough analysis and to extract the relevant information.
• Exceptional Problem Solving and Sound Decision Making capabilities, along with the ability to resolve difficult situations.
• Professional with extensive experience in the development, implementation and integration of strategies within a team oriented environment, utilizingquantitative and qualitative analytical skills.
• Competent inusingbusinessintelligencetools of enterprise resource planning, online analytical processing, data mining
• Excellent communication and presentation skills.

EDUCATION

• Master of Business Administration.
• Bachelor of Arts (Major: History and Spanish).

TECHNICAL SKILLS:

Project Methodologies: Rational Unified Process (RUP), UML, Agile, Scrum
Business Modeling Tools: MS Visio, MS Project
Requirement Management Tools: Rational RequisitePro
Operating Systems: Windows NT/XP/2000, MS Dos, UNIX
Databases: SQL Server, MS Access
Languages: SQL, UML
Quality Assurance: Software Application Testing Life Cycle
Business Applications: Microsoft Office Suite- Word, Excel, Project, Outlook,PowerPoint

WORK EXPERIENCE:

Confidential, New York, New York Aug 2010- February 2012
Business Analyst / EDI Specialists

Group Health Incorporated (GHI) is a statewide health insurer serving New Yorkers since 1937. GHI and its wholly owned subsidiary, GHI HMO, provide health care coverage and administrative services to more than 2.6 million people. GHI offers customers a variety of PPO, EPO, and HMO programs, as well as prescription drug, dental, and vision plans. Throughout its history GHI has pioneered many of the programs that are now standard in the health insurance field. The project was ERRP (Early Retiree Reinsurance Program).ERRP a provision of Patient Protection and Affordable Care Act (PPACA), provides reimbursements to plan sponsors for a portion of the cost of providing health benefits to retirees between the ages of 55-64, and their covered dependents regardless of their age. This temporary program makes available $5 Billion to help employers continue to provide coverage to early retirees.

• Worked as the First line of contact forthe company regarding E-Commerce, EDI, and other B2B for customers, suppliers, and internal users.
• Created business requirement document, functional specification document, test plans for the project.
• Responsible for the smooth functioning of all ecommerce activities of the organization.
• Worked closely with business users and IT team leads to identify, prioritize, and complete systems projects for the assigned area and help to apply the SDLC and Scrum Methodology in a logical and reasonable manner identifying opportunities for tailoring the process to the specific project needs
• Provided technical support assistance for customers which may include the identification of mapping issues, high level explanation of business processes, resolution of production problems, monitoring/researching of error reports/emails, and the reprocessing of data.
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Gathered accurate and relevant incident information and Documented problems for escalation
• Identified Early Retirees, Completed Early Retiree list Setup, Formatted and Submitted Retiree List and Reviewed the Early Retiree Response File. .
• Coordinated the setup of new trading partners, including planning, project management, testing, documentation, and implementation. Developed and maintained functional specifications for new / existing applications needed to maintain/enhance EDI processing and address the requirements of new trading partners. Participate in transaction analysis and mapping needs, system / interface analysis, and work with programmers to implement changes as needed. Ensure that regulatory transactions and security standards have been met.
• Developed several detailed summary reports including line and pie charts and trend analysis report using business intelligence
• Performed MBD check for response files (Verified ERRP coverage by checking Medicare coverage dates).
• Enhanced or developed new documentation of current business process flow and definition of future EDI business information flow.
• General process improvement input by attending conference calls and partner visits.
• Actively used Scrum Agile Methodology with daily status meetings, weekly iterations, iteration planning meetings, test driven development, continuous integration, constant communication with end users.
• Responsible for managing relationships with the business units as well as interacting with software vendors and consultants for development and support.
• Participated and coordinated the validation of the solution, regression testing, user acceptance testing, and training.
• Developed and maintained documentation of all technical and procedural changes affecting the Specialist's area of responsibility.
• Developed and maintained SOPs and operational procedures to follow good business practices and remain compliant with the governing regulations.
• Responsible for the accuracy and timeliness of the daily processes of the organization's electronic data interchange systems, support of internal users, trading partners, testing and roll-out of related procedures.

Environment: MS SQL, Windows XP, Requisite Pro, Clear Case, UML ,Business Objects, MS Visio, MS Project, MS Excel, UAT, Software Development Lifecycle, Business Intelligence, TSO.

Confidential, Philadelphia, Pennsylvania Jun 2009 - July 2010
Business Analyst

Confidential provides health care and related benefits in the United States and internationally. The Health Care segment offers insured and self-funded medical, dental, behavioral health, vision, and prescription drug benefit plans; health advocacy programs; other products and services that provide individuals with health care benefit programs; and disability and life insurance products, as well as operates retail pharmacies. This project aimed at streamlining and standardizing of the claims process which was achieved by incorporating the business rules to increase automation, enhanced interfaces for seamless integration with back-office systems and claims tracking system. For successful implementation of the new ICD10 codes and HIPAA 5010 guidelines, was responsible for mapping everything from business processes and policy changes to budget and communication plans.

Responsibilities:

• Gathered requirements from Business Managers, Supervisors, stakeholders, Data Governance Team and the subject matter experts through meetings to understand needs of the system.
• Conducted Interviews, user meetings, JAD sessions, and Requirement Elicitation Sessions to extract the Business Requirements to understand their need to upgrade the existing system to 5010 compliant.
• Performed gap analysis to identify and document the gaps between the existing system 4010A1 compliant and new 5010 compliant system.
• Analyzed and categorized the impacts of new HIPAA standards and applied changes on the targeted systems, processes, business-associate relationships and Providers.
• Analyzed trading partner specifications and created EDI mapping guidelines.
• Involved with project management team in developing project plan.
• Attended JAD sessions to define System Requirement Specifications (SRS) and Detailed Designed Discussions with the technical team.
• Assisted technical and testing team to ensure that the requirements are communicated accurately and that the system being developed is verifiable against the requirements gathered.
• Developed strategy for upgrading and implementing the user interfaces to be 5010 compliant.
• Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837-(I, P, & D), 835Remittances and others.
• Followed the Business Rules, and ensured that HIPAA compliant Rules are followed to display minimum benefit information.
• Managed the privacy and security environments of healthcare data that was governed by HIPAA and other government mandates.
• Maintained a record of recommendations, communications, activities, and schedules to monitor the progress of project in real time using MS Project.
• Used Share Point for document management,
• Dealt with HIPAA transactions.
• Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange (EDI).
• Documented various key elements of HIPAA compliance and made sure that they are understood by the development teams.

Environment: MSProject, SQL, Rational Unified Process (RUP), Rational Requisite Pro, Rational Rose, Clear Quest, Microsoft Visio, Windows 2000/XP, Mercury Test-Director, MS Visio, Business Objects, Software Development Lifecycle.

Confidential, Overland Park, Kansas Jul 2007 - May 2009
Business Analyst

Project Scope: Confidential sells individual and group life insurance as one of their many insurance products. It evaluates its customers' line of business with help of team of statisticians, actuaries and underwriters for feasibility of the plans proposed under different terms and conditions. State and federal Law compliance is a major factor in deciding the ROI and maturity of the insurance plan. The project was to design an automated underwriting business function, Consumer Portal-Interface for online enrolment, e Health, e Vendors-Broker sites that route business to Humana through their websites, Billing and enrollment-for Approval/Declines of applications. Involved in upgrade and integration of ICD 10 and HIPAA 5010 changes with the new application.

Responsibilities:

• Worked extensively with the users and with different levels of management to identify requirements, use cases and to develop functional specifications.
• Worked with the statisticians and underwriting team to analyze and validate run-time decision models.
• Analyzed and documented the changes in the compliance rules for adverse action redesign.
• Worked on different E-commerce and EDI scenarios for batch processing.
• Ensure day-to-day EDI transmission, Reject tracking and Reconciliation.
• Run EDI Reconciliation reports daily and document in MS Excel.
• Involved in up-gradation of HIPAA X12 4010 transaction to HIPAA X12 5010 and ICD 9-CM (Clinical modification) to ICD-10-CM/PCS (Clinical modification/procedure coding system) simultaneously.
• Maintained and monitored project progress and status through MS Project.
• Extensive use of Use cases and written business flows and work flow diagrams for effective plans.
• Created Use-Cases after accessing scope of the project and understanding the business processes.
• Integrated Requisite Pro to provide all teams visibility and maintain tractability among requirements, use cases and change requests.
• Managed all the requirements, making requirements available to all team members.
• Created requirements analysis and design phase artifacts using Requisite Pro and MS Visio.
• Conducted Asset Management, Risk Analysis of the Requirements and Traceability focus areas of the various projects and worked with the project team to help them identify the high-risk areas.
• Created Use cases, Activity, Sequence and Collaboration diagrams.
• Data mapping, logical data modeling, used SQL queries to filter data within the Oracle and Sybase.
• Responsible for co-coordinating business meetings and generating monthly status reports etc.
• Syndicated with various cross-functional teams for building business use cases.
• Assisted QA team with Test Plans and executing Test Cases.
• Design specifications and Test Case usages for the HIPAA 837i, 270/271, 276/277, 835, 824, 275 and others.
• Assist end users and IT staff in the use of data to satisfy informational and reporting requirements and implementing and using SQL and DBMS.

Environment: MS SQL, Windows XP, Requisite Pro, Clear Case, UML ,Business Objects, MS Visio, MS Project, MS Excel

Confidential, Minneapolis, MN Mar 2006 - Jun 2007
Business Analyst

Project Description: Confidential is a national organization dedicated to the delivery of quality health care plans and products to its customers. The project involved generating reports on various service providing systems such as Financial Eligibility, Claims Budget System, Claims Processing System, Automated Authorization System, Insurance and Third Party System, Correspondence, Liquidation and Encumbrance. The system primarily aimed at handling Medicare / Medicaid insurance claims and process exceptions.

Responsibilities:

• Extracted the Business Requirements from the client and end users keeping in mind their need for the application (Internet, Claims, Provider, and Recipient) and documented it for the developers following the HIPAA Guidelines for an Individual functional area by conducting JRD and JRM sessions.
• Facilitated collection of User Requirements and Business Requirements from Business User Group such as to document Business/User/Functional/Technical Requirement Specification using MS Word and MS Visio that provided appropriate scope of work for technical team to develop prototype and overall system.
• Created Use Case diagram, Sequence diagram and Activity diagram for understanding the business processes.
• Involved in the day-to-day implementation of the Rational Unified Process (RUP) methodology of application development with its various work flows, artifacts and activities.
• Identified system integration requirements, coordinated the collection and verification of business needs to reach the Requirement Analysis (Requirement Validation Specification), Detailed System Design Documentation Milestones.
• Involved in Independent verification and validation of requirements (IV and V) to ensure that all the requirements are satisfied and meet the security objectives.
• Developed Traceability Matrix using Rational Requisite Pro.
• Analyzed if the system abides HIPAA regulations as portal displays member's private information.
• Reviewed and approve technical recommendations related to software and hardware proposals (RFP).Also written Request for proposal (RFP) for getting new MMIS system.
• Involved in development of Advance Planning Document (APD) to request for federal funds and participated in the Implementation of Advance planning document (IAPD) and released RFP for new MMIS system.
• Well versed with HL-7, HIPAA, claim adjustments, claimprocessing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions
• Managed and developed EDI specifications, gap analysis, and applications structures for data feeds and mappings for integration between various systems, including XML, to follow ICD 10 Code set, ANSI X12 4010 formats including 270 Eligibility/Benefit Inquiry , 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 700 Attachment Request, 701 Attachment Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice, 837 Claims and Encounter, and 997 File Transmission Acknowledgement, to meet and exceed HIPAA requirements set forth by the federal government.
• Involved in Documenting/Executing business test cases and once the Unit testing was performed and after the results are reviewed, The Functional and System Integration testing is executed in Model Office, by which the EDS was able to systemically test and validate the system through any combination of data or cycles deemed appropriate for the Implementation and User Acceptance Testing.
• Followed Six Sigma discipline andmethodologyfor eliminating defects in process.
• Actively Participated in the Weekly Defect Status meetings, to review and prioritize the defects with in a Functional area.
• Performed detailed analysis of data issues encountered during business acceptance testing.

Environment: Windows, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), MS Access, UML, SQL, RequisitePro, Agile, Rational Rose, Quick test Professional (QTP)

Confidential Web Portal incorporates a wide range of features for policyholders and new customers. Worked with an application that was taking care of Online Account Services that included Billing Application, Checking the bill history, Changing customer profile, Ordering auto insurance ID cards and Modifying the load provider details.

Responsibilities:

• Implemented an integrated RUP solution with complete line of trace ability for all the artifacts of web development projects.
• Create tasks and update tasks in the MS Project and Project Management Directory for the senior management reviews.
• Collaboration and reviews with different application owners and SME's to ensure the GAP Analysis was performed accurately.
• Business Process Modeling: Business process improvement and optimization, Document and model business processes, Automated workflows and Manage business rules.
• Involved in documenting Business Requirements Documents by conducting interviews with the project stakeholders, SME and Business users.
• Documented business requirements to ensure they are aligned with UI from the scratch.
• Performed GAP analysis and documented business and system level use cases to derive the requirements illustrating the functional behavior.
• Detailed study of Enterprise architecture model to overcome Legacy systems that are originated from unplanned, stovepipe development or were developed as batch, single tier.
• Involved in documenting various modeling diagrams using UML.
• Thorough understanding of business process to help determine the user needs.
• Documented Traceability to ensure all the features for the project has been captured and mapped back to the requirements in the BRD.
• Performed application functionality user acceptance testing experience (i.e. front-end application testing) in a controlled testing environment that replicates the end user usability of the application.
• Documented test plan, test cases and test summary to ensure the desired application functionality is desired.
• Ensure the UAT test scripts review sessions with business owners to test the application functionality and providing necessary training material.
• Clear quest and HP quality center to log defects and assign to the right team to ensure the defects are addressed on a timely manner.
• Documented and reviewed the post implementation summary with the senior management regarding the gaps identified during the project.

Environment: RUP, Rational Rose, Clear Quest, Soda, Requisite Pro, UML, SQL, MS-Office, MS Project.

Confidential, India Jun 2003 to Nov 2004
Business Consultant
Confidential specialized in a wide variety of mortgage products. Prime function of the project was to automate the Mortgage Loan Origination Process beginning with the customer initiation to title transfer. The system performs all the business functions of the loan process such as set-up Account Information, New Loan set-up, Escrow Analysis, the Appraisal, Credit, income and Title functionalities. My primary responsibility was to develop functional specification documents for the appraisal and credit departments by gathering, analyzing and documenting requirements from various Business users associated to the system, analyze external factors and the third party data sources such as regulatory agencies and credit bureaus and document the constraints.

Responsibilities:

• Worked as business analyst to support the re-design of the Mortgage Asset Management System. Extensively involved in the development of Reporting Data Warehousing System.
• Designed the business requirement collection approach based on the project scope and SDLC Methodology.
• Facilitated and managed meeting sessions with committee of SMEs from various business areas including Mortgage Servicing, Loan Monitoring and Asset Management.
• Conducted interviews with key business users to collect requirement and business process information.
• Developed Sequence Diagrams, OOD using UML.
• Designed and implemented basic SQL queries for QA testing and report / data validation.
• Established a business Analysis methodology around the RUP (Rational Unified Process). Helped develop use cases, project plans and manage scope.
• Developed requirement reports for day-to-day retail banking needs for opening account, online baking using rational SoDA.
• Functioned as the primary liaison between the business line, operations, and the technical areas throughout the project cycle.
• Partnered with the technical areas in the research and resolution of system and process problems.
• Used SQL, Toad, Data Warehousing and Data Cleansing for the arrangement of customer data.
• Used Rational Clear Case and Clear Quest as Configuration Management and Change control tools.
• Performed User Acceptance Testing (UAT)
• Ability to work with all members of the project team, following the project through the Systems Development Life Cycle and ensuring business objectives are met (extensive project life cycle experience).

Environment: Mainframes, Cobol, Jcl, Db2, Oracle, Rose, MS Word, MS Excel, MS Visio