SUMMARY:

• Experience as a Business Systems Analyst with extensive industry experience in Healthcare Domain.
• Experienced in software development life cycle such as Waterfall, Agile/SCRUM and SAFE methodology, Business Analysis and Modeling.
• Outstanding skills in Business Requirements Gathering, Functional requirements. Gathering, Business Process Reengineering, Requirements Traceability Matrix (RTM) and Software/System Requirement specification (SRS).
• Proficient in working with Business Analysis, Risk Analysis, Business Process. Models, Business Flow Diagrams and Business Requirement Documentation.
• Experienced in performing Business Process Analysis to check the compatibility of the existing system infrastructure with the new business requirements and translating user expectations into detailed specifications by using various Text formats &Unified Modeling Language (UML).
• Ability to work with functional teams in an Agile/SCRUM and SAFE environment.
• Design, conversion and configuration experience.
• Work in health care sector with prime focus on claims adjudication, Migration, Provider, Eligibility and prior authorization for Medicare and Medicaid program
• Well - versed in writing and documenting Business Plan, Business Requirement document (BRD), Functional Specification document (FRS), Test Plan, Test scenario, Test Case as well as involved in white box, black box, Integration, Functional, Regression, System and Smoke testing.
• Involved in using FACETS for various health insurance areas such as products, enrollment, members and other modules related to FACETS.
• Skilled in reviewing Test procedure, Defining Test cases, reviewing and maintaining test scripts, analyzing bugs, interacting with team members in fixing errors and User Acceptance testing.
• Good knowledge and experience with SAFe Scaled Agile Framework.
• Strong analytical, communication, problem-solving, decision-making and organization skills
• Extensive experience in designing Use Cases, Process Flow Diagrams, Contest diagram, As- Is, To- Be process.
• Skilled at performing Risk Analysis, Impact Analysis and Cost/Benefit Analysis, along with good knowledge of process work flow tools and technique
• Hands-on experience in Soap UI for testing and validating the Web services
• Experience in conducting/facilitating Joint Application Design/Use Accepting Testing (JAD/UAT) session with super organizational and presenting skill
• Hands on experience on facilitating and gathering requirements with several elicitation techniques: Document Analysis, Interface Analysis, Prototyping, Reverse Engineering, Observation, Survey, Interview, Brainstorming, Focus Group and Requirements workshop.
• Functional experience in health Care Industry with vast knowledge on Medicare and Medicaid.
• Experienced in Facets and its modules such as Claim, Member/Subscriber, Billing, Provider, Medicare, and Medicaid and experienced with several Facets Batches.
• Developed and implemented UAT testing strategies and Test plans.
• Experienced in using Share Point, Microsoft Office and various Agile Sprint Tracking tools
• Knowledge and experience of Health Insurance Portability and Accountability Act (HIPAA) and Health Insurance eXchange (HIX).
• Experience in performing GAP Analysis to outline transaction strategy from HIPAA 4010 to HIPAA5010
• Strong knowledge of HIPAA EDI compliance regulations, transactions: 270, 271, 276, 277, 834, 835, 837) and code set.

TECHNICAL SKILLS:

Project Methodologies: Waterfall, Agile, Scrum (SAFE)

Databases: Oracle 9x/10x/11x, SQL Server 2000/2005/2008/2012 , Teradata

Operating Systems: Windows 7/8/10, Unix

Business Modeling tools: MS Visio

Web Technologies: SOAP, REST, XML

MSVisio, MS: ProjectMSWord, MSExcel, MS: PowerPoint

Other tools: MS Office Suite, MS Project, Share Point

PROFESSIONAL EXPERIENCE:

Confidential, Mason, OH

Business System Analyst

Responsibilities:

• Coordinated in all phases of IT projects based on the Agile Framework and Scrum
• Organized and facilitated Agile and Scrum meetings, which included Sprint Planning, Daily Scrums or Standups, Sprint Check-In, Sprint Review & Retrospective.
• Responsible for managing the scrum process with the coordination of the scrum team in an Agile methodology.
• Wrote User Stories -- Elaborated User Stories and Acceptance Criteria; Reviewed user stories with teams
• 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.
• Updated the SPIDER generated XML and Canonical XML to implement Coordination of benefits (COB) calculation Methods by using ALTOVA SPY
• Updated the Admin Method with Hard - Dup Applies
• Updated the COB calculation methods like Non-Dup Applies, Highest Allowed and Carve Out Applies with the new admin value for SIT Testing
• Worked with Dev team in providing logic for COB calculation.
• Provided the analysis for current Live Health Online (LHO) providers in different states.
• Prepared and Maintained XML, Pivot tables and UML diagrams.
• Worked with American Well vendor in implementing them as Preferred Provider for Tele-Health and Tele medicine
• Worked with 279/271 Blue Exchange EDI for Service Type Code 9 (STC-9)
• Worked with SPIDER generated XML loops for STC 9 (Tele health and Tele medicine)
• 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.

Environment: Windows, Oracle, UML, Agile/SCRUM, SQL, SOAP, XML, MS Office suite, MS Visio, AltovaSpy, XML, JIRA.

Confidential, Hartford, Connecticut

Business System Analyst

Responsibilities:

• Captured and Maintained Functional Specification Document (FSD) for different projects.
• Prepared and Documented Program Performance, Member Satisfaction, PMPM Billing reports for various clients like Empire, Connecticare, Aetna, Cigna, Florida Blue, Horizon, Walmart etc.
• Gathered and Maintained Level of Effort (LOE) for all the System Analyst Team (BA Estimation Tool)
• Created and Documented SQL queries to provide logic for Data Mapping and Reports generation
• Created and Maintained Data Mapping Documents for various projects.
• Organized daily Business System Analyst (BSA) Team Meeting to track the change and progress in Projects
• Conducted and Facilitated meeting, JAD sessions to capture requirements and find project solution
• Conducted JAD sessions to upgrade CCX Standard File Layouts and Templates
• Created and Maintained Requirements Traceability to track requirements and report CCB (Change Control Board)
• Created and Maintained Change Request (CR), Enhancement Request (ER) for various projects
• Helped vendors in upgrading the Standard Satisfaction Survey Scripts and Surveys
• Helped in creating and defining the scope of projects to the stakeholders
• Performing data conversion by transforming XSD files to sample XML files for customer use.
• Worked very closely with the Business to create Business Requirements Documents (BRD)
• Monitored Project progress by Project Tracker, Progress Reports and provided recommendation
• Created and Maintained UML diagrams for CMS ODAG, Do Not Call (DNC) projects
• Worked with EIW (Enterprise Integrated Warehouse) in defining, creating and storing different data elements in Data Warehouse
• Gathered and document requirements around HL7 interfaces for HIS and ancillary apps and involved in source mappings and translation tables
• Helped Quality Testing Team (QA) in preparing the test cases based upon the requirements from FSD
• Helped Dev team in understanding the logic for Automated Reports Generation
• Worked with Provider Portal (HomeBridge) team in upgrading the User Interface (UI) by providing recommendations
• Worked with Nursing liaison in providing best Post Acute Care like Home Infusion, Traditional Home Health (THH) and Home Health (HH) to patients
• Worked with Customer Care and Training Department in preparing suitable training courses for Trainee and New Hire
• Worked closely with the Manager in defining Team LOE’s and allocating proper resources for the projects
• Maintained professional and technical knowledge by attending Educational seminars, training, reviewing professional publications etc.

Environment: Windows, Oracle, MS Access, MS Excel, Oracle, UML, Agile/SCRUM, SQL, JAD, BRD, FSD, PRD, SOAP, XML, MS Office suite, MS Visio, Teradata Studio, Claims2.0, Elig2000, HL7, HomeBridge

Confidential, North Carolina

Business/Systems Analyst

Responsibilities:

• Conducting System Impact Assessment for different projects.
• Writing high level requirements from reverse engineering documents for PSOR to iSeries interface, PSOR to Calidus interface, 1099 interface, Relationship Extract interface and Relationship Extract - error interface
• Gathering Level of Effort (LOE) from different team at discovery phase and document them for E3C approval
• Assisting project manager in preparing project plan and deliverables and keeping track of the all the deliverables
• Conducting requirements elicitation session for ODS project. Conducting walkthrough meeting for requirements
• Created and maintained FRD for JCAPS and ODS project.
• Followed Scrum and SAFE Agile Methodology for the SDLC.
• Creating Change Management (CM) ticket for different project. Coordinating with Developers and Testers through RTC for project release. I was project manager for ACL upgrade project.
• Created SQL queries for data analysis. Executed SQL with joins for extraction and verification of data.
• Worked on Data Mapping to map Facets data to outbound eligibility extracts.
• Reviewing and testing reported defects in the concerned applications in both UAT and Production testing environments
• Extensively used SQL statements to query the Oracle Database for Data Validation
• Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems.
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 837, 835, 270/271, and others.
• Involved in Release planning (SAFe) for 5-6 sprints meetings.
• Assisted QA Team in defining Test sets; create test scenarios on HP ALM.
• Integrated with other internal applications using SOAP and REST web services by generating the necessary stubs from the WSDL files for extracting the data from other applications.
• Analyzed relational data with SQL to quickly understand existing data stores and to validate source/target mappings and transformation logic.
• Used Rest services for communication of XML into web services and validated the response XML by defining the transformation logic required to transform the response XML into parsed JSON format.
• Provided HIX production support via application entry and notice generation validation.
• Gathered requirements and created BRD for the Medicaid managed care incoming 834 enrollment file / data to FACETS for Accumulator Synchronization using ABI Subsystem to load in Facets Accumulator.
• Managing and Billing Medicare, Commercial HMO/PPO claims on a daily basis.
• Conducted JAD Sessions and discuss the UAT with developers on regular basis and also updated daily status report to the PM.
• Sustained the data flow using the Teradata and data modeling tools to help complete the daily tasks
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals.
• Worked on the claims related to Medicare (Part A, Part B, Part C, Part D).
• Worked with the testing team for writing test cases and test scenarios for testing UAT.
• Performed Gap Analysis for 5010 enhancements using the TR3 implementation guides and side-by-side HIPAA guides provided by CMS (Center for Medicare & Medicaid Services).

Environment: Facet, Windows, HP ALM, SAFE Agile, HIX, Oracle, MS Access, SOAP, XML, MS Excel, SQL, Oracle, UML, SCRUM, PL/SQL, JAD, BRD, FSD, PRD, MS Office suite, UAT, Teradata, MS Visio.

Confidential, Hanover, NH

Business/Systems Analyst

Responsibilities:

• Responsible for creating and maintaining the Requirements Traceability Matrix (RTM)
• Documented and distributed all processes among the five SDLC phases.
• Facilitate scrum ceremonies (grooming, sprint planning, retrospectives, daily stand-ups, etc.)
• Document Business & Systems requirements for the new DOCIIS system functionalities.
• Gathered requirements for HIX (Health Insurance Exchange) and add those changes to the present system.
• Implementing new functionalities onto the legacy system.
• Well-coordinated with the team and maintained independent workload of several Programs including Medicaid, SNAP, TANF, CHIP, Presumptive eligibility and ACA.
• Responsible for analyzing Eligibility for State Welfare Program, Children’s Health Insurance Program (S-CHIP), Food Stamps (SNAP), Child Care and Temporary Assistance to Needy Families (TANF) (CHIP, SNAP, and TANF).
• Worked on electronic Medicaid eligibility verification system and the Medicaid and Medicare intermediary along with their roles in claim processing.
• Also involved in implementing relating to Health Insurance Exchange (HIX), Eligibility and Enrollments to improve and access quality healthcare.
• Responsible for delivering recommendations in establishing data exchanges between the State's Medicaid Management Information System (MMIS) and the Federally Facilitated Exchange (FFE) via the Federal Health Information Exchange (HIX) Hub for Affordable Care Act (ACA) requirements.
• Worked on Different Modules like Billings, Membership, Claim and Provider in MMIS application.
• Involved in the testing of web portal of New MMIS system.
• Responsible for Medicaid Claims Resolution/Reimbursement for state healthcare plan using MMIS
• Created Medicare, Medicaid, Coordination of Benefits (COB) claims during the testing effort.
• Actively participated in the UAT transition, retested UAT defects and updated comments in JIRA.
• Manually performed Back End Testing by extensively using SQL queries to verify the integrity of the database.
• Responsible for checking member eligibility, provider enrollment, member enrollment for Medicaid and Medicare claims.
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 834, 837, 835, and 270/271.
• Applied Transformation logic in various complexities in transforming and transferring the data into downstream Teradata EDW.
• Integrated with other internal applications using SOAP and REST web services by generating the necessary stubs from the WSDL files for extracting the data from other applications.
• Performed Gap Analysis for 5010 enhancements using the TR3 implementation guides and side-by-side HIPAA 5010 guides provided by CMS (Center for Medicare & Medicaid Services).
• Extensively worked to extract data from flat files and Oracle, and to load the data into the Teradata database.
• Developed ETL test cases for various lines of businesses based on ETL mapping document.
• Involved in analysis of requirements for Medicaid and Commercial line of businesses.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Developed Use Cases, Process Flow Diagrams, and Activity Diagrams and Context flow Diagrams.
• Involved in Iteration or Sprint Planning meeting (SAFE Agile) with the team members to plan and agree on the stories and backlog items.
• Used MS Visio for Process Flow and Workflow diagrams.
• Extensively used the SQL queries to validate data from source system to target systems.
• Assisted with UAT (User Acceptance Testing), developing and maintaining quality procedures, and ensuring that appropriate documentation is in place
• Worked on Data mapping, logical data modeling used SQL queries to filter data within the Oracle database tables
• Works collaboratively and proactively with QA Team, BA Team, Development SCRUM teams and others to design and develop effective automation solutions troubleshoot issues and resolve bugs.
• Plan, develop, and implement the research of new or improved processes, tools and systems.
• Provided CTO and CIO with updates to the projects and reports pertaining to the progress
• Analyze software defects; conduct weekly bug triage meetings with development and product management.
• Met with Senior Management and discussed program and project plans for the whole year.
• Thoroughly communicated day-to-day status of current projects to stakeholders.
• Building a high performance QA team by hiring, training, coaching and mentoring Engineers& Analysts.
• Facilitated walkthrough meetings with Business Users / Directors.
• Planned, estimated and tracked the progress of portal projects.

Environment: Windows, UML, Agile/Scrum (SAFE), SQL, EDW, JAD, BRD, FSD, PRD, UAT, Teradata, MS Office suite, MS Visio.

Confidential, Buffalo, New York

Business/System Analyst

Responsibilities:

• Gathering requirements as well as scheduling a daily scrum meeting to elicit, analyze, verify, and manage the needs of the project stakeholders, customers and end users.
• For Medicare services such as Hospital, Medical insurance, Medicare advantage plan and Prescription drug coverage.
• Work on project documentation that defines the process requirements required to implement Guiding Care.
• Configure provider demographics, billing information and contract information in claim system while maintaining departmental quality and production goals and objectives.
• Configure Facets Procedure Codes application on Application Support Application by setting up the table and populate the field's name, description, Table name and Columns' name.
• Partnering with third party vendor to drive and assess strategic initiatives like; cloud compatibility, application rationalization and datacenter migration.
• Used and prepared UML models to define Business Rules of the application. Contained the role of a Business SME by solving queries from developers and testers of the application.
• Successfully delivered business information solutions for data transfer from multiple data sources and formats to target Teradata and Oracle databases.
• Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets
• Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 7 transactions.
• Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems
• Configure different applications of Facets such as, Individual user set up, Group set up, Process Control Agent and Duplicate claim rule application on Medicare application, ICD Procedure codes, MDC Codes on Application Support Application.
• Knowledge of several functionality available in the Facets several applications such as Billing, Member/Subscriber, Accounting, and Utilization Managements.
• Tested claims adjudication and group and enrollment in for new Medicare advantage members.
• Conduct impacted analysis on the Facets functionality that is affected by 5.01 upgrade
• Collaborated with third-party vendor to analyze and decompose Target's product backlog items to ensure appropriate prioritization.
• Work on Rapid SQL to get access to Sybase Data base to see impacted table and column that is affected by upgrade
• Created SQL queries to read data from databases
• Facilitated Release session among customers to check as to what is the functionality they would like to enhance which are available in Facets.
• Created conceptual diagram using MS. Visio of the business process to find out the impacted area and to fix the problem.
• Tested the eligibility inquiry, enrollment in Facets, Billing and Invoice in Facets.
• Enhanced test cases and scripts by adding the required functionality as per the new business requirements
• Provided the management with test metrics, reports, and schedules as necessary using MS Project and participated in the design walkthroughs and meetings.
• Facilitated JAD session to find out the impacted area of functionality of Facets due to upgrade and cooperate with developer to come up with solution.
• Gathered Functional requirement and documented them.
• Adhere to existing configuration procedures established by department seniors and/or management.
• Communicate with vendor to regarding new updates on Facets and solution to their existing system.

Environment: Windows XP Professional, Oracle, MS Access, MS Excel, Oracle, UML, Jira, Agile, SQL, MS Office suite, Teradata, MS Visio.