PROFESSIONAL SUMMARY:

• 7+ years of varied experience in Business Analysis across various domains like Re-insurance, Health care, Medical Billing and Claims Management
• Domain expertise in Health care insurance and Claims Analysis and Management
• Good working knowledge of HIPAA ICD10 and HIPAA transaction requirements. Experience with Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12 formats including 270/271, 276/277, 834, 835, 837, 997, and NSF formats for interfaces and images to third part vendor applications
• Strong understanding of medical coding and transition from ICD 9 – ICD 10
• Experience with Healthcare systems like FACTES in various areas like Enrolment, Customer Service, Billing and Network X Pricing
• Experience with claims process and adjudication in the Medicare, Medicaid and Private Insurance Sectors
• Expertise in highly automated transformation and routing of complex data across many points of integration in real time to support high-message volumes using Websphere Transformation Extender (WTX) / Mercator
• Solid experience in Claims Processing 837 transactions and remittance 835 EDI files
• Experience working with Health Care Client Server Product TRIZETTO/ERISCO FACETS
• Adept with different methodologies which include Agile, Waterfall and Rational Unified Process (RUP)
• Well versed in Requirement Gathering through techniques such as JAD sessions, Interviews, Document analysis and Reviews
• Expertise in documenting Business requirement document (BRD), Functional and Non-functional requirements in a Traceability matrix (RTM), Use case Specifications and the complete System requirement specifications (SRS)
• Design and development of Use Cases, Activity Diagrams and Sequence Diagrams using UML
• Creation of data flow diagrams (DFD) and interpretation of ER diagrams
• Experience in UML 2.0, MS Visio, Rational Rose, Rational Clear Case, Rational Requisite Pro, Rational Clear Quest & MS office Suite (MS Word, MS Excel, MS Visio, MS Project Plan & MS SharePoint)
• Expert in Tracking and Managing the Requirements using Requirement Traceability Matrix (RTM) that controls numerous artefacts produced by the teams across the deliverables for a project
• Worked with different data repositories such as Oracle 9i, MySQL and MS Access
• Experienced with current industry standards such as HIPAA and SOX
• Involved in meetings for Test Planning, Test Preparation, Test Execution and Issue Resolution and Report Generation to ensure that all aspects of a Project are in Compliance with the Business Requirements
• Reviewed Test plans to make sure all the requirements have been covered and corresponding test cases have been created
• Involved in training of end users
• Documented Training Manuals for new product releases
• Excellent analytical & problem solving skills and a team player with strong interpersonal and communication proficiency
• Involved with long term projects from the requirements gathering phase to the implementation phase
• Interface with clients from Operations, Marketing, Sales, Technologies, and Outside Vendors and act as their customer interface point as the lead of the Projects
• Highly motivated team player with excellent Interpersonal and Customer Relational Skills, Proven Communication, Organizational, Analytical, Presentation Skills, and Leadership Qualities

TECHNICAL SKILLS: UML, SDLC, Waterfall, QA, MS Access, MS Excel, SQL Server, MySQL, PL/SQL, Oracle DBA, Windows 98/2000/XP, HTML, basic DHTML, basic XML, MS Office Suite-Excel Macros, Project, Visio, Adobe Photoshop, Flash, Rational- Rational Rose, SharePoint

EDUCATION: BS Computer Science

CERTIFICATION: HIPPA privacy & security, CPR, blood borne pathogens and collection law

OTHER SKILLS:

• Inpatient/outpatient Coding, Self-pay collections, TAR
• Experience with both Government and commercial insurance companies such as Medicare, Medi-Cal, Blue shield, Blue Cross, United Healthcare, Champus, workers comp, etc.
• Cpt-4, Cash Posting, HMO, ICD-9
• Code Master, Lytec, Medisoft XP, Caminar, Vista AR, Alteer

PROFESSIONAL EXPERIENCE:

Confidential, CA September 2008-Current Business Analyst/Subject Matter Expert

The project was to develop a Provider Desktop module for the EHR (Electronic Health Record System) with the objective to improve productivity and patient care. It serves as a central dashboard for providers to access crucial information such as Patient appointments, Clinical results, Messages, Electronic lab orders and Patient encounter notes anytime anywhere. The project was implemented securing patient privacy and health information conforming to HIPAA standards and guidelines.

Responsibilities:

• Interacted closely with the Business users along with the administration and management to gather business requirements and analyze the functionalities to be incorporated into the system
• Worked on HIPAA 5010 transaction requirements and analysed and tested HIPAA ANSI X12 formats including 270/271, 276/277, 834, 835, 837, 997, and NSF formats for interfaces and images to third part vendor applications
• Analysed processes in medical coding and transition from ICD 9 – ICD 10.
• Worked with BA and UAT tasks involving FACETS application and claims processing
• Attended demo sessions to understand existing system functionalities
• Arranged interviews with all the stakeholders to review and understand the gathered business requirements
• Coordinated with system architects and developers to convert business requirements into system requirements
• Conducted meetings to document Change Requests for new requirements
• Analyzed business requirements and segregated them into Use Cases.
• Created Use case diagrams and documented Use case specifications
• Maintained various versions of the documents generated during the project using Rational Clear Case
• Was responsible for creating and updating project schedule and managing resources and timeline using MS Project
• Prepared the project status reports and represented the BA team in the PMO meetings
• Participated in UAT along with the development & testing teams
• Gathered requirements from collection, claims, Billing, and insurance appeal departments
• Working with the business and various technology departments, and acting as a liaison between the underwriters and application developers to provide production support for the National Pricing Solution web based application
• Interacting with National Pricing Staff (Underwriting, Actuarial & Sales/AM) on daily basis with regards to how the NPS application functions, troubleshooting incidents/issues for Users and completing defect and enhancement requests on daily basis
• Performing system administrator duties i.e adding/removing users to system Participating in UAT and working
• Maintaining and modifying training documents
• Extracting data from databases and preparing reports for auditing/SOX compliance purposes
• Traveling throughout regional offices to provide support and training to end users as an SME (Subject Matter Expert) in Claims processing & management, mentored & trained entry levels

Environment: Microsoft Word, Project, Excel, PowerPoint, Visio, Oracle 10g/11g

Confidential, Alameda, CA July 2007 – August 2008 Business Analyst

The assignment was to build a web based real time Patient Care and Safety Solution (PCPS) with the objective of increasing patient safety, streamlining processes, and improving communication across departments and care teams. The key features included are customized status boards, point of care documentation and specialized bed side verification for delivering safe and quality patient care. Adopted HIPAA standards for securing Electronic Protected Health information (EPHI)

Responsibilities:

• Gathering business requirements from the Business team and generating system workflows Involved in creating the targeted questionnaire for SMEs and Business users for elaborating requirements
• Worked on HIPAA 4010 transaction set and good understanding of changes in HIPAA 5010 transaction set
• Conducted analysis and testing in HIPAA X12 transaction sets (270, 271, 277, 278, 820, 834, 835, 837 & 997)
• Participated in JAD sessions / conducted interviews for analysing business requirements and reviewing them with business and technical teams
• Designed and developed Use Cases and UML models using Microsoft Visio
• Prepared the cost estimate for the business analysis involvement of the project
• Prepared the BRD and conducted reviews with the stake holders
• Writing change requests & follow up with the respective teams on the impact and action
• Reviewing the test cases and requirement traceability matrix along with the testing team Tracked the project status in MPP, prepared the project status reports and represented the BA team in the PMO meetings
• Involved in Customer UAT along with the Development & testing teams
• Participated regularly in walkthroughs and review meetings with PM, QA Lead and development teams
• Assisted the PM in setting up realistic expectations and in evaluating the impact of change requests and risks and conducted project related presentations
• Gathered requirements from insurance, billing, and health services departments Worked extensively with the QA team for designing Test Plan and Test Cases for the User Acceptance Testing
• Enhanced the job properties for performance tuning

Environment: Microsoft Word, Project, Excel, PowerPoint, Visio, Windows NT 4.0,UNIX, Oracle 8i, PL/SQL, DOS and UNIX Sequential Files, MS Access, XML File, RUP, MS Visio, MS Project, MS Office Suite (Word, Excel, Access, Power Point, Outlook), HIPAA.

Confidential, Pleasanton CA Mar 2005 – Jun 2007 Jr. Business Analyst

The project was the application for hospital management Support System. The patient data which is relating to patient health check-up, insurance, up gradation of different lab reports was captured using an Electronic Medical Record Management System. The purpose of this system was to have a Paperless Medical Record and instant retrieval of data by the persons in medical department. The patient's medical record contains information such as physical examination and information specific to the medical discipline. The system also captures information about the patient's appointments, medical summary and flow of medical activities of his/her throughout the clinic visits

• Conducted user interviews, gathered Requirements, analysed the Requirements and managed change requirements by implementing change management methodology
• Worked according to Health Insurance and Portability and Accountability Act (HIPAA) Worked on 837 (I, P, D), 277, 276 transactions
• Worked with HL7, EDI ANSI 4010 and 5010 Standards Knowledge of ICD 10
• Documented and delivered Functional Specification Document to the project team
• Understand and articulate business requirements from user interviews and then convert requirements into technical specifications.
• Identified and documented issues, risk and gaps, their descriptions, their impact and provided recommendation and alternatives to develop the application to meet the user requirements
• Worked in a team to develop use cases for their newly added application layout. I understood all the business processes related to newly added layout and designed use cases that helped Application developers to build application.
• Interacting with the developers on resolving the reported bugs and various technical issues
• Involved in UAT to confirm that the system under test meets the user needs and provides confidence in its use
• Reports were the main driver for cross-functional team meetings that were held twice a day to direct priorities and resources
• Performed verification tests to make sure the data had integrity
• Used excel to perform pivot table to make sure the data was easily presented and actionable for the executive team
• Worked cross functionally with developers, QA and project managers to make sure each the data could address their needs
• Developed documents and implemented appropriate policies and procedures related to patient accounting, including follow-up on all patient accounts receivables
• Actively participated in and monitored the accounts receivable management activities, including collection efforts, to insure their effectiveness
• Prepared and coordinated the collection process, analysis and reporting of timely and accurate data regarding providers productivity and revenues that facilities effective management decision-making
• Close month end and ensured system, batches and deposits match
• Ensured all audits are conducted and are on time. These included and are not limited to denial audits, co-pay audits, patient collection audits, staff accuracy audits

Environment: Rational Test Manager, Data Stage, Rational Requisite Pro, Rational Clear Case, Clear Quest, Rose, SQL Server, UNIX, Oracle 8i, PL/SQL, MS Word, MS PowerPoint, MS Access, MS Visio, MS Excel.