SUMMARY

• Business Analyst Consultant with 8+ years of diverse experience in Business Modeling, Document Processing, EDI, Mapping, HIPAA regulatory changes and Application Integration in healthcare domain.
• I am experienced in gathering business requirements, JAD Sessions, Gap Analysis, UML techniques and diagrams using IBM Rational Requisite Pro, Clear Case, Clear Quest & Rational Rose/ MS Visio to create Business Documentation, Claims Processing & Testing and Claims Adjudication for Medicare and Medicaid, Data Mapping / Modeling, and Medical Billing and specialized in ANSI 10 or ICD 9/10 implementation.
• I am a self - starter with motivation and capable to work independently.
• Experience with Business Analysis, Project Management, Rational Unified Process Methodologies, SDLC Methodologies and Modeling Techniques, Software Validation and Process Re-engineering
• Experienced in GAP Analysis of HIPAA with particular attention to qualifier, length and required field and situational rules.
• Reporting experience with business intelligence tools such as Cognos products, Crystal reports.
• Verified and documented HIPAA regulator changes found when moving from .
• Performed gap analysis and data mapping for HIPAA X12 4010A1 to 5010 migration.
• Expertise in verifying and understanding EDI raw data, both in 4010 and 5010 format.
• Strong understanding of ICD 9 and ICD-10 structures and formats.
• Expertise in Interviews, Joint Application Development Sessions (JAD), Focus sessions for requirements gathering, analysis and design with stakeholders, SME’s, Developers and system architects.
• Performed several levels of testing of the conversion from which included syntax verification, balancing of the segments, situational cases and verification of the loops as per the guidelines of the implementation guides and companion guides.
• Have experience in healthcare industry in working with various modules which include claims processing using EDI X12 transactions like 837, 834, 835, 270/271, and 276/277 which fall under the HIPAA compliance.
• Strong Analytical skills in determining and conducting Feasibility Analysis, Cost/Benefit Analysis, GAP Analysis, Risk Analysis and Mitigation and Change & Configuration Management for complex process and systems.
• Adept at gathering Functional requirements and specifications through interviews, facilitated sessions, brainstorming, questionnaires and organizing JAD to accomplish user-client objectives and results .
• Performed User Acceptance Testing (UAT) with business users.
• In depth understanding of Software Development Life Cycle (SDLC) starting with requirement gathering, analysis and documenting the requirements as various deliverables and validating output of each phase from the SME’s and Project Manager.
• Proficient in creating UML Diagrams, including Use Case Diagrams, Activity Diagrams, Class Diagrams, Sequence Diagrams using various tools such as MS Visio, Rational Rose
• Strong Project Management skills including planning, scheduling, monitoring and budgeting with proficiency in MS Project for planning & reporting and assisted Project Managers in the development of weekly and monthly status reports.
• Conducted communication between the client and IT department, involved in gathering, analyzing, and documenting Requirements. Understand the Business Rules and can effectively implement them in Business Process Flow.
• Excellent communication and analytical skills with strong problem solving capabilities to interface with end users, business representatives and development teams.
• Experience in EDI 837 testing which involved writing test cases which forced security, data integrity and usability with special emphasis on 837 syntax validation.
• Considerable experience in preparing the impact analysis due to migration from and ICD-9 and ICD-10 on the business process model and the application.
• Knowledgeable in User Acceptance Testing with experience in performing UAT with business users.
• Clear understanding of testing concepts and hands on experience writing test cases, test plans and planning test strategy using testing tool Quality Center.
• Experience in GUI, Functional and web testing both with manual testing and automation testing using tools as Quality Center and Rational Robot.
• Skilled at reviewing Test Cases making sure they are in accordance with requirements, and assist the overall testing process by activities such as Change and Defect.
• Highly motivated team leader with excellent communication, presentation and inter-personal skills, always willing to work in challenging and cross-platform environments.
• Knowledge and implementation experience of Quality Assurance, Testing Principles, and Configuration and Change Management Disciplines.

TECHNICAL SKILLS

Testing tools: Requisite Pro, Robot, Clear Case, Test Manager, Quick Test ProfessionalLoad Runner, Win Runner

Defect Tracking tools: Quality Center, Rational Clear Quest

Web Technologies: XML/XSL, HTML

Operating Systems: MS Windows, DOS, UNIX, XP, Vista, Mac OS

Database: SQL, MS Access, Oracle

Tools: and Applications: MS Visio, MS Office, MS Project, Excel, MS Word

Requirement Management Tools: Rational Clear Quest, Req Pro, MS Project, VISIOMercury Quality Center, Rational Rose

Programming Languages: Java, C#, C, C++, Perl, JSP, Servlets, Swing, SQL

PROFESSIONAL EXPERIENCE

Confidential, Southfield, MI

Sr. Business Analyst

Responsibilities:

• Interacted withstakeholdersto get a better understanding of clientbusiness processesandgathered requirements.
• Involved working with the following list ofHIPPA-EDI ANSI X12 Transaction Code sets:
• Worked on EDI 837 for checking that if receiving claims has all the required information or not.
• Responsible for processing claim and generated EDI 835R
• Used Graphical Process Modeler and Map Editor of Gentran Integration Suite (GIS) to work on X12 files.
• Involved profoundly in theGAP Analysisof thetransitionfromHIPAA (EDI 835 and 837)focusing on how current transactions and system was going to be effected by the new5010compliance
• Wrote Stored Procedures, complex SQL Queries & queried the database using TOAD and produced reports for CRM (Enterprise systems)
• Organized and facilitatedmeetingswith themanagementanddevelopment teams..
• Reporting experience with business intelligence tools such as Cognos products, Crystal Reports.
• Conducted requirement gathering sessions with the purpose of creating and defining theBusiness Requirement Document(BRD) and theFunctional Requirement Document(FRD) usingRationalRequisite Pro.
• Responsible for mapping of ICD9 to ICD10 and also did testing for 270/271, 837I/P/D, 835R transactions to migrate to 5010
• Conductedfunctional requirement reviewsandwalkthroughswith the designers, developers, and stakeholders.
• Worked with the development of data modeling tool by the use of Erwin Data Modeler
• Involved inRequirement Scopingand analyzing high priority requirement for implementation.
• Conductedsign-off meetingswith IT teams to lock down the requirements
• ConductedJAD sessionsto allow different stakeholders to communicate their perspectives with each other,resolveanyissues and come to an agreement quickly.
• Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Involved ingapandfeasibility analysisfor the design and architecture of the new application.
• ExecutedSQL queriesto test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Knowledge and implementation experience of Quality Assurance, Testing Principles, and Configuration and Change Management Disciplines.
• Involved with the Quality Assurance Team to developTest planand driveTest Cases.
• Also developed a (UAT) User Acceptance Testing plan to guide a select group of key end-users in testing the user interface and functionality of the application.
• Mapped data sources to targets by the use of Warehouse Builder Mapping Editor.
• Created training manuals, user guides and shortcut training documents with tips and tricks for users.
• Involved in support of System testing when performed on the entire system in the context of a Functional Requirement Specification (FRS) and System Requirement Specification (SRS).

Environment: Rational Rose, Rational Requisite Pro, UML,MS Project, MS Visio, MS Office Suite, PL/SQL Developer, HTML, Visual Basic, SQL, Toad, Windows XP, Unix, HIPAA, Outlook, Test Director.

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Helped developers with the following list of HIPAA-EDI Transaction Code sets: 837.
• Thorough knowledge about HIPAA ANSI X12 transaction code sets (4010A1 and ICD10).
• Conduct detailed requirements gathering sessions for Business Intelligence project
• Perform assessments / gap analysis to identify opportunities for new Business Intelligence project.
• Conducted Data analysis for enterprise systems: inducing business intelligence capabilities into the claims module for reporting.
• Involved in process analysis and defined executed data migration plans for local data for global applications.
• Good knowledge of GIS and Used Business Process Monitor and Map Editor to work with X12 files
• Created Inbound/Outbound EDI business processes and process to move outbound acknowledgements, Enveloping processes etc.
• Involved working with the following list ofHIPPA-EDI ANSI X12 Transaction Code sets:
• Responsible for receiving Claims and Encounters using EDI 837. Worked on 834, 835, and real time 270/271 transactions.
• ConductedJAD sessionsto allow different stakeholders to communicate their perspectives with each other,resolveanyissues and come to an agreement quickly.
• Database support that includes activities required to correct, delete or summarize medical history of members as well as provider information.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between the 4010 and 5010.
• Created use case narratives to record Subscription business rules. Analyzed the business rules for the international user subscription and impact of localization. Implemented SDLC which included requirements specifications, design analysis and testing. Experience with RUP methodology and using Rational Test Suite for various phases of RUP. 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.
• Collaborated on the development of user requirements and design specifications using standard UML techniques such as use case, activity, sequence, and class diagrams.
• Conducted JAD sessions, Focus groups and individual interviews to facilitate elicitation with regards to analysis, specifications, and design of the relevant business processes and systems.
• Designed User Interfaces for several modules using Adobe Photoshop.
• Conducted claims systems migration as well as platform migration
• Developed Project Status metrics for weekly evaluation of Project Status.
• Documented detailed business, functional, and User Interface system specifications using standardized company templates for the business, development, and QA team.
• Produced clear user manuals & training guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and created appropriate GUI screenshots.
• Responsible for writing SQL Queries to find out that the data is correctly populated in each field.
• Knowledge of System Development and Bug Life Cycle to perform testing and defect tracking.

Environment: MS Windows XP, Snag IT, Nitro PDF, HTML, Visual Basic, Rational RequisitePro, MS Visio, MS Project, MS Access, Web trends, Toad, SQL, Oracle, Crystal Reports, Rational Clear Quest, QC

Confidential, St Louis, MO

Business Analyst

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.
• Conducted JAD sessions, Data mapping for Enterprise systems project: CRM and complex data analysis for accurate reporting.
• Responsible for validating claim processing transaction of MMIS.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Hosted the application online using Microsoft share point excluding some functionality those were developed to use by employees only.
• Documented the Use Cases and prepared the Use Case, Activity, Sequence diagrams and Logical views using MS Visio, MS Office and Rational Rose for a clear understanding of the requirements by the development team.
• Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Conducted sequence checking, duplicate number checking, work on administering maps using GIS
• Worked on 270/271, 837I/P/D and 835R transactions.
• Responsible for checking NPI and approval of claim payment.
• Data modeling using UML, and wrote complex SQL queries against the data warehouse.
• Worked on Lotus notes for getting feedback, web based requests and bill approval.
• Working with Medicare operational management to monitor, trend, and report on operational metrics such as timeliness, workload, and staff trending, customer satisfaction, and other key measures to facilitate performance excellence.
• Responsible in testing and analyzing data consolidation, organization, and presentation in MMIS.
• Create and maintain Use Cases, visual models including activity diagrams, logical Business process models, and sequence diagrams using UML.
• 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.
• Documented all the aspects of Systems validation lifecycle in accordance with the FDA regulations, including Validation Plan and Protocol, Installation Qualification (IQ) Specifications, Operation Qualification (OQ) Specifications, Performance Qualification (PQ) Specification.
• Involved in preparing project plans and identifying major milestones for each stage as per the SDLC model (RUP Methodology).
• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
• Produced User Manuals and provided training to business.
• Responsible for teaching sessions for end user to tell how to use tools using training sessions, designing user manuals.
• 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, HTML, Windows.

Confidential, Des Moines, IA

Business Analyst

Responsibilities:

• Coordinated with the stakeholders and project key personnel to gather functional and non-functional requirements during JAD sessions.
• Studied the existing business process and created AS-IS workflow to illustrate the existing system.
• Responsible for the fullHIPAAcompliance lifecycle fromgap analysis, mapping, implementation and testing for Medicaid Claims.
• Involved in writing test scripts of claims (835), updating them by in Quality center, executing them in Quality Center using TOAD and Ultra Edit.
• Responsible forgap analysisin changing old MMIS and Involved in testing new MMIS.
• Responsible forMedicaid ClaimsResolution/Reimbursement for peach state health plan usingMMIS.
• Implemented enterprise wide solutions and methodologies for improved efficiency and productivity
• Analyzed 837,835, 834 Transactions. Worked with Data Mapping, Data mining and Building 835 Maps to pass correct information into formats from input files.
• Recorded requirements in the Requirement Traceability Matrix (RTM) defining each technical requirement in detail from areas like: main hardware, application software, networks, servers, internet and desktop configuration.
• Used dashboard components and modeler’s/map editors to work on X12 files.
• Assisting the project manager in creating the business case and project plan.
• Served as a liaison between the internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and the project team.
• Actively analyzed current business processes (Claims, Recipient eligibility and enrollment etc.) and worked with management to improve and implement enterprise solutions to ensure compliance.
• Work with business representatives to understand data marts requirements and priorities and ensure that IT works is appropriately aligned.
• Responsible for creating business work flows and processes and creating management reports based on the analysis.
• Created training manuals and FAQ’s for hands-on-training sessions.
• Followed the UML based methods using Rational rose to create use cases, activity diagram, sequence diagram, collaboration diagram that include functional and non-functional specifications to hand off to development teams.
• Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.
• Defects and bug testing by using Rational Clear-Quest, Configuration management and Version control with Clear-Case..

Environment: Rational Unified Process (RUP), UML, Windows, SQL, Microsoft Office, HTML, XML, Java Script, Java, ASP, HTML, MS Access, DB2, Oracle, Test Director.

Confidential, Denison, TX

Business Analyst

Responsibilities:

• Facilitated JAD sessions, which focused on the definition of business requirements, security access groups and third party insurance company’s business process.
• Conducted detailed walkthrough of business requirements and functional requirements with Business users, Development and QA Team
• Induced BI capabilities into enterprise systems for enhanced efficiency.
• Created use cases that defined the role of customers, medical practitioners, clearing house Administrators and healthcare plans such as: Medicare, Medicaid insurance plan.
• Used Data flow diagram, sequence diagrams and business process models that describe how predefined HIPAA compliant formats are used to submit a claim with EDI.
• Worked on 270/271, 834, 835R, 837I/P/D transactions and adjudicated claims.
• Created Copybook for the development team which included data length and data type.
• Performed GAP analysis of requirements and used them to write detailed system specification requirements.
• Developed EDI X12 files and worked with map editors and modelers.
• Performed manual testing of the functional items by checking a summary of all claims entered and submitted.
• Created various documents such as Use Cases and Activity Diagrams in a format that can be reviewed and understood by both business and technical people.
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in a claims application.
• Produced clear user manuals & training guides for User Acceptance Testing (UAT) and deployment for end-clients with step-by-step instructions and created appropriate GUI screens

Environment: MS Word, Visio, UML, RUP, SQL, Java, C, XML, TOAD, Visio, XSLT, RDBMS