SUMMARY

• Over six years of professional consulting experience as a Business Analyst and in Quality Assurance with a subject matter of expertise in healthcare sector and system migrations.
• Worked extensively on all phases of the SDLC based on RUP using Agile, XP and Waterfall methodologies in large multi - million dollar Data Warehousing, Business Intelligence and Migration initiatives for Fortune 500 companies.
• Problem Solving & Analytical skills leading to successful project implementations & problem resolutions.
• Leadership and Project Management skills required to manage Sprint Cycles.
• Strategic Business Process Modelingand Re-engineering based on company, industry and products’ understanding using Unified Modeling Language (UML) including Activity, State, Sequence, Dataflow and Swim Lane Diagrams.
• Skilled at developing Technical Architecture Designs, template documents and End User guides.
• Comprehensive Requirements Gathering through effective JAD Sessions, Interviews, Questionnaires & focus group.
• Effective Requirements Analysisand prioritizing through BRD’s, FRD’s, Gap Analysis, Use cases and prototyping.
• Data Modeling using SPSS, ER Diagrams, Data Maps and General Equivalence Mapping and Data Validation.
• Attention to detail required for writing Test Casesand Test Scripts for System, Functional, Integration and User Acceptance Testing and use of Requirement Traceability Matrix to deliver products according to Business needs.
• Back-End testing to check the system Data Integrity for Insert, Update, Delete and Retrieve transactions through Complex SQL queries including joins, group by, having clauses etc.
• Design, Development and Implementation support for Internet and Client Server Applications using both Service Oriented Architecture and Object Oriented Analysis.
• Project Coordination, Planning, Tracking and Release Management skills for effective Scope, Resource and Conflict Management while facilitating End-Users, SMEs and developers/testers throughout system development lifecycle.
• Extensive Healthcare industry experience with expertise in HIPAA regulations and gateway&CFR.
• Healthcare claims processing, vendor management and interactions with Providers, Members and Clearinghouses.
• Migration Environments for HIPAA and ICD 9 to ICD 10 Conversions and forward and backward mapping with Impact Analysis of external databases.
• HandlingHIPAA ANSI X12 4010, 5010 formats and primary analysis for business processes using EDIs (270, 271, 276, 277, 835, 834, 837, 997).
• Managing Internal and External Trading Partners, Provider Contract Development and Medical Case Management.
• Experience in Managed Care Plans (HMP, PPO and POS) and Government Sponsored Programs (Medicare, Medicaid, Medigap) with understanding of compliance and regulation of CMS and other State/Federal regulations.
• Various modules and GUI, Data Structure and Batch Processing in FACETS and QNXT.
• Codes: NCDP, HCPCS, NDC, DRG, NPI and NPS.

TECHNICAL SKILLS

Databases: SQL Server 2012, Oracle 11gand MS Access 2013

Testing: HP Quality Centre, Test Director, Rational Test Manager, Rational Manual Tester, WinRunner and LoadRunner, QTP

UML: MS Visio, Rational Rose and Open Office Source

Change Management: Requisite PRO, DOORS (requirements) and Clear Case (version control)

Reporting: Cognos, MS Reporting Services, Crystal Reports, SharePoint and Business Object

Utilities: MS Project, MS FontPage, Adobe Photoshop

PROFESSIONAL EXPERIENCE

Confidential, Washington, DC

Sr. Business and Quality Assurance Analyst

Responsibilities:

• Led the Change Control Process for changes submitted since the initial BRD was submitted and conducted business requirements and priorities walkthrough to avoid project scope creep.
• Prepared product backlogs in close workings with SMEs and prioritized items for assigning to different sprints.
• Reassessed the impact of the conversion on critical functions like Members and Enrollment, Claims Processing and Vendor Management.
• Managed a team of diverse professionals from business, SME and development for scrums andto manage robust monthly sprints.
• Facilitated ICD-9 to ICD-10 code conversion by mapping the conversions using General Equivalence Mapping
• Applied knowledge of regulatory and compliance issues to ensure compliance with industry standards.
• Used data analytical techniquesand Statistical Models using SPSS to extract data from various databases to create master lists of ICD-9 codes.
• Wrote Use Cases and developed a Test Strategy around them and wroteTest Plan and Cases and conducted Integration, System and Regression tests while maintaining Traceability Matrix.
• Documented and facilitated UAT ensuring that every requirement has been included in UAT test.
• Designed user guides to ensure all business needs are addresses efficiently.

Environment: Agile/Scrum, SQL Server 2012, Adobe Photoshop CS4, MS Visio, SharePoint 2010, MS Project, Requisite Pro, Clear Case, HP Quality Centre, QTP, SPSS

Confidential, Buffalo, NY

Sr. Quality Assurance and Business Analyst

Responsibilities:

• Participated in company-wide design, development, testing and implementation from legacy systems to TriZetto’s FACETS and assisted in defining technical requirements for implementation.
• Worked closely with cross functional teams of Business and SMEs for requirements elicitation through meetings, interviews and JAD sessions.
• Coordinated with various technical teams, on-site and off-site to ensure the deliverables and targets of each sprint were met.
• Designed future state processes for transition to HIPAA 5010 transaction processing various EDIs.
• Translated Business Requirements to SRS using BRDs, FRDs and Use Cases.
• Conducted Gap Analysis for HIPAA 4010 and 5010 transactions for EDI 835 and 837.
• Part of the team that conducted Impact Analysis for HIPAA 5010 implementation on other systems.
• Designed Data Models to build up Object Oriented Design and assisted developers with Service Oriented Architecture.
• Mapped Data for migration to the new system and used General Equivalence Mapping for forward mapping from ICD-9 to ICD-10 and backward mapping from ICD-10 to ICD-9.
• Verified adjudication processing system and Configured FACETS for different modules including Claims Processing, Member Enrollment and Products with legacy systems accounting for HIPAA ANSI X12 5010, EDIs and Medicare.
• Managed complete SDLC in Agile/Scrum environmentand HIPAA Compliance lifecycle.
• Ensuring quality with End to End Testing by developing A Test Strategy and Plan and writing and executing Test Cases and Test Scripts, tracing them back to requirements and creating technical documents and End User guides.
• Used SQL 2005 to create queries for data, testing and to generate reports.

Environment: Agile/Scrum, FACETS 4.8, SQL 2005, Rational Rose, SAS, SharePoint 2010, MS Project, Requisite Pro, Clear Case, Quality Centre, Sybase

Confidential, Springfield, MA

Sr. Business Analyst and Quality Assurance

Responsibilities:

• Delivered results on both projects in a record time while efficiently working on them simultaneously in matrix structured teams involving business, QA, developers and TriZetto’s team.
• Assessed high level business requirements and translated them to software requirement specifications while analyzing FACETS’ capabilities, identifying gaps and making recommendations to streamline programming efforts.
• Managed JAD Sessions involving a large number of stakeholders from Business, SME and technical teams and developed BRDs and FRDs.
• Conducted Impact analysis for all critical functions including Memberships and Claim Processing.
• Actively managed the development of the new systems in Agile-Scrum environment with robust monthly sprints.
• Utilized leadership experience and built relationships to help monitor project Scrum Teams and interfaced between users and diverse development teams, both on-site and off-site.
• Successfully managed the change process through prioritizing the requirements and assigning to different sprints based on business needs.
• Conducted gap analysis while identifying risks & requirements for ICD-10 changes for compliance.
• Developed data modelsand data maps based on FACETS’ data structurefor efficient migration.
• Defined ICD-9 to ICD-10 mapping process through General Equivalence Mapping and prepared 5010 GAP documents involved with EDI transactions including 835 and 837.
• Provided support for automatic claims adjudication and tested for discrepancies.
• Developed a Test Strategy and formulated Test Plans and Test Cases accordingly.
• Managed all the phases of testing from Integration and Regression Tests to User Acceptance Testsincluding FACETS’ GUItests, System and Load testswhile maintaining traceability matrix.
• Applied technical writing skills to document progress and results and creating training material.
• Ensuring compliance with CMC, CFR and other regulations for information and claims processing.
• Verified Healthcare Eligibility, Claims, Benefits and Services using ANSI ASI X12 Standards.

Environment: Agile/Scrum, SQL Server 2012, Adobe Photoshop 8.0, MS Visio, Cognos, MS Project, DOORS, Clear Case, Rational Manual Tester, WinRunner and LoadRunner

Confidential, Naperville, IL

Business Analyst

Responsibilities:

• Followed Rational Unified Process (RUP) methodology for the entire SDLC.
• Assessed Business Requirements using questionnaires, interviews and JAD sessions.
• Modeled process flows from B2B and B2C perspective in High Level Requirement Document using UML-based case models and process and state flow diagrams.
• Created BRDs, FRDs and Use cases to translate business requirements in to SRS.
• Managed communications with teams located in four different states and in India.
• Had daily meetings and regular coordination with the project managers, QAs and developers to manage the scope of the project, prioritize and adjust functional requirements.
• Developed test strategy, plan and test cases in collaboration with QA and maintained requirement traceability matrices to ensure all business requirements were answered.
• Worked with QA in writing test cases and conducting tests including security and load tests.
• Responsible for User Acceptance Testing with end users and SMEs.
• Developed Data Models using ER diagrams and used SQL to generate reports and filter data within the existing Oracle database.
• Mapped data from the existing database to the new database.
• Interfaced with the development team for prioritizing deliverables and represented them to the business.

Environment: Agile/Scrum, SQL Server 2005, SPSS, MS Front Page, MS Visio, SharePoint 2010, MS Project, Requisite Pro, ClearCase, HP Quality Centre, Informatica, Oracle

Confidential, Seattle, WA

Business Analyst

Responsibilities:

• Actively operated in all the phases of SDLC in Waterfall environmentmaking sure that the whole process followed a structured process and every requirement was clearly incorporated in the iterations.
• Worked with a Sr. Business Analyst to gather requirements by assisting in interviews and scribing JAD sessions and drafted BRDs and Use Cases.
• Performed gap analysis for the Medicare Advantage and State Programs for State of Washington
• Assisted Project Manager in developing project timelines and estimating resource requirements.
• Created User specification documents and system specification documents for system interfaces for QNXT System for Medicare (Part A, B, C and D) and Medicaid Programs.
• Worked with the team that configured QNXT systems for various modules, including Providers and Members while covering areas of claims, auto adjudication scope and definitions, financial transactions, ID cards, enrollment, Health Premium Rating and Capitation.
• Communicated with off-shore clients to gather accurate data for members, claims and benefits for State Program members who have prescription benefits.
• Frequently interacted with vendors for the business resolution and building strategies for B2C e-commerce regarding benefit health plans.
• First hand experiences with Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12 formats including EDI 270, 271, 276/277, 820, 834, 835, 837(P, I, D), 997 while working on QNXT provider and member modules and dealing with NPI for billing and services.
• Assisted Incident Control (IC) Management for effective incident resolution for claims processing.
• Assisted QA in by creating data models and writing Test Scenarios and Test cases.

Environment: Waterfall,QNXT 3.4, MS Front Page, MS Visio, Requisite Pro, Clear Case, Rational Manual Tester, Cognos, B2C eCommerce, MS PowerPoint, Oracle 9i