SUMMARY

• 8 years of Business Analysis/ Quality Analysis experience with in - depth knowledge of business processes in health care and financial industries.
• Expert in analyzing, identifying, tracking, evaluating, and recommending systemic changes to enhance productivity and efficiency as well as the methods and procedures for system maintenance.
• Expert in Requirement Gathering, analyzing, detailing and tracking.
• Experienced in documenting requirement using Unified Modeling Language
• Excellent communication skills, Interpersonal skills, interacting with team members, leadership qualities, mentoring, ability to work independently.
• Strong understanding of various SDLC methodologies such as Waterfall and Agile and have experience in all of them.
• Extensive experience in IBM Rational Team Unifying Platform containing tools such as IBM Rational Unified Process (RUP), RequisitePro, ClearCase, ClearQuest, Share Point and Rose.
• Good knowledge in healthcare insurance domain including Medicare. Proven experience with HIPPA X12 EDI transaction codes such as 270/271(inquire/response health care benefits), 834(Benefit enrollment) 835(Payment/remittance advice), 837(Health care claim).
• Experience and strong understanding of ICD9-ICD10 Conversion Process with BTS Team of Rates & Benefits Department, Claims Processing, and other standards.
• Experience in writing requirements and specification like Business Requirements Document (BRD), USE Case Realization Document, Functional Requirements Specifications, Systems Design Specification (SDS), Systems Requirements Specification (SRS), Business Continuity Plan (BCP), Requirements Traceability Matrix (RTM), Process mapping.
• Expertise in performing GAP Analysis and Impact Analysis in several projects.
• Quick learner, self-starter, can learn and adapt to new atmospheres and technologies with confidence and ease.

TECHNICAL SKILLS

UML Tools: Rational Rose / Microsoft Visio / Enterprise Architect 4.0/Provision

Rational Tools: Clear Case/ Clear Quest, Requisite Pro, SharePoint

Databases: Mainframe, Oracle, DB2, MS Access, SQL Server

Methodology: Waterfall, RUP, SDLC, UML, Agile, JAD

Web Design: HTML, DHTML, XML

Front end tools: Microsoft Project, MS Visio

MS Office Tools: MS Outlook, MS Word, Ms Excel, MS Access, MS PowerPoint

Operating Systems: Windows 98/2000/XP/Vista/7, Mac OSX

PROFESSIONAL EXPERIENCE

Confidential, New York, NY

Business Analyst/Quality Analyst

Responsibilities:

• Validated Global, Professional & Technical Rates for RBRVS File for Radiology & Surgical Lab
• Analyzes, identifies tracks, evaluates, and recommends systemic changes to enhance productivity and efficiency as well as the methods and procedures for system maintenance.
• Develops complete business specifications and screen designs for MCS and HCS system enhancements/modifications, recognizing any gaps and deficiencies and making recommendations to enhance current processes.
• Oversees all system modifications that impact Rates and Benefits tables related to provider, facility, and member reimbursement.
• Identify systemic issues based on daily reviews in both the HCS and MCS systems and develop process improvement plans.
• Responsible for monitoring & adding rates in the Mainframe systems such as Corpprod & GHIpro.
• Validate system modifications and perform user acceptance testing for I10 related changes, such as field expansion, code conversion, business rule configuration, and other related updates.
• Perform postproduction validation to ensure accuracy of file releases.
• Compiles, completes, and/or coordinates all documentation required by BTS, such as: special reports, Business Objects (BO) reports, spreadsheets, and other required forms.
• Recommends system enhancements needed to be in compliance with contractual agreements.
• Upload rates of EH Provides for previous years in mainframe systems.
• Involved in Special Projects by Editing data in Mainframe and creating a report
• Updated data in Mainframe for Fees schedule & Prevailing Rates.
• Involved in meeting to identify the requirement related to BTS from BRD’s & Test Plans for ICD-10 Testing
• Involved in loading of rates packages in Prototype for MCS.
• Involved in Creating Quest & RBRVS Test Plan for production in MCS system
• Involved in Uploading Add On Codes for Special Handling Indicator, Winthrop Lab Rates in Mainframe for MCS
• Validation for RBRVS rate file in Prototype Region
• Loaded rates in MCS systems for the RBRVS Drug rates
• Created test plan for MAPD Table & WPS table by taking screen shots from production region and test region of Medical & Hospital systems to ensure its copied correctly in test region for conversation of ICD9 to ICD10 conversation
• Created MAPD ICD10 Diagnosis table for testing
• Responsible for creating test plan overview by testing all the related screens on MAPD table & WPS table are copied correctly
• Verified all the screens are accurately maintained its functionality and commands
• Ensured all ICD fields continue to display from 5 bytes to 7 bytes and 125 fields from ICD9 to ICD10 conversion
• Verified all ICD fields are left justified in MCS & HCS systems
• Validated the data/codes to ensure accuracy of ICD9 to ICD10 codes, effective/termination dates and the new codes with the associated proprietary codes
• Validated the ICD9 codes mapping to the ICD10 by taking screen prints of the mapping spread sheet according to the CPT codes
• Revalidated open defects by updating in the Testing Verification Log
• Reviewed Child rates are loaded correctly in systems by doing QA
• Compared test plan screen shots with the respective extract grid to ensure all the new ICD10 codes are copied correctly in medical & hospital system
• Loaded Quest Rates for few networks in medical system
• Also involved in helping other team mates for creating HCS ICD10 Diagnosis Codes File by validating Mapped codes, Unmapped codes & the original set of codes from Extract file
• Loaded RBRVS drug codes to ASP file in MCS system
• Ensured by checking New 2014 CPT Codes for tabs labeled in file as CAT III and CAT II are loaded correctly in Medical system
• Terminated the list of HCPCS codes in MCS system which are not in used in ICD10
• Responsible for completing a post validation test plan for the assigned test plans by taking a screen print from MCS system
• Terminated list of codes in MCS system on Crosswalk file
• Reviewed ICORE codes in the crosswalk file in system to see if RNE is still on file.
• Responsible in creating Mass Adjustment Test Plan & Overpayment Test Plan from settled report to verify that claims paid correctly for various departmental audits.
• Develops and reviews post implementation reports for all assigned PPM’s and corporate projects. Reports discrepancies for resolution.
• Involved in doing Post Validation for test plans created by other team mates to ensure that its calculated & paid correctly
• Responsible in ensuring % rates for providers are correctly loaded in MCS in compare to provider contracts by creating PIV Test Plans to ensure that claims paid correctly
• Loaded rates in MCS systems based on CPT codes & GHI codes for particular Svc codes
• Involved in adding Benefit contract for Benefit Configuration department
• Responsible for adding In-Network OP Mental Health cost-sharing to all the partial hospitalization target svc’s
• Responsible in Updating CARC’S & RARC’S Denial Codes & Check Message Codes Update in Mainframe
• Responsible in loading new Contract for Benefit Team in contract file of Mainframe system
• Involved in updating Benefit change on existing account for Benefit Team as per the requirement from Membership/Sales Team
• Responsible for Post Implementation with Corrections/Update on existing accounts for Benefit Team
• Verified new and Existing accounts loaded by teammates & ensuring that its loaded correctly in system
• Involved in Terminating accounts which are no longer an EH member as per the instruction sheet provided by Membership/Sales Team
• Maintaining Diagnosis & Procedure files in MCS & HCS system for Benefit Team
• Involved in updating Emblem Health CR/ER Benefit Grids for Benefit Team
• Developed & Maintained departmental PPM/Project Request for the team
• Responsible for all Email Inquiries for the team
• Involved in scanning instruction sheet provided by Membership/Sales department for our record and was also responsible in doing Post Implementation for contracts
• Responsible in working on Departmental Projects related to ICD9-ICD10 codes & CPT/Diagnosis Code Validation

Environment: Window2003/2010, Mainframe, SharePoint, QCare, MS Office Suite, Mercury Quality Center 10.0, SQL Server 2000, MS-Project 2000/2007.

Confidential, Manhattan, NY

UAT Tester

Responsibilities:

• Involved in EDI UAT Testing by creating test cases in Quality Center and executing for 270/271, 276/277, 837I, P and D, 835 transactions.
• Reviewed GAP Analysis to enumerate major differences between 4010 and 5010 transactions format.
• Interacted with BA’s, PM & Lead to discuss functional and Non-functional testing in regards to system
• Worked towards resolving various defects and updating status reports for weekly business and technical meetings.
• Leveraged Quality Center to log and co-ordinate defects.
• Involved in creating test cases with positive & negative scenarios for all EDI transactions.
• Created dummy claims by using Ultra Edit to check the response of the system.
• Used BizTalk In & BizTalk Out for dropping all edited claims to check claim process & procedure to get desired output

Environment: Window2003, Mainframe, BAM, BizTalk In & BizTalk Out, Ultra Edit, SharePoint, MS Office Suite, Mercury Quality Center 10.0, MS-Project 2000/2003.

Confidential, Sunrise, FL

Business Analyst

Responsibilities:

• Assisted in identifying project scope, to conform to the regulatory compliance related to X12 837 (I/P) and 835.
• Provided timely processing and adjudication of claims.
• Created daily, weekly and monthly reports for the claim system using Business Objects.
• Responsible for soliciting and eliciting requirements for conversions.
• Carried out Risk Assessment, GAP analysis and Impact Analysis for the conversion project.
• Involved in one-to-one interview sessions and JAD sessions with stakeholders, SME’s and business owners to discuss the scope of the conversion.
• Produced for transaction sets 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy.
• Involved in up-gradation of 4010 transaction to 5010 by conducting Impact Analysis and Risk Assessment and worked on the mitigation plan to avoid the risks.
• Worked as a liaison among stakeholders both business and IT side in order to elicit, analyze, communicate and validate requirements for changes to business processes.
• Involved in creating Reports and Documents like Requirements Documents, and Management Plan, Issue/Alternatives documents, Project Summary and Plans with formats like PDF, HTML, Excel and Word.
• Prepared UML diagrams (Activity diagrams, Sequence Diagrams, Use case diagrams) for Extensions.
• Involved with reviewing defects reported from UAT efforts and analyzed for root cause and took actions based on the findings.
• Identified the master file changes and builds needed to enable the 5010 format to be utilized.
• Conducted Business Process (As Is/To Be) sessions with various department directors and staff to ensure the Testing Plan and Test Approach would meet the identified Business Requirements, and the Training Program covered all identified new and changed processes.
• Gathered requirements for impacted system and business areas for ICD-10 and their needs to embrace the changes.

Environment: Rational RequisitePro, SharePoint, Rational ClearCase, RUP, UML, HTML, MS Project 2000, MS Visio, MS Office (Excel, Word).

Confidential - Tampa, FL

Business System Analyst

Responsibilities:

• Gathered requirements and prepared business requirement documents (BRD).
• Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Created and maintained data mapping document(s) in reference to the claim process transactions.
• Involved in processing the claims to ensure claims are being processed correctly
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to define the Data Process Models.
• Involved in /EDI transactions Analysis, Design, Implementation and Documentation.
• Reviewed in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Maintained Requirement Traceability Matrix (RTM).
• Presented the nursing outcomes to C-Level executives in Confidential Nursing and Data Management group using Crystal Reports XI.
• Use Case development using modeling tool MS Visio.
• Maintained documents for change request and implemented procedures for testing changes.

Environment: s: Rational ClearCase, SharePoint, MS Visio, MS Project 2000, HTML, SQL Server, MS Office (Word, Excel, PowerPoint).

Confidential - Charlotte, NC

Business/ Systems Analyst

Responsibilities:

• Stakeholder interviews, Requirements review, preliminary system design, and joint application design workshops, and Error and Corrective Policy and Procedure.
• Developed project delivery schedule, managed projects and identified resources to successful completion
• Set up HR vendor system, Benefits, Benefits Open enrollment, Compensation and Payroll.
• Managed Project Management staff, Quality Assurance and Technical Writing staff.
• Acquired comprehensive knowledge of Banking activities and operating processes
• Collected and documented business processes as well as business rules.
• Participated in the identification, understanding, and documentation of business requirements, including the applications capable of supporting those requirements.
• Maintained data mapping from source to target files.
• Translated the business needs into system requirements, communicating with the business on a non-technical level, and with the System Analyst on a more technical level.
• Collaborated with development architect and the business to develop both high-level and detailed application architecture to meet the business needs.
• Documented and delivered Functional Specification Document to the project team.
• Performed GAP Analysis and conducted User Acceptance Testing (UAT).
• Conducted project related presentations.

Environment: MS Visio, MS Excel, MS PowerPoint, UAT, Rational Requisite Pro, Rational ClearCase, SharePoint.

Confidential - Seattle, WA

Business Analyst

Responsibilities:

• Reviewed and analyzed Business requirements and interacted with the business users to resolve conflicts.
• Constructed data lineage information on usability and conceptualized data applications in a program-level scenario, high-lighting the “happy” or base flow and probable exceptions.
• Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures.
• Constructed, developed and deployed ACH Money Transfer documentation for Overseas Business Unit, created functional and technical specifications (mid-level), highlighting chief actors, process flows and exception errors.
• Responsible for working with various Overseas Funds Transfer Applications.
• Interacted with Offshore development team, incorporating the analysis and requirements in the final detailed design documentation.
• Reviewed and provided critical document feedback to team members, communicated document analyses to team lead and stake holders.
• Data Mapping from source file to target file.
• Used MS Project to develop project schedules and tasks.
• Worked with QA team to design test plan and test cases for User Acceptance Testing (UAT).

Environment: Rational RequisitePro, RUP, UAT, MS-Project, MS Visio, Java, MS Office, Windows XP.