SUMMARY

• Around 6+ year of experience in business process and software development life cycle, including analysis, design, development, testing and implementation of software applications in Health Care domain as business analyst.
• Expertise and Strong knowledge of ISO, Six Sigma standards.
• In depth knowledge and understanding about Business Requirement gathering, Business Process flow, Business Process Modeling and Analysis, design documentation.
• Experience in all phases of the Software Development Life Cycle (SDLC) including Requirement gathering, Design, Development, Testing and Deployment.
• Done requirement gathering by conducting formal interviews, surveys, questionnaire, and joint application development (JAD) sessions with the subject matter experts (SME’s) and stakeholders of the projects.
• Well versed with Joint Application Development method (JAD), Rational Unified Process (RUP), have knowledge of Rapid Application development and Agile Application development methods.
• Expertise in Analysis and Review of Software and Business Requirement Documents.
• Experienced in performing Business Process Reengineering/Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
• Experienced working in Medicare and Medicaid projects.
• Managed complex business initiatives to balance requirements for functionality, efficiency and quality.
• Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction, code set rules such as 837-Institutional, 837-Professional,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, EDI 834, ICD9-ICD10.
• Exceptional Problem Solving and Sound Decision Making capabilities, along with the ability to resolve difficult situations.
• Experienced with Rational tools like Rational Req Pro, Clearquest, ClearCase, JIRA, Rational Rose, and FACETS.
• Extensive expertise in databases like Oracle, SQL.
• Exceptional Documentation Skills for writing Use Cases and Functional Requirement Documents.
• Expertise in creating Use Case diagrams, Activity diagrams, Data Flow Diagrams (DFD), Sequence diagrams, State diagrams based on UML Methodology and business process flow diagrams using MS Visio/Enterprise Architect/Rational Rose.
• Good Knowledge of Test Plan, Test Scripts and Test Cases for Functional, System, Integration, UAT, and Regression Testing based on the Design Document and User Requirement Document for the Functional, Security, and Performance Testing.
• Excellent communication and presentation skills. .
• Professional with extensive experience in the development, implementation and integration of strategies within a team oriented environment, utilizing quantitative and qualitative analytical skills.

TECHNICAL SKILLS

• Project Methodologies: Rational Unified Process (RUP), UML, Agile
• Operating Systems: Win 98/XP/Vista/Windows 7, UNIX, LINUX, Mac.
• Databases: Oracle, MS SQL server, MS Access, IBM DB2
• Languages: C, C++, Java, SQL, HTML, XML, C#, VB, ASP, .Net
• Tools: MS Office: Word, Excel, Access, Power point, Project, Visio, Front Office, Rational Rose, Software Modelenr, Business Modeler , Doors, PROLOG, Clearcase, Clearquest, WinRunner, LoadRunner, WebSphere, Team Test, HP Quality Centre, Ultra Edit, MMIS,TOAD and Test Director.
• Industry Standards: HIPAA, ISO,SOX, Six Sigma, CMM, HL7.

PROFESSIONAL PROFILE

Confidential, Overland Park, Kansas (Mar 2011- Present) Business Analyst

HUMANA 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. The company’s managed care plans include preferred provider organizations (PPO); health maintenance organizations (HMO); point-of-service plans (POS); traditional indemnity plans; and other hybrid plans, including consumer-driven health plans, hospital only, and limited benefit products. The Company provides full-service benefits and wellness solutions, offering an array of health, pharmacy and supplemental benefit products for employer groups, Government benefit programs, and individuals, as well as primary and workplace care, through its medical centers and worksite medical facilities. The project was to develp Claims record system to validate patient demographics and verify insurance claims eligibility in real time. The features of this project included Medicare/ Medicaid Eligibility and Billing Verification, Self-Pay/Commercial Eligibility and Billing Validation, Real Time Processing, Billing Address Verification with Address History and Insurance Eligibility Verificationand HMO/PPO member valification and provider list. Wellpoint is using HIPAA 4010 transactions to support the analysis of current business, also analysing and testing HIPAA 5010 for claims.

Responsibilities:

• Maintained and monitored project progress and status through MS Project.
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837,835, 270, and 271.
• Analyzed HIPAA 5010 related to 837,835, 270, and 271. Transactions and performed gap analysis between the 4010 and 5010.
• Extracted the business requirements from the stakeholders keeping in mind their need for the application and documented them using Rational ReqPro.
• Implemented the entire Rational Unified Process (RUP) methodology of application development with its various workflows, artifacts and activities.
• Analyzed business requirements, tested high level and low level Use Cases and Activity Diagrams / State Chart Diagrams using Rational Rose, thus defining the Data Process Models.
• Conducted the FRS and URS reviews and walkthroughs with designers, developers and stakeholders. Also conducted feasibility and adaptability study.
• Developed the business anomalies workarounds and described them in documentation and presented the matter to the upper management for review.
• Developed non-functional requirements and documented them as Business Rules, Quality attributes and constraint documents.
• Responsible for GAP analysis of ICD9-ICD10.
• Involved with ICD10 implementation testing.
• Involved in Facets Configuration to make sure all information will be sent without any error.
• Effective communication made possible between the developers and the end-clients to guarantee that development efforts were within the scope of the project and the development was as expected.
• Attended Facet’s training and discussion session.
• Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.
• Facilitated smooth transition of the project from the project environment to the live environment.
• Worked with QA lead in validating Test Plan and Test Scenarios.
• Executed test scripts in different cycles to get the perfection and logged defects in defect tab of Quality center.
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Executed test cases manually. Compared and analyzed actual with expected results and reported all deviations to the appropriate individual(s) for resolution.
• Involved in automation testing using QTP.
• Involved in performance testing using Load runner.
• Assisted Business User during deployment in formulating User Acceptance Testing (UAT) for customized application and getting confirmation for product Release

Environment: MS Project, SQL, Rational Unified Process (RUP), Rational Requisite Pro, Rational Rose, Microsoft Visio, QTP, HP Quality centre, Load Runner, Rational Clear Quest, Windows, MS Office, XML, TOAD, Ultra Edit.

Confidential, Sacramento CA (Mar 2010– Feb 2011) Business Analyst

ACS HealthCare also offers behavioral health benefits, assistance and work/life support programs, medical management and a range of industry-leading health & wellness services. ACS Navigator Web Application, which provides the quality level of Health services for customers. The web site and the supporting system are developed to provide online insurance services to their customers and Agents. The insurance Application involves quotation tool and also enables the customer to complete the transaction after selecting the insurance plan, pricing, location details etc. Also agents are allowed to quote or complete the application online on behalf of the customer. This includes Health insurance, Policy and Claim Service modules. Health insurance claims automation was the module I focused on. The existing mainframe based batch processes were gradually replaced with distributed processes.

Responsibilities:

• Fully responsible for requirements gathering and documentation.
• Created use case narratives to record Subscription business rules.
• Analyzed the business rules for the international user subscription and impact of localization.
• Provided technical Expertise on the use of Rational Clear Case and Requisite pro, which were used for Data archiving and Requirements Management.
• Defect Tracking with Clear Quest, Configuration Management with Clear Case.
• Involved in preparing test plan, test script and test cases based of functional requirements using Rational Test Manager.
• Executed test cases and saved result.
• 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.
• Worked with Business users to come up with Reporting Requirements. Reports were developed in Cognos.
• Produced various artifacts e.g. Functional Requirement Specifications (FRS) and Wireframes.
• As a point person responsible for resolving business rules/conflict resolution for the development team.
• As member of system architecture team designed and reviewed user interface.
• Developed Business case and assessed the ROI.

Environment: RUP, Rational Requisite Pro, Rational Clear Quest, MS office, Visio, Project, Clear Quest, Clear Case, Windows XP, HP Quality Center, Test Manager.

Confidential, Nashville, TN (Jan 2009– Feb 2010) Business Analyst

The Tennessee Department of Health works to protect, promote and improve the health and well-being of Tennesseans and those who visit our great state. Keeping people healthy by preventing problems that contribute to disease and injury is the overall emphasis of the department. The project involves enhancement to an existing system, DOSS (Derivative Operations Support System), that supports all of DAG’s key functionalities including reconciliation, debt accounting, hedge accounting and non hedge accounting.

Responsibilities:

• Performed SWOT and Gap analysis for the new functionality requirements
• Worked with HIPPA rules and regulations to draft business rules and claim processes.
• Interacted with the client and the Technical Team for requirement gathering and translation of Business Requirements to Technical specifications.
• Tested different functionality of the application like Medicaid eligibility data, state available funds program, Medicaid claim processing etc.
• Identified and documented the dependencies between the business processes.
• Responsible for testing Medicaid Claims for peach state health plan using MMIS.
• Tested all internal and external file transfer outputs manually and automatically.
• Extensively involved in mapping data from various sources to the target database tables.
• Helped improve the loading process for various external data into Oracle database.
• Work
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
• Responsible for teaching sessions for end user to tell how to use tools.
• Used MS Project for various planning and budgeting activities.

Environment: Rational Unified Process (RUP), UML, Dreamweaver, Rational Test Manager, WinRunner, Rational Clear Quest, Windows, MS Office, Rational Rose, HTML, Windows.

Confidential, Minneapolis, MN (Feb 2007– Dec 2008) Business Analyst

Unicare is a national organization dedicated to the delivery of quality health care plans and products to its customers. This project 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:

• Analyzed current business process flow by understanding preset business rules and conditions.
• Conducted formal interviews, Live Meetings and JAD sessions with business users Subject Matter Experts (SME’s)
• Designed and developed Use Cases, Activity Diagrams and Sequence Diagrams using UML.
• Involved in Backend Testing to verify data integrity by using SQL.
• Documented, organized and tracked the requirements using Rational Requisite Pro.
• Created Data Flow Diagrams (DFDs), ER diagrams for data modeling and Web-page mock-ups using MS Visio for acceptance from end users.
• Defined project milestones, schedules, and monitored progress using MS-Project and updated plans as required.
• Analyzed and tested Data Interface needs with external systems.
• Analyzed, manipulated and updated Database using SQL.
• Gap Analysis: Analyzed the client’s applications programs to determine the impact of the HIPAA rule on EDI Transaction Set and Code List implementation and defined the changes to bring the affected systems into HIPAA compliance.
• Assisted with user testing of systems and maintained quality procedures and ensured appropriate documentation is in place.
• Maintained Requirement Traceability Matrix (RTM) and Utilized Clear Quest for change requests and defect tracking.
• Claim validation and Pend/Denied Claims Analysis for the Health plans Medicaid programs.
• Worked closely with the technical team to look up for the best possible solution on requirements by keeping business needs and technical constraints in mind.
• Updating, transferring and sharing Files using FTP between Windows and UNIX machines.

Environment: UML, MS Word, Rational Requisite Pro, Rational Clear Quest, Quality Center, SQL, FTP, TelNet

Confidential, Pune India (June 2006 – Jan 2007) Jr. Business Analyst

Spang Technologies provides a unique "In-the-cloud" Delivery model using a Software-as-a-Service ("SaaS") platform. This solution helps organizations reduce the time; cost and risk associated in delivering key infrastructure services like Unified Communication, Security and Compliance. Spang Technologies hosts its "SaaS" platform (called CASPER) in key locations for effective delivery. Spang Technologies's regional centers provide businesses hour support locally in partnership with channel partners. The regional centers are supported by 24x7 monitoring centre in India. The primary purpose of this project was to replace the previous “SaaS” tool with the newly built in-house system. Perform quality checks for the developed software. Analyze the risks and market potential of the system

Responsibilities:

• Derived Functional Requirement Specifications (FRS) based on User Requirement Specification (URS). Understand and articulate business requirements from user interviews and then convert requirements into technical specifications
• Reviewed Test plans, Test cases, Test case execution using specification documents and Rational Test Manager.
• Performed Smoke Testing to ensure that the compiled software components of the Applications adhere to Project Standards, Performance Criteria and Functional specifications to ensure feasibility of testing effort.
• Facilitated User Acceptance Testing (UAT) with the stakeholders and the business users, and the errors discovered were fixed and then verified via regression testing.
• Frequently updated the requirement and defect status as per the current status of the testing project in the Clear Quest.
• Experience of managing help desk workflows, processes and SLA matrix using tools like Service Desk, Remedy or similar tools

Environment: HTML, RUP, UML, SQL,MS-Office, MS Project, MS Visio, Requisite Pro, Test Director, Data Warehousing.