• Business Analyst with 6 plus years of work experience in Healthcare Insurance processes, Retail, E-Commerce and CRM. Extensive experience communicating with Subject Matter Experts (SMEs), performing Requirements Gathering, Business Analysis, Data Analysis.
• Excellent skills in Data Mapping, Reporting Analysis, Requirement Analysis, Business Modeling, Functional Specifications, Test cases, Test plans.
• Concrete knowledge of Healthcare systems, HIPAA compliance and CFR Part 11 electronic exchange guidelines.
• Excellent facilitation skills in conducting walkthroughs, surveys, questionnaires, interviews and JAD and JAR sessions.
• Medicaid and Medicare claims knowledge.
• In-depth knowledge of benefits, coding, claims systems, reporting tools and health care concepts.
• Extensive experience in Business Process Modeling, Data Modeling, Data Analysis, use case diagrams, sequence diagrams, activity diagrams using fundamentals of UML modeling.
• Performed Feasibility analysis, Risk analysis and Gap analysis.
• Excellent analytical & problem solving skills and a team player with strong interpersonal and communication proficiency.
• Assisting data management team in writing simple queries to extract reports as required by the business using SQL.
• Expert in gathering, analyzing and defining business and functional requirements; creating global metrics, trend charts and other decision-making tools.
• Possess strong communication skills with the ability to facilitate requirements meetings and clearly manage expectations among all levels of an organization.
• Extensive experience in gathering of requirements with strong Co-ordination with Business Owners, Developers, Testing Team and End Users.
• Demonstrated ability to work both in independent and team-oriented environments with well-developed organizational skills, excellent interpersonal and communication skills.
• Effective in managing multiple tasks & assignments concurrently with excellent communication and inter-personal skills.
• Ability to diffuse and resolve issues at investigative site level and sustain strong communication link with project teams.

EXPERIENCE:

BUSINESS ANALYST: June 2008 Present
Confidenital,
Indianapolis, IN.

• Responsible for providing support to technical professionals with regard to a variety of administrative, systems, and business operations problems, and participation in related system development projects.
• Extensive HIPAA analysis and assessment, knowledge of HIPAA rules and regulations.
• Works cooperatively and collaboratively with HIPAA Program Management Office co-workers and HIPAA Project Team members.
• Leads the Business Analyst team in identifying and documenting requirements for the HIPAA 5010 and ICD10 Enhancements.
• Ability to coordinate with internal customers, participating on a project team on a day to day basis, while effectively providing status to Management.
• Serve as a subject matter expert working with senior level clients to identify impacts, analyze issues and drive solutions for both the HIPAA 5010 and ICD-10 initiatives.
• Leads a team of business analysts and technical analysts through the HIPAA assessment and gap analysis activities.
• Participates in the Business Requirements Document (BRD) creation.
• Plans and conducts audits and reviews to assess departmental and business unit compliance with HIPAA and contractual requirements and accreditation standards.
• Reviews programming requests and works with business users and technical staff to identify, gather, analyze, and document business system requirements
• Knowledge of HIPAA 4010 and 5010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions.
• Defining and designing future state processes for HIPAA 5010 transaction processing 837 and 835, through written documentation, flow charting and facilitate sessions with current users of the systems.
• Set up JAD sessions with project manager and stake holders for a detailed analyses and better understanding of the impact in projects.
• Works closely with Business Owners and end users to develop detail requirements to meet business needs.
• Communicates any requested changes to project scope and coordinates needs with Project Manager.

BUSINESS ANALYST: July 2006- May 2008
Confidenital,
Bethesda, Maryland.

Project 1: Membership & Billing Enroll

• Responsible for reviewing plan provisions and applying specific rules inherent to each enrollment scenario.
• Apply contractual, state and federal guidelines as appropriate and utilize various databases in support of business rule application.
• Coordinate enrollment exception processing, document enrollment specific in support of quality measures.
• Ensure timely and accurate identification card and various fulfillment materials are prepared for new and existing members.
• Prepare written communications utilizing department standards and templates.
• Regularly monitors source data for the presence of new codes in source data and works with regional and national customers and team members to transform these values.
• Performs and develops on-going and ad-hoc validation of source and destination data. Verifies the accuracy of data against source, over time and between membership, benefits, claims, group, division and risk score subject areas..
• Project 2: Claims Adjudication Analyst
• Reviews, evaluates and adjudicates claims not automatically adjudicated by the processing system according to productivity and quality standards.
• Reviews and analyzes data from system-generated reports for in-process claims in order to identify and resolve errors prior to final adjudication.
• Ensures Rx Claims approval by performing a series of edits to discover denials during the adjudication process by resolving discrepancies with Pharmacists.
• Alerts claims management to claims aging issues as well as provider billing problems.
• Maintains current knowledge of members\' benefits, policies/procedures, provider network development and contract issues, processing system issues, as well as industry standards for claims adjudication.
• Communicates claim status to members and providers as needed, and promptly responds to any questions received regarding claims and payment in a professional manner.
• Understands provider agreements for assigned bills, including financial arrangements and authorization/referral requirements

JR. BUSINESS ANALYST CONSULTANT: August 2004 June 2006
Confidenital,
Louisville, KY

Project 1:

• Review weekly report of emergency claims that have been denied to ensure appropriateness.
• Executes and analyzes reports/data to verify the accuracy of system configuration against contract intent and claim payment trends.
• Use understanding of claims data to extract and manipulate data for various analyses.
• Initiating letters, filling out of state reporting forms and all other necessary state regulated documents as required.
• Sound knowledge of administering Pharmacy benefit management for health plan clients.
• Through understanding and up to date knowledge of CMS policies, guidelines and PBM.
• Timely and accurate coordination of data including receipt of monthly reports, follow-up on missing information, new claim set up, claim data entry, reconciliation for accuracy and submission for payment.
• Handles phone calls, faxes or paper inquires that are received in the office from providers, facilities and internal customers.
• Assesses and interprets intent of institutional and physician contracts to determine system compatibility and configuration accuracy.
• Responsible to determine if correct billing/coding rules have been followed during the claims review process.
• Identify and communicate claims system and/or billing problems to the Team Leader and/or Manager.

Project 2: Medicaid Claims Analyst

• Contact Medicaid and Medicaid carriers to obtain missing information, explain and resolve underpayments and arrange for payment or adjustment processing on behalf of client.
• Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting.
• Review state-specific Medicaid fee schedules and contracts to gain thorough understanding of payment methodologies.
• Performs policy research to understand and interpret Medicaid service coverage and payment policies as well as client service coverage and payment policies.
• Attend client, department and company meetings, Comply with federal and state laws company policies and procedures.
• Collects and interprets research data and performs analysis for use in the detection, recovery, and prevention of potential fraud, waste, or abuse within healthcare.
• Maintain regular contact with necessary parties regarding claims status, including payers, clients, and managers.

TECHNICAL SKILLS:

• •Knowledge of SAS programming techniques and leadership to the design, development, implementation, and maintenance of data quality and medical review reports and utilities.
• Identified and resolve a data monitoring, management and reviewed issues as SAS reports.
• Knowledge of transforming data in various formats (Excel, csv) in to SAS datasets.
• Knowledge of cleaning and resolving data issues as well as merging data from different sources in to a single integrated datasets.
• • Operating System: Windows XP/NT/2000, UNIX, Linux
• • Modeling Tools: MS Visio, Rational Suite (Rose, RequisitePro, Clear Case,
• Clear Quest)
• • Utility Tools: MS Office Suite, MS Project, TOAD, Adobe Photoshop
• • Packages: MS Office Suite, Dream Weaver, Adobe Photoshop.

EDUCATION:

Master of Science
Bachelor of Science