SUMMARY:

• Over 8 years of experience in Information Technology Consulting developing projects in different SDLC methodologies like Agile (SCRUM), RUP, Lean - IT, Iterative and Waterfall models.
• Strong Business/System Analytical Analysis Skills including in depth knowledge of Software Development Life Cycle (SDLC) , having thorough understanding of various phases like Requirements, Analysis/Design, Development, Testing and Implementation.
• Excellent business writing skills in writing Preliminary Investigation Report, Business Requirements document, Systems Requirements/Design Specification, Functional design documents and System Requirement Change Request.
• Experienced in conducting Gap Analysis sessions for “As-is” and “To-be” systems and mapping present as well as future state business flows/processes.
• Excellent business writing skills in writing Preliminary Investigation Report, Business Requirements document, User Stories, Project Charter, Functional design documents and Change Request.
• Proficient at transforming business requirements into functional/technical requirements and designing business as well as architecture models using Rational Requisite Pro and MS Visio.
• Experienced in outsourced projects having worked as Team Lead on onsite-offshore model
• Expert in analyzing/designing/re-engineering complex systems internal to the enterprise and also to integrate with several external systems on different platforms/architectures.
• Expert in Root Cause Analysis, Feasibility studies and Risk Assessment studies.
• Extensive Knowledge of Systems Management, Design and Domain Driven Data Modeling.
• Experienced in Functional, Regression, Integration and User Acceptance testing with development, execution and maintenance of test plans, test cases, test scenarios and metrics.
• Experienced in documentation defined as per Sarbanes Oxley (SOX) compliance.
• Skilled at handling multiple projects simultaneously supported by strong communication and management skills.
• Expert in Trizetto Health Care Management System - Facets
• Experience with Medicare, Medicaid and commercial insurances in HIPAA ANSI X12 formats including 270/271,276/277,820, 835, 837, 997/999
• Trained resources on-board by devising appropriate and support documentation .
• Demonstrated high capacity to learn new technologies rapidly with no formal .

FUCNTIONALSKILLS:

ANSI 4010/5010 versions of 837,835,270,271,276,277 ICD-9, ICD-10, HCPCS, CPT codes Facets 4.11/4.41/4.71 , MZI EZNET, MZI EZCAP, FileNet Code sets HealthCare industry, EDI, Claims adjudication and processing, Pricing, Claim Validation Routines, Utilization Management, EOB, Remits, Provider, Group, Member, Billing, Accumulators, CDHP (HAS/HRA/FSA), HIPAA 4010/5010, Individual/Group/ASO/National/State Sponsored/Medicare Business, ITS,CMS 1500, UB04, Pharmacy Prior Authorizations, Formulary files, NCPDP file formats.

PROFESSIONAL EXPERIENCE:

Confidential, New York, NY

Sr. Business Analyst

Responsibilities:

• Perform, track, and support all EDI system configurations such as; mapping EDI segments , member and provider data to analyze enrollment production cycle.
• Maintain claims processing system documentation using Business Requirement Documents (BRD) and functionality oriented User Stories.
• Work on creating Change Requests (CR’s) to enhance claims scrubbing through implementation of additional claim validation routines.
• EDI testing of 837 Outbound files and 835 Inbound files by clear documentation
• Report all EDI file issues by clear documentation
• Keep a track of project progress by identifying project milestones and resolving problems.
• Create user stories, Flow diagrams, Screen mockups and Performance metrics.
• Quality Analysis on production data using SQL to find data discrepancies.
• Implement AGILE framework for our client and help senior project manager to create agile scrum framework
• Develop and analyze RFI’s in response to RFP’s from clients
• Design proof of concept using mock up’s and wireframes for clients
• Develop real time profitability reporting for client creating visualization in Tableau 9.1
• Provide strategic, forward-looking vision when designing solutions to maintain flexibility for future integration opportunities.
• Responsible for complete Automation of manual claims operation processes.
• Prepared detailed project and resource schedule to manage timelines and dependencies
• Hosted project planning sessions by constantly providing estimates, determining order of sprints and conducting impact analysis to timelines during scope change due to agile nature of project.
• Implement Salesforce.com CRM health module for client
• Deliver timely project estimates through Risky Professional

Environment: SQL Server Management Studio, TFS, JIRAA, MS Visio, Claim Pricing and EDI tools, Tableau, Salesforce.com, MS Office Suite .

Confidential, Charlestown, MA

Sr. Business Analyst

Responsibilities:

• Collect, document and analyze business and user requirements to translate into user stories, functional specifications, wireframes, system requirements, business process flows and issues for use in complex system development.
• Created business prototypes using Balsamiq Mockups
• Initiated SQL queries for production data analysis on payment generation for eligible SSP recipients.
• Provided strategic, forward-looking vision when designing solutions to maintain flexibility and future integration opportunities.
• Acted as an intermediary between business managers and users to technology teams.
• Defined the scope of activities required to address issues, including requirements definition, process review, impact assessment and operational streamlining.
• Worked on automation of daily ETL process through analysis of database stored procedures.
• Delivered to end users.
• Acted as front line support for live solutions.
• Conducted an in-depth Six Sigma analysis of ICD-10 diagnosis codes to prioritize based on frequency of occurrence for migration.
• Worked closely with the Claims Analyst on ICD-10 conversion
• Represented SSP in meetings with DTA to discuss the approach and upgrades needed for SSP application to support ICD10 transformation.
• Produced Gap Analysis documents for ICD-9 to ICD 10 conversion.
• Provided current architecture of SSP system prepared in MS-Visio.

Environment: SQL Server Management Studio, MS Visio, SSP Administration System, SSRS Reporting tool, JIRAA, Microsoft Team Foundation Server, Balsamiq Mockups

Confidential, Boston, MA

Sr. Business Analyst

Responsibilities:

• Created and maintained system documentation supporting all application patches and upgrades ; created test cases and was responsible for performing full cycle testing.
• Maintained system protocols by writing and updating procedures .
• Initiated claim scrubbing process by running various validation routines to determine whether the claim is payable or not.
• Provided material for end-users by writing and maintaining documentation .
• Provided support in production environment and to all users.
• Reported all system issues (bugs) by clear documentation
• Perform, track and support all non-technical system configurations such as; setting up new user profiles , mapping EDI segments , creating provider profiles , and creation of user roles based on new programs.
• Kept a track of project progress by identifying project milestones and resolving problems.
• Performed data analysis and documentation through various mechanisms such as claims system, queries ; and review of the system
• Identified potential areas of automation , and reengineered the underlying business processes .
• Determined operational objectives by business functions; gathering information ; evaluating output requirements ; analyzing requirements ; constructing workflow charts and diagrams ; studying system capabilities; writing specifications .
• Served as a liaison for IT Manager(s), development staff, and the project stakeholders.
• Elicited business knowledge such as process flows, business rules and algorithms from knowledge workers.
• Created BRD 's (Business Requirement Document) and FRD 's (Functional Requirement Document)
• Initiated SQL queries to perform various DDL and DML operations on Oracle database.
• Created user stories, Flow diagrams, Screen mockups and Performance metrics.
• Quality Analysis on production data using SQL to find data discrepancies.

Environment: SQL Server Management Studio, MS Visio, MZI’s EZNET, EZCAP for Claims Processing, Administration Utility and Webstrat for Claims Pricing, MS Office Suite.

Confidential . Minneapolis, MN

Business Analyst

Responsibilities:

• Performed detailed analysis of current state application by conducting Discovery sessions with CSRs (Customer Service Representatives), Pharmacists and Medical Directors - Documented Current State Business Model/flows using MS Visio.
• Extensive Data analysis is performed as part of identifying problem areas and areas of optimization within current business process.
• Mapped complex future state business processes with resolutions for problems identified in current state, researching future trends across industry and identifying gaps ( GAP Analysis ) from several state pre-requisites . - Used MS Visio and PDF generator
• Assisted in Business Proposal document, Project planning, Resource management and ROI determination to handle changing business needs - Used MS Project Plan, Excel and PowerPoint.
• Resource Management - Outlined the Resource requirements and interviewed potential candidates by working with external vendors.
• As a lead BA, assisted in Project Planning by constantly providing estimates, determining order of sprints and conducting impact analysis to timelines during scope change due to agile nature of project
• Documented Business Requirements , which encompass - Purpose of the project, Scope, Business Requirements with Priority (Must haves and Wish list), Risks/Assumptions.
• Conducted Story board telling sessions with multiple business partners across various departments and generated complex Use Cases with several alternate flows.
• Used Business Process Management techniques to come up with a system that is more streamlined and can be easily configurable by business with minimum effort and IT support.
• Involved in discussions with Lead System Architects across different internal vs external vendors while integrating different applications onto a single platform with real-time capabilities for quick turn around and greater efficiency.
• Hosted iterative JAD sessions with System Architect, Developers and appropriate business representatives throughout the application development process for continuous feedback to ensure that the product is being developed as per Business needs.
• Created technical mapping documents depicting the data transformations from various applications using SOAP web services.
• Automated the prior authorization loads into Claims systems through batch file processing.
• Designed system to meet the CMS mandated TATs (Turn Around Time) and SLA regulations.
• Developed/Customized PEGA CPMHC framework to meet the customer needs and business process.
• Automated Drug Search/Selection by designing ‘Connect SQL’ between PEGA and Medispan databases.
• Analyzed huge volumes of data in Formulary files received from external vendor in NCPDP format and designed business rules in PEGA to handle prior authorizations based on formulary files.
• Designed and assisted development in building a very complex and dynamic Clinical rules engine , which determines if the member has met all the clinical criteria for the drug requested.
• Designed User Interfaces (sections, data property rules, decision tables, screen flows, flow actions, Workbaskets and Workbaskets in PEGA as per customer requirements.
• Reported Status and Conducted several Demos to the Project Sponsors in a timely fashion.
• Documented Help Desk Procedures and material.

Environment: Facets 4.71, MS Visio, MS Office, Microsoft Visual Studio, Oracle, SOAP UI, PEGA 6.1SP2, CPMHC framework, Mercury Quality Center

Confidential, Indianapolis, IN

PMO Business Analyst

Responsibilities:

• Performed detailed Gap Analysis with EDI, End users, Down-stream systems to analyze the impact of changed/new/deleted loops and segments on incoming claim in 5010 format.
• Partnered with Trizetto (owner of Facets application) and analyzed the features/technical modifications provided with Facets 4.71 upgrade for 5010 acceptance.
• Provided technical/functional/data/hardware/software and licensing requirements to satisfy business requirements.
• Re-engineered provider scrubbing process in line with changed loops/segments maintaining 98% first pass rate.
• Assisted Project Manager with the pricing analysis of existing and potential projects, providing time and resource estimates, cost and margin calculations and revenue forecasts.
• Planned, Arranged and initiated meetings with project stakeholders.
• Delivered timely project estimates through Risky Professional using Monte Carlo Schedule Risk Analysis
• Worked on writing proposals, SOWs, RFP replies and other submission documentation.
• Managed resource allocation and project forecasting through CA clarity PPM
• Tracked project progress by identifying project milestones and resolving problems.
• Managed the implementation of several application components that will integrate with clients including all phases of the project life cycle (Initiating, Planning, Executing, Monitoring & Control and Closeout)
• Interacted with portfolio managers and senior financial stakeholders to streamline requirements
• Assisted in identifying and managing cross-team dependencies early in the program life cycle.
• Communicate cross-team issues to the Program Director and other appropriate managers.
• Hosted project planning sessions by constantly providing estimates, determining order of sprints and conducting impact analysis to timelines during scope change due to agile nature of project.
• Assisted in the long-term planning of the Project Management Office by engaging in strategy formulation
• Assisted in development of tools, standards, policies and procedures for the Project Management Office
• Managed and lead a team of 6 offshore analysts.
• Assisted development team in understanding the complex logic involved in each state law by providing state and logic flow diagrams created on MS-Visio.
• Designed complex reports for each state which gives the amount of interest paid by claim type, business, type of interest, provider type and various other factors as mandated by state departments.
• Executed complex database queries and submitted analysis reports during audits.
• Upgraded database from Sybase 12.5 to Sybase 15. Involved in analyzing the system due to changes in indexes and designed system to ensure the functionality/stability is not disturbed due to database upgrade.
• Upgraded Trizetto Facets application from . Modified functional design documents to integrate with the new Facets version while safeguarding the existing business and functionality. Involved in testing all the batch jobs (ERCMCRUNXC00, ERCMCRUNCLMU, ERCMCRUNCKMM, CLPO and BILO).
• Modified provider scrubbing logic to include NPI as the primary identifier for provider.

Environment: Facets 4.11/4.41/4.71 , Sybase 12.5/15, AQT (Advance Query Tool), Sybase Advantage, Ultra Edit, Unix, Ultra Edit, Rational Requisite Pro, Rational Clear Quest, Rational Clear Case, Rational Quality Manager, MS office, MS- Visio, Brio-Hyperion, SQL, Java, SharePoint, Lotus Notes, Windows 2000 sever/XP.

Confidential, Indianapolis, IN

Business System Analyst

Responsibilities:

• Performed sandbox testing of a new HRA module from Trizetto to understand the functionality, technical configurations, and business/functional integration with existing process.
• Involved in documenting the functionality, configuration and step by step business/data flow of new DHRA module.
• Transformed business requirements into functional/technical/licensing and data requirements.
• Hosted several meetings with Lumenos to gather requirements on the file formats to be used for receiving/sending accumulators.
• Documented functional designs which include database tables to be created/modified/used, functional/data flow diagrams, data mappings, step-by-step logical flow to meet business requirements systematically.
• Conducted sessions on the new module for developers, testers and other project teams.
• Provided LOEs at different confidence levels for each gate of implementation.
• Collaborated with architecture team in re-designing the existing system to integrate the new HRA module.
• Involved in discussions for test approach, test data needs and provided suggestions during test plan reviews.
• Assisted end-users in creating data models in business objects for report generation.
• Managed a team of 4 offshore analysts.
• Conducted JAD and review sessions with external vendors to gather requirements and to agree on a business flow feasible to both systems.
• Involved in documenting Service Level Agreements for file transfers and procedures to follow in case of any delays/failures.
• Documented technical requirements and functional design documents eliciting data and logic flow.
• Created Data Mapping documents and inbound as well as outbound file formats.
• Worked with Development SMEs to determine the file transfer methodologies and batch integration.
• Involved in end-end UAT testing to ensure the accumulators are posted accurately by processing a huge variety of claims.
• Involved in production check-out and validations by executing queries and reviewing reports.
• Prepared documentation and got approvals as required by Sarbanes-Oxley act.

Environment: Facets 4.11/4.41/4.71 , Sybase 12.5/15, AQT (Advance Query Tool), Sybase Advantage, Ultra Edit, Unix, Ultra Edit, Rational Requisite Pro, Rational Clear Quest, Rational Clear Case, Rational Quality Manager, MS office, MS- Visio, Brio-Hyperion, SQL, Java, SharePoint, Lotus Notes, Windows 2000 sever/XP .

Confidential, Hartford, CT

Systems/QA Analyst

Responsibilities:

• Gathered business requirements using structured interviews, workshops and brainstorming
• Analyzed client’s business requirements and designed use cases
• Documented Software Requirements Specifications
• Coordinated creation of end user documents such as User and Configuration guides
• Aided JAD session follow-ups for project plan updates and gained consensus for User Acceptance Testing requirements
• Worked with UAT team to validate the developed application meets the business requirements
• Conducted daily status meeting with development team, deployment team, and business during UAT to resolve outstanding issues and assign priority and severity to defects.
• Worked with the Quality Assurance Team to test different releases and to develop test plans and test cases.
• Performed Data-driven testing by inserting multiple sets of data into the application.
• Compiled Test Scripts and generated reports for identified errors in the application using Test Director 7.6.
• Prepared SQL scripts to verify the database updates, inserts and deletes of the records in Oracle database.
• Provided User Acceptance Testing support by feeding data and running scripts.