SUMMARY

• Extensive experience working as Business Analyst and Lead business analyst for past 8 years in healthcare and IT domain.
• Worked extensively in different methodologies like RUP (Rational Unified Process), RAD (Rapid Application Development) and Agile.
• Worked extensively in Agile environment creating user stories, sprint lifecycles documents, and essential business use cases.
• Extensive experience in capturing requirements for large scaled projects using Joint Application Development (JAD), requirements workshops, SME surveys, process analysis etc.
• Analyzed and synthesized results from JAD and other requirements processes and transformed those into Business Requirement Document (BRD), Functional Requirement Specifications Document (FRD) and Use Case Narratives.
• Extensive knowledge using Unified Modeling Language (UML) diagrams (use case, activity, sequence) using Rational Rose and MS Visio.
• Worked on all major Healthcare initiatives like HIPAA migration from, ICD 9 to 10 migration, Affordable Care Act (ACA or Obamacare) and Health Care Reform initiation.
• Extensive knowledge in Health Insurance Portability & Accountability Act (HIPAA) standards, Electronic Data Interchange (EDI), HL7 and ICD - 9 to ICD-10 coding.
• In depth analysis and working experience in data modelling, data profiling, data warehousing, Metadata Management Services and other data concepts.
• Experience with various ETL, data warehousing tools and concepts.
• Extensive working experience with X12 file formats collaborating with Claims file systems like 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Extensive knowledge on the various types of health insurance programs such as: Medicaid, Medicare (Part A, B, C and D), PPO (Preferred provider organization), HMO (Health maintenance organization), and POS (Point of Service).
• Knowledge of MMIS (Medicaid Management Information System), MITA (Medicaid Information Technology Architecture, HIX (Health Insurance Exchange), EMR (Electronic Medical Record), EHR (Electronic Health Record) and healthcare reforms like the Patient Protection and Affordable Care Act (PPACA), Emergency Medical Treatment and Active Labor Act (EMTALA)
• Experience in conducting GAP analysis, SWOT analysis and Root Cause Analysis.
• A solid base in gathering and documenting user and business requirement.
• Extensive working and using experience in IBM Curam (HCR and CGIS).
• Expert in writing complex queries using SQL using various tools like Db Visualizer, TOAD etc.
• Trace and inform business requirement changes through the lifecycle of the project using Rational Requisite Pro and Rational Clear Quest while maintaining customer needs and maintain a Requirements Traceability Matrix (RTM) to keep the stakeholders informed of the progress of the project.
• Feasibility studies, Document generation and conducting sessions.
• Strong experience in the creation of Test Plan and Test Cases from the Requirements document.
• Documentation of the Test Plans, Test Cases, Test Scripts, Test Procedures based on the Design Document and User Requirement Document for the Black Box, Functional, Usability and User Acceptance Testing (UAT).
• Adapt at creating, editing and coordinating extensive communication networks (facilitation of joint application design (JAD)) sessions and interviews, implementation requirements, project status reports, project impact analysis, request for estimates, oral presentations and email to keep executive staff and team members apprised of goals, project status, resolving issues and conflicts
• Developed User interfaces, mockups, wireframes for users to relate in the requirements sessions.
• Comprehensive knowledge of the testing lifecycle within web, client server & Mainframe environment.
• Experience working in a team-oriented environment and contributed effectively as a problem-solver. Attention to details and ability to prioritize tasks along with excellent communication, project management and problem solving skills. Analytical, methodical, and resourceful approach to problem solving, identifying root causes and corrective.
• Working knowledge of Bug Reporting Tools like Test Director.
• Expert level skills in MS Office products like MS Word, MS Excel, MS Project, MS Visio, MS PowerPoint and MS SharePoint.
• Use Case development and UML modeling using modeling tools like Rational Rose/MS Visio.

TECHNICAL SKILLS

Business Methodologies: RUP, RAD, JAD, GAP Analysis, SWOT Analysis, Root Cause Analysis, GANTT Charts

Business Modeling Tools: UML, Rational Rose, MS Visio 2010, Brio

Requirement Analysis: Rational Requisite Pro, Test Director, Rational ClearQuest

Databases/ languages: Oracle, SQL Server, XML

Operating Systems and Envioronments: Linux, Unix, Windows XP, Mainframe, COBOL

Others: SAP Material Management Module, Facets, MS Office Suite, MS Project, Toad, SQL Developer, Lotus Notes, MS Sharepoint

PROFESSIONAL EXPERIENCE

Confidential, Minneapolis, MN

Sr. Business Analyst

Responsibilities:

• Responsible for business process analysis that includes requirements facilitation, definition & analysis, Business process design and mapping.
• Used MS-Visio BPMN for developing Medicaid AS-IS and TO-BE business process flow.
• Assess system, business process impact of the ACA on the existing Medicaid business process and systems
• Worked on the HIX (Health Information Exchange) project to provide state specific Medicaid support.
• Being part of the HIX renewal project, performed the process for renewing Medicaid as well as Qualified Health Plan (QHP) and Qualified Dental Plan (QDP) coverage of members for the next benefit year.
• Support for, and documentation of, required changes to business processes in connection with ACA (Affordable Care Act).
• Worked on requirements emphasizing on Employee Application and Case Worker Portal with customized triggers to send notices via EP Notify in IBM Curam platform.
• Created data requirements to extract data from Curam and Connecture and exact sources for reports.
• Performed testing on application Renewals to determine case is renewed and program determination given as per IBM Curam rules engine.
• Worked on design and implementation for the Participant Management module of IBM Curam and Data migration from an existing system.
• Assisted in Functional black box testing on IBM Curam web application.
• Tested the Curam Enterprise Framework (CEF) citizen portal & case worker application that supports citizen enquiries.
• Worked with development and IT Infrastructure team to work on security requirements for IBM Curam web service calls.
• Worked in capturing requirements for advanced features of IBM Curam such as Intelligent Evidence Gathering (IEG2).
• Worked on IBM Curam Data Mapping Engine (CDME) piece for integration process.
• Worked with technology team on knowledge of IBM Curam Evidence Broker etc.
• Initiated a standardized ACA Program Level Requirements and Defect Management Plan for all ACA projects that included documentation and a software implementation.
• Support the new Affordable Care Act (ACA) Branded Prescription Drug (BPD) initiative as the key Business Analyst.
• Worked Life event changes, 8001(Medicaid and CHIP), Notices, Income Verification, Outstanding Verification (90 days and 30 days)
• Post deployment Assessed ACA applications to ensure accuracy, and that the eligibility of the insured was in accordance with the terms of the ACA.
• Assisted in defining the initial common terminology to be used throughout the project lifecycle.
• Conducted interviews with the clients for gathering requirements and evaluation/analysis of their data. Converted the business requirements into IT specifications.
• Extensively involved in Data Extraction, Transformation and Loading (ETL process) from Source to target systems using Informatica.
• Performed GAP Analysis, conducted walkthroughs and acted as a liaison between the business users, stakeholders and the team to perform requirements, quality and risk analysis.
• Worked with the Dental division SME’s to assess the current system issues and come up with solution to make sure that the problem can be remediated.
• As part of the project generated requirements and automated solution to send COB survey to new members within 30 days of enrollment confirmation.
• Identified and resolve any COB discrepancies between the dental plan and current system to identify the issue and work with teams to remediate it.
• Worked on and was responsible for using established methods to investigate, verify, and record third party liability (TPL) coverage information on behalf of our Medicaid payer clients.
• Worked on a solution to establish a system that COB teams can use to maintain accurate TPL coverage information in the client’s Medicaid Management Information System (MMIS) to trigger appropriate cost-avoidance and recovery activities.
• Worked on enhancing the provider research requests to get accurate results for payment and claims summary.
• Documented and reported the progress to the management on an ongoing basis.
• Develop Mapping rules, Design specifications and Use Cases for the HIPAA 834i/p/d; 820; 835, 824, 275 and others.
• Worked on multiple 837, 820 and multiple Eligibility (270/271) and healthcare claim status (276/277). Create EOB systems (835).
• Extensive use of Rational Requisite Pro for reviewing and analyzing the user requirements.
• Maintained Traceability matrix throughout the project.
• Used Rational Clear Quest to maintain and track the requested enhancements and changes by the stakeholders.
• Interacting with the development team to explain to them the various design documents: Business Use Case Model, Detailed Use Cases, and Vision Document.
• Creating detailed design of the system with the project team including class diagrams, activity diagrams, and sequence and collaboration diagrams.
• Used SQL, Data Warehousing and Data Cleansing for the arrangement of customer data.
• Transforming detailed use cases into test cases in the pre-testing phase.

Environment: Rational Unified Process (RUP), Agile, UML, Rational Test Manager, Win Runner, Rational Clear Quest, Windows, MS Office, HTML, Windows

Confidential, Baton Rouge, LA

Business Systems Analyst

Responsibilities:

• Defined the scope of the project and worked with the project managerin creating the business case and project plan.
• Performed GAP analysis to identify the AS-IS a process and TO-BE processes required to achieve the targeted goal.
• Worked with the Doctors & other Medical staff to understand the existing processes & the requirements for new features.
• Documented & validated the requirements for Patient Care Module which includes the IPD & OPD modules. The main components of IPD & OPD modules were Patient Appointments & Hospital visit history. These modules also included prescription & medication details as well as patient Admission details.
• Worked on capturing the requirements for generating solution for patient appointment & hospital visit history required a unique Patient MRN (Medical Record Number) to be generated so that these details could be tracked accordingly. It also needed the search feature so that a patient could be searched on MRN, Name & DOB.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS).
• Validate system performance through audits for MMIS files.
• Acted as a liaison between the Managed Care Organizations (MCOs)/Medicaid providers and the development team in gathering requirements.
• Worked on interface requirements for the Patient Appointment feature in the system that allowed the user to check the Doctor's availability & their schedule before finalizing the patient's appointment.
• Gathered requirements to allow feature that allowed the user to capture notes in the quick notes section where any important points related to the appointment could be entered & viewed.
• Identified, researched, investigated, analyzed, defined and documented business processes and Use Case Scenarios.
• Analyzed and synthesized results from Joint Application Development (JAD), proposed alternative tasks and transformed those into Business Requirement Document (BRD).
• Throughout the entire project used Agile methodology to smoothly work on the project and get process move faster.
• In the Agile environment, actively participated in the status calls, SCRUM standups, burn down chart analysis and other day to day activity for successful project implementation.
• Designing Functional Specifications for the targeted system implementation.
• Maintained a Requirement Traceability Matrix to ensure that all Functional Requirements are addressed.
• Actively analyzed current business processes (Claims, Recipient eligibility and enrollment) and the impact on the enhancements on these processes in order to get the desired results.
• Worked closely with business, regulatory compliance (HIPAA) and security groups to setup the data restriction roles for the system.
• Constructed SQL to assist business and end users with data analysis. Provided inputs to create and maintain SQL queries.
• Coordinated testing efforts with business, testing and UAT teams.
• Worked in close co-ordination with the QA analyst and testing team, reviewed and validated test plans, test cases and test scenarios.
• Monitored and assisted in designing and development of Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML.
• Scheduled walkthrough meeting with technical andbusinessteam in order to verify all thebusiness needs are fulfilled
• Maintained department's daily suspension reports of pending claims and appropriate adjustments.
• Corresponded and compiled weekly reports to include production, claims payment and denial status to senior management.

Environment: - Remedy, Crystal Reports, Business Objects, Microsoft Sharepoint, MS Visio, MS office Suite, MS Project

Confidential, Tampa FL

Business System Analyst

Responsibilities:

• Used UML diagrams for data capture activities which required working with SMEs ensure consistency and accuracy of data during the data loading process and that the data passes validation and integrity constraints with corporate database repositories.
• Clear understanding of Medicare (Part A, Part B and Part D) and Medicaid benefits as well as business processing.
• Involved in process analysis and defined executed data migration plans for local data for global applications.
• Worked with 837, UB92, UB04, CMS 1500 claims and HIPAA 834, 835, 820, 270/271, 276/277, 278 transactions.
• Database support that includes activities required to correct, delete or summarize medical history of members as well as provider information.
• Experience in CMS and MMA Guidelines.
• 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.
• Thorough understanding of health benefit products, assisted in consolidating the summary of Benefits.
• Executed Smoke, Functional, Integration, End-to-end and Regressions Tests in each environment by tracking the test status in Quality Center (Test Director).
• Applied advanced Excel skills (pivot tables, macros, lookups, charts) and Access database querying skills in streamlining and automating accounting processes.
• Documented detailed business, functional, and User Interface system specifications using standardized company templates for the business, development, and QA team.
• Build relationships with Information Systems and other relevant business partners, balancing practicalities with innovative and efficient business systems solutions.
• Knowledge of HCFA 1500 and UB 92 claim forms.
• Helped developers with the following list of HIPAA-EDI Transaction Code sets: (837, 835, 820, 270/271, and 276/277).
• Created test cases and performed manual testing of the functionality of the application by inserting varying data on different test runs.
• Documented Requirement Traceability Matrix in Requisite Pro for traceability of requirements through test cases.
• Developed Forms using MS Access using Forms and Reports for reporting.
• 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.

Environment: SQL Server, UML, Rational Requisite Pro, Test Manager, Clear Quest, Windows, Agile, MS Visio, MS Access, MS Project, UAT, JAD, UML Diagrams.

Confidential, Worchester, MA

Business Analyst

Responsibilities:

• Independently work with business units and management to gather/understand business requirements for new project requests.
• Create Prototypes, Testing Specifications, Business Specifications, with some experience with Technical Specifications used for customer website.
• Query and analyze claims, operational and vendor data from various environments.
• Used Fallon Health Business Intelligence platforms such as Advantage Suite, and SQL Server, and SAS databases as well as understand the underlying data structures of each data source.
• Testing of both Medicare and PCMH Searchlight in conjunction with the portal development team in order to identify and document system defects and ensure its adherence to specifications
• Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintainace), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/Advice).
• Implemented RUP methodology for iterative and incremental development of the system.
• Performed GAP analysis to identify AS-IS a process EDI transaction set 834,837 and 835 of 4010A and TO-BE processes of HIPAA standard and based on that developed Business Requirement Documents.
• Data mapping, logical data modeling, used SQL queries to filter data within the Oracle database tables.
• Developed, reviewed, understood and validated Testing scenarios/script and Defect Tracking with Test Director. Also developed Test plan and Test cases based on Use cases and Functional Specifications.
• Maintained and submitted periodic/monthly status reports to the Program Manager to serve as the team’s assessment of the project and its schedule.
• Reported progress against Development/Action Plan routinely to the Program Manager with recommendations for corrective actions, where necessary.
• Used JAD sessions, brainstorming, questionnaires, and storyboarding techniques to derive ideas.
• Used RUP methodology for the entire SDLC.
• Researched on the medical disciplines and documented Business Requirement Document.
• Traced High level into Detailed Requirements in Functional Requirement Document (FRD).
• Modeled functional requirements using UML and MS Visio to create Use Case Diagrams, Activity diagrams, Sequence Diagram and logical Class Diagram for interaction between the various actors and system and to supplicate the Workflow Models.

Environment: - MS Office, Quality Center, Oracle, SQL, Toad, Linux, Windows.