SUMMARY

• 7 years of extensive experience as a business analyst with strong experience in Healthcare Insurance claims, Pharmaceuticals and Hospital Domains with a solid understanding of Business Process Flows, and Business Analysis. Detail-oriented and good documentation and process management skills
• Extensive practical knowledge of various SDLC methodologies like Waterfall, Rational Unified Process, Agile and Scrum.
• Extensive experience in gathering Business and Functional Requirements, performing Gap Analysis and Impact Analysis.
• Experience in developing UML use case diagrams, Work Flow Diagrams using tools like MS Visio.
• Excellent Business writing skills in creating Business Requirement Document BRD , Use Case Specifications, Functional Requirement Document FRD , and System Requirements Specifications SRS .
• Effective problem solving skills - ability to think out of box and give solutions that are feasible under given circumstances.
• Created and managed change requests using Change Management Process and conducted feasibility analysis for those changes.
• Experience working with HIPAA ANSI X12 4010/ 5010 270/271, 276/277, 834, 835, 837 for institutional, professional and commercial claims, and up-gradation of ANSI 4010 to ANSI 5010.
• Excellent understanding of ICD 9, ICD 10, HCPCS, and CPT Codes.
• Functional experienced in Claim Life Cycle and Health Care Payer domain process along with various line of health insurance system like PPO, HMO, POS.
• Strong work experience of Medicaid and Medicare Part A, B, C and D Medicare Prescription Plan .
• Gained extensive knowledge and understanding of MITA, MMIS, Electronic Medical Health Record EMHR and Pharmacy Benefit Management PBM .
• Experience working on HL7 Messaging Standard and worked with TriZetto Facets team on different modules like Claims processing, Claim Pricing, Provider network management and Reporting.
• Proficient in Developing and executing Test Plans, performing functional, usability testing and ensuring that the software meets the system Requirement.
• Experienced in working with QA testing teams, while interacting with business users and gathering user's requirements to develop necessary Test plans, Test Cases, Test script and assisted the QA team in UAT.
• Excellent team player work in conjunction with testing, development and other teams in validation and testing complex scenarios and projects and in the maintenance of Quality Standards in Projects.
• Knowledge in documenting project related information like test execution procedures, backup plans, new tester training documents, maintaining test logs, release notes etc.
• Performed Data mapping in XML, Xquery and performed data analysis with SQL Queries

TECHNICAL SKILLS

• Operating Systems Windows all - HP-UNIX, Linux, MVS/ESA, OS/390
• Programming Languages - Java, COBOL, C, C , Tibco
• Mainframes - CICS, Clear Quest, NASCO, NPS
• RDBMS SQL Server 2000 2005, ORACLE 11i, My SQL, DB2
• Healthcare Tools - Facets 4.51 4.41, EDIFECS
• Automation testing tools - Mercury QTP, Rational Robot, HP Test director, Quality Center, Clear Quest
• Business Analysis Tools - Relativity Application Analyzer, Profiler, Clarity, NAEGS
• Business Rule Manager, Req Pro/Web,BPR
• Special Software - MS Visio, MS Excel, MS Word, MS PowerPoint, ETL, Rally, Cognos MS Access, MS Share point, Lotus Notes-Citrix client, MS Outlook,
• Methodologies - Agile, Scrum, V-Model and Waterfall Model, ITIL
• Knowledge on HIPAA- EDI transactions of 270/271, 834, Medicaid/MMIS 820, 276/277, 275, 835, 278 and 837 I/P/D, ACT/Obama Care, HIPAA ANSI X12 4010/5010, ICD 9 to 10 and PBM

PROFESSIONAL EXPERIENCE:

Confidential

Business Analyst

• The pharmacy system RxConnect is built specifically to support this defined operational process and all 7400 CVS pharmacies have the same defined behavior for receiving and preparing a prescription for a patient.
• Very good experience interacting with stake holder on requirement gathering.
• Project with methodology for successful execution with Joint Application Sessions JAD to collect and report requirements, perform data analysis / reconciliation
• Worked to provide operational problem management to manage Health Insurance Exchange solution application problems as they occur during the Maintenance Operations phase of the project, including issues associated with all system components outlined in this RFP.
• Worked with Prescriber Border State regulation of MA - Health connector and HIE related to pharmacy.
• Very good experience interacting with stake holder on requirement gathering.
• Project with methodology for successful execution with Joint Application Sessions JAD to collect and report requirements, perform data analysis / reconciliation
• Analyzing the Prescriptive authority system / business requirements which prepared for RxConnect.
• Reviewed logical design documents and use cases and making sure the enhancements based on the Prescriptive authority changes with business team
• Microsoft SharePoint, RTM used to manage the project related deliverables to client and maintained internally for the audit purpose.
• Creating the business use cases in the quality center for the Prescriptive authority project
• Creating SDLC PMLC documents for Prescriptive authority projects to manage the project.
• Validating requirements test coverage in test strategy, test plan and test scenarios
• Support the Solution Architect in defining the solution and communicating to the application team
• Clearly articulate the system solution to all business partners and application Business Analysts
• Facilitate meetings with business and IS people, over phone using web conferencing with large number of people
• Coordination with system, regression and UAT testing team and creating test plan for UAT testing for Prescriptive authority enhancements project.
• Cycle's execution for the latest project and defects tracking and validating the results in QC.
• Worked on developing and testing functionality for the subgroups module like PBM Pharmacy Benefit

Confidential

System Analyst

• Confidential provides a range of pharmacy benefit management PBM services in Confidential .
• The company's PBM services include retail network pharmacy management and retail drug card programs home delivery pharmacy services specialty pharmacy services patient care contact centers benefit plan design and consultation drug formulary management compliance and therapy management programs information reporting and analysis programs rebate programs,electronic claims processing, and drug utilization review consumer health and drug information bio-Pharma services, including reimbursement and customized logistics solutions medication therapy and safety through pharmacogenomics, and assistance programs for low- income patients. The project involved careful transaction of claims among several insurers my main objective was to design a system that would enable safe and accurate exchange of data among the parties through this system. I helped enhancing the performance of all activities of the Retail business that support the collection, management and reporting of other insurance coverage of Medicare beneficiaries through this project.

Responsibilities:

• Requirement gathering and preparation of business requirement documents BRD .
• Interaction and gathering of all the necessary information from various companies and
• necessary records to create and provide an error free software solution.
• Responsible for translating BRD into functional specifications and test plans. Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Efficiently handled claims processing as well as enrollment, medical-management and workflow processes involved during and for the project given.
• Developed and maintained all operational and technical flows using Visio and Power point.
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to UML methodology thus defining the Data Process Models.
• Defined Use cases from requirements and helped convert them into software specifications
• Responsible for the regulatory management process for the services provided by the pharmacy.
• Helped in development and functioning in workflow analysis and process design.
• Actively involved in Knowledge Transfer Phase.
• Maintained Requirement Traceability Matrix RTM .
• Involved in HIPAA/EDI Medical Claims Analysis, Design, Implementation and Documentation
• Responsible to prepare UAT cases.
• Design, build and test maps to translate X.12 EDI to and from transaction formats such as EDIFACT, SAP IDOC, and other multiple formats
• Analyze business requirements from Black Box testing:
• Creation and maintenance of documents for change request and implemented procedures for testing changes.

Confidential

Business Analyst

Cigna major service lines include workers compensation claims administration and healthcare management services, property and casualty claims management, class action services and risk management information services. As a Business Analyst in Cigna I was involved in development of claim management data warehouse to assist claim professionals to analyze and administer the claims in an efficient manner. The operational data came from multiple sources and was then loaded into claim management data warehouse

Responsibilities:

• Helped in defining Change Management Process for Release Management Team.
• Mapped process flow assess as-is processes through user interviews, data collection and analysis, design andevaluation of to-be process solutions.
• Prepared Business Object / Business Process Models that included modeling of all the activities of business from conceptual to procedural level.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• Assisted the QA team in designing the Test Plan and Test Cases for User Acceptance testing. Designed and developed Use Cases using UML and Business Process Modelling. Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits including Medicare .
• Developed data conversion programs for membership, claims, and benefit accumulator data - converted thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Validated the following: 837 Health Care Claims or Encounters , 835 Health Care Claims payment/ Remittance , 270/271 Eligibility request/Response , 834 Enrollment/Dis- enrollment to a health plan
• Identified gaps in the business process.
• Performed Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data
• Assisted process owners in process training and implementation.
• Streamlined the Restatement Financial Data Warehouse access review Process.
• Gathered requirements from users of the Clear Quest CQ tool for any Enhancements or change requests for any defects.
• Planned and defined system requirements to Wire Frame with Use Case, Use Case Scenario and
• Use Case Narrative using the UML Unified Modeling Language methodologies.
• Coordinating with the development team to set up test environment for issue escalation and issue resolution process for SIT and UAT testing to enable smooth operation
• Interacted with the users and logged any defects, enhancements from the UAT.
• Wrote test cases and test scripts for the User Acceptance Testing
• Led and conducted JAD sessions for requirements gathering, analysis and design of the system.
• Created context and workflow models, information and business rule models, Use Case and Object Models during the analysis using Rational tools.
• Designed and developed project document templates based on SDLC methodology
• Established RUP Rational Unified Process methodology and provided assistance in developing Use cases and project plans.
• Involved in reviewing test plans and test cases and ensuring test cases reflect user needs. Also responsible for conducting user training and user acceptance testing to ensure and verify system is designed according to user needs.

Confidential

Business Analyst/Systems Analyst

Confidential with the Medicare Centers and Medicaid Services CMS to provide quick, easy, and affordable access to the health care service of their choice.Market Prominence is the only system that provides management with the ability to tailor each step of the regulatory process based on the health plan's interactions with each of its beneficiaries. Project involves integrating Market Prominence and the Claims processing System with the data warehouse to support the reporting requirements. My duties were included designing the model of ODS to automate and maintain the ETL process

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• Responsible for writing Functional Requirement Specifications FRS and User Requirement Specification URS .
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Understand the As Is system and develop the To Be system concept and also prepare the System Process Maps.
• Interacted with the developers to report and track bugs using Test Director.
• Successfully conducted JAD sessions, which helped synchronize the different stakeholders on their objectives and helped the developers to have a clear-cut picture of the project.
• Conducted presentations of the Q/A test results with analysis to the stakeholders and users and documented modifications and requirements.
• Provided data modeling support to each logical data model according specifications of EDM.
• Coordinating and Developing QA activities.
• Created Process Flow diagrams, Use Case Diagrams, Class Diagrams and Interaction Diagrams using Microsoft Visio and Rational Rose.
• Wrote Test Cases and performed User Acceptance Testing, documented the in detail defects using the Defect Tracking report.
• Used Test Case distribution and development reports to track the progress of test case planning, implementation and execution results.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created Use cases, activity report, logical components and deployment views to extract business process flows and workflows involved in the project. Carried out defect tracking using Clear Quest
• Maintained proper communication with the developers ensuring that the modifications and requirements were addressed and also monitored these revisions.
• Involved in compatibility testing with other software programs, hardware, Operating systems and network environments.