SUMMARY

• 6 years of diverse experience as a Business Analyst in developing and implementing innovative business processes.
• In - depth knowledge and experience in full SDLC with RUP, agile and waterfall methodologies.
• Functional experience in health Care Industry with vast knowledge on Medicare and Medicaid.
• Expertise in creating the companion guides on various EDI transactions.
• Specialize in HIPAA 5010 implementation including GAP analysis
• Expertise in impact analysis on the key application systems (claims processing, reporting, payments) and business process of health insurance companies.
• Well versed with ANSI X12, HIPAA and HL7 standards.
• Functional experience in healthcare industry with vast knowledge of Medicare and Medicaid benefits.
• Facets support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834 transactions.
• Medical Claims experience in Process Documentation, Analysis and Implementation in 835/837/834/270/271/277/997 (X12 Standards) processes of Medical Claims Industry from the Provider/Payer side
• Strong experience in conducting User Acceptance Testing (UAT) and documentation of Test Cases. Expertise in designing and developing Test Plans and Test Scripts.
• Strong knowledge of the Software Development Life Cycle methodologies (phases and gates) like Agile and Waterfall models
• For Executing Scripts manually, Involved in preparing data in FACETS.
• Experience in facilitating Joint Application Development (JAD) sessions, Rapid application development (RAD) sessions, conducting user interviews and acting as a liaison between the customers, development team and testing team
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensive experience in Healthcare/Claimsadjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277)
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Expertise in creating prototypes and mock-ups for user interface designs.
• Experience in Business Requirement and System Specifications Analysis.
• Specialized in creating UML Diagrams like Use Case, Activity and data flow diagrams using Rational Rose and MS-Visio and consistently translate business requirement into IT solutions.
• Extensive knowledge of reporting tools such as SQL and ACCESS for underlying database tables and resolve data issues.
• Expertise in RDBMS concepts and running SQL queries.

TECHNICAL SKILLS

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint, Access

Requirements Management: Rational Requisite Pro

Business Modeling: Rational Rose, MS Visio

Defect Tracking Tools: HP Quality Center, Rational ClearQuest

Languages/Standards: SQL, XML, HTTP, Java, HIPPA 4010/5010, ICD9/10, ANSIX12

Methodologies: Rational Unified Process (RUP), Agile, Waterfall

PROFESSIONAL EXPERIENCE

Confidential, Topeka, KS

Business Systems Analyst Lead

Responsibilities:

• Reviewed and analyzed CAQH CORE phase I & II requirements and make them suitable to Kansas MMIS system.
• Created Business requirements document (BRD) and Functional specification document (FSD) for CAQH CORE project
• Worked as part of the EDI team
• Worked with most of Healthcare electronic transactions (270/271, 276/277, 278, 835, 837I, 837P, 837D)
• Organized meetings with business side in order to find out which requirements are already met and what are the impact of rest of the CORE requirements to the system.
• Worked with system architects to define changes in database based on CAQH CORE project.
• Created Change Orders based on CORE project implementation.
• Conducted meetings based on new change orders.
• Organized JAD sessions to find out how and where Microsoft BizTalk solution will be implemented.
• Organized meetings for other part of Kansas MMIS team to introduce new CORE rules and BizTalk solution.
• Worked as part of the Front End Billing (FEB) project, based on different factors FEB will direct the claims to the right MCO (Managed Care Organization) or Kansas Medicaid System.
• Conducted testing on new system changes based on new policy or change policy from Business.
• Reviewed and analyzed new companion guides of electronic transactions based on CAQH project and made changes when needed.
• Worked on proprietary applications by HPES in order to conduct different testing and analysis: Provider Electronic Solutions (PES), Test Transaction Generator (TTG).
• Conducted testing through Kansas Medicaid Web Portal.
• Conducted testing on ICD 9 to ICD 10 changes.
• Used Soap UI to test new BizTalk web services solution.
• Worked with Managed Care Organization files to check if encounters tracked based on business rules.
• Modified X12 files to test certain edits and rules.
• Run batch jobs to process electronic transactions using Putty in order to test system changes.
• Involved in bug tracking and defect prevention activity, configuration management and UAT.
• Used SQL queries to get information when needed from database.
• Reported new defects on time and discussed it with developers about solutions.
• Conducted testing on new built after defects are fixed.
• Helped other resources with testing.
• Provided weekly status report on CAQH CORE project to upper level management.

Environment: MS Word, MS Excel, MMIS, Putty, SQL, MS Outlook, MS Visio, Soap UI, XML, Oracle, EDI

Confidential, Bronx, NY

Business Analyst

Responsibilities:

• Performed GAP analysis as it pertains to membership management and claims processing to evaluate the adaptability of the new application with the existing process.
• Produced Activity diagrams with defined swim lanes as part of the claims process analysis.
• Involved in gathering and prioritizing requirements using 1 to 1 interviews, brainstorming & developing questionnaires.
• Translated business requirements into functional specifications and documented the work processes and information flows of the organization.
• Created BRD and FRD for Medicaid managed care requirements.
• Participated in all phases of the Facets Extended Enterprise administrative system implementation to include the planning, designing, building, validation, testing, and Go-live support phases.
• Analysis and Design of the Trizetto FACETS Data Model to ensure optimal system performance and tuning.
• Clarified to claims personnel the new Affinity payments and Explanation for payments (EOPs) for same claim processing cycle.
• Clear understanding of Medicare (Part A, Part B and Part D) and Medicaid benefits.
• Assisted the QA in performing simple SQL queries for QA testing and data validation.

Environment: Facets, Oracle, MS Project, MS Office suite, MS SQL, Rational Suite, Citrix, MS SharePoint.

Confidential, Jefferson City, MO

Business Analyst

Responsibilities:

• Organized Joint Application Development (JAD) sessions with users to identify and understand requirements.
• Conducted extensive JAD Session and communicated with Stakeholders, Development team, SMEs, System Analyst, Business Analyst and Project Manager.
• Met with client companies to determine user requirements and goals
• Facilitated requirements gathering activities, including meeting with users to discuss System Task Requests (STRs), Enhancements, and Project Assessment Quotations (PAQs) requirements.
• Developed and maintained a work plan for system projects
• Identified Actors, Activities, Artifacts and Workflows and developed use case diagrams using Rational Rose.
• Propose strategies to implement HIPAA 5010 in the new MMIS system.
• Facilitated JAD sessions for Requirement Validation to gather requirements for the new MMIS.
• Strong visual modeling and business process modeling skills in Rational Unified Process (RUP) and Agile Modeling with tools like Rational Rose, MS Visio.
• Provided reports and other documentation on projects to client and internal staff, as needed.
• Created BRD and FRD for Medicaid managed care requirements.
• Wrote requirement according to the business rules of risk adjustment model.
• Was involved in understanding the risk factors of the marketplace database.
• Documented the Business Requirements Document (BRD) and the Functional Specification Document (FSD).
• Documented issues and resolutions, and wrote specific requirements for system changes
• Responsible for doing the gap analysis for the interfacing system.
• Coordinated updates with client's staff and implement efficiencies in documentation maintenance.
• Perform periodic checks to ensure that data is entered and retrieved correctly and that all regulations regarding confidentially and security are being followed.
• Worked closely with Project Manager, team leaders and supervisors to ensure project and organizational deadlines are met.

Environment: Rational Requisite Pro, MS Office Suite, MS Visio, SQL, HP Quality Center, MS SharePoint

Confidential, Raleigh, NC

Business Analyst

Responsibilities:

• Conduct gap analysis between the current system and new requirements to be implemented thereby mapping the business requirements to the application
• Involved in training and test session on HIPAA Privacy policy.
• Prepared high level and detailed system requirements documents for the application
• Analyzed HIPAA 5010 standards for 837P transactions, related to providers, payers, subscribers and other related entities
• Identified the requirements for accommodating HIPAA 5010 standards for 837P transactions and captured these requirements to develop new GUI for the internet based application
• Involved HIPAA regulations in Facets HIPAA privacy module
• Involved EDI Claim Process according to HIPAA compliance.
• Involved in daily Scrums to determine the status of the project and impediments, if any
• Involved in sprint planning meeting to identify the tasks for the sprint and getting team members acceptance/commitment for the assigned tasks.
• Involved in Sprint review meeting with the team and stakeholders to review the achievements from the sprint and get approvals
• Identified the requirements that go in each sprint, collect them in the sprint backlog and collecting and managing the requirements that are not part of the current sprint into the product backlog
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Designed High level design, for New process, integrating with legacy and Facets.
• Designed the Internet based application and managed the business and design specifications in the business specific wikis
• Write high level and low level business requirements and design mock-up screens for the application
• Analyzed the existing data model and provided suggestions and recommendations
• Translated the requirements prepared for SDLC methodology to User Stories and implementing Agile methodology as a standard for the ongoing project
• Wrote user stories and acceptance criteria for the requirements of the project
• Involved in daily scrum meeting to discuss any roadblocks or impediments in the project path
• Involved in sprint planning session to identify the features and functionalities that should be achieved by the new application
• Preparing Requirements Traceability Matrix and Test cases to insure the desired functionalities are present
• Identified various points of integration among the new and existing applications and required integration with other IT components
• Worked closely with the business team, development team and the quality assurance team to ensure that desired functionalities will be achieved by the application
• Provided business and technical suggestions and recommendations during the project life cycle

Environment: MS Office Tools, Windows XP, MS Project, Requisite Pro, MS Visio, MS PowerPoint, Mercury Quality Center, MS-SharePoint, MS-Word, MS-Excel, Facets