SUMMARY

• Over 10 years of professional work experience with an earned reputation for meeting demanding deadlines and delivering critical solutions on various levels of Quality Assurance in IT, Insurance and Healthcare Industries. Involved in thorough study of Business Requirement Documents Design RDD and functional requirement specifications. Participated in weekly meetings with Business Analysts, Development and QA team to discuss the milestones, progress and the issues.
• Strong Knowledge of Medical Billing Rules and Regulations to bill the claims to the Insurance offices to get paid. Having Good Experience with denial management and appeals processes. Sturdy knowledge to handle the 835 and 837I, 837P claims Data Analysis and Strong Experience in Provider Credentialing.
• Good Hands on Experience with EDI Systems. Able to identify performance issues, assess root cause and develop successful action plans for the Production and Quality improvement. Have good Experience with Facets Claims Processing. Have good Hands on Experience working with Physician Claims (HCFA or CMS1500) and Hospital claims (UB04).
• Having Good knowledge in US Healthcare Industry end to end (Billing Rules and Regulations, Hospital Claims, DME Claims, Physicians office Claims submission and Insurance office all type of Claims adjudication). Good Hands on Experience to use ICD 9 codes and Good and Strong Experience on EMR files. Good Knowledge of ICD 10. Experience testing migration of 4010 to 5010 EDI transactions and data mapping
• Extensive experience in Healthcare/Claims adjudication with knowledge of ICD - 9 & ICD-10
• Strong Knowledge in Epic Systems which is a major provider of electronic health records software for large and medium-sized organizations.Epic the need to advance technology in a new specialty, for example- they take the time to develop what they call “modules”, built on the same platform and data structure as all of their other products. Breakdown of the major Epic Systems modules that have released, along with the clinical areas where are used: EpicCare Ambulatory,Epic Beacon Oncology, Epic Bugsy,Epic Care Everywhere,Epic Hyperspace,Epic MyChart etc.

TECHNICAL SKILLS

Methodologies: SDLC, Waterfall, Agile, Scrum, Lean, Kanban,XP, Crystal, ADS, FDD, DSDM

Operating Systems: Win NT/2000/XP, VISTA, LINUX, UNIX. Windows 8/10, UNIX, Sun Solaris.

Testing Tools: Quality Center, RQM Rational Quality Manager, RFT Rational Functional Tool, QTP, TIBCO, FIRST PASS, INTEL ESG,508 Compliance Sheriff, JAWS, WAT, WAB, HP ALM, SIEBEL CRM, VM WARE, Google doc, ITSM/ITIL, ServiceNow, JIRA

Programming Language: HTML, SQL, ORACLE, C, C++, UNIX, VBScript, UNIX Shell Scripting, Pega

Business DATA Modeling Tools: UML, Power Designer and Oracle SQL Developer.

PROFESSIONAL EXPERIENCE

Confidential

Sr. Business (Healthcare Analyst )

Responsibilities:

• Strong demonstrated analytical skills applied to business software solutions maintenance and/or development. Knowledge of software development and standard practise.Demonstrated ability to find effeciencies and improve Processes.
• Proved ability to determine systemic process faults and improve overall process performance across organizations.Understanding of health industry diagnosis, procedure and revenue codes and their application.
• Served as liaison between business and development teams to translate business and design requirements into technical requirements, providing strong leadership to both Product Owners and Development Teams in support the customers.Experienced in a software application development environment in an analytical role.
• Analyzed business requirements to understand the business needs and to determine how their applications can best functionally fulfill those needs. Combined knowledge of what the business wants with knowledge of how the systems are built and used to create functional designs across applications.
• Facilitated the production of key documents including business requirements, master story list, detailed user stories, sprint planning and design documents.
• Facilitated project planning sessions with project managers, business analysts and team members.
• Responsible to Implement HIPAA Gateways EDI maps for transactions with standards EDIFACT, ANSI X12, Rosettanet, Tradacoms, XML.EDI mapping specifications experience, working in an EDI production support environment.Strong fundamental understanding of EDI X12 transaction sets (270, 271, 276, 277, 820, 834, 835, 837, 277U/277CA, 997, 999, 824).
• Responsible for identifying the mapping between source and target data elements in support of mapping resource specifications.Identify, analyze and devise solutions for business and technical EDI data problems. Analyzes, and assess areas for performance improvements, and recommends and implements changes for better system process performance.
• Interfaced with members of your scrum team, and line of business product teams, business analysts from other teams to deliver solutions. Worked with scrum team to test and certify applications before they are deployed to production.
• Worked with technology and business partners to develop and refine our software delivery process. Perform critical analysis on information consolidated from multiple sources, identify and resolve conflicts, and break down high-level information into detailed workable requirements.
• Experienced in developing As-Is and To-Be process flows and gap analyses.
• Worked with Developers and Subject Matter Experts to understand the work effort for a requirement, and, if needed, facilitate making adjustments that satisfy all parties. Developed data maps (source to target and target to source).
• Actively participated in adding to the wiki that is living documentation of the latest business and technical requirements. Elicited, analyze, document, and validate technical requirements
• Worked with the client to obtain requirements through interviews, document analysis, surveys, site visits, business process descriptions, workflow analysis, and Use Cases. Served as the liaison between the customer community and the software development team via clearly documented functional, system and process requirements.
• Worked with clients to obtain requirements through interviews, document analysis, surveys, site visits, business process descriptions, workflow analysis and use cases.
• Evaluated the information from those multiple sources to develop an understanding of the client's business requests and needs and translates them into application and operational requirements.

Confidential

Sr. Business System Analyst

Responsibilities:

• Worked directly and collaboratively with the business and technical teams to deliver high quality functional IT specifications, gathering and creating specifications from the business teams. Analyses, interprets and recommends through formal proposals and presentations to management on new and effective ways to provide new/updated technology based business systems applications. Designed, build, and test business rules to support operations and business objectives for Community and State claims processes. Passion turned into information is used for decisions made by leadership.
• Strong Knowledge of Medical Billing Rules and Regulations to bill the claims to the Insurance offices to get paid. Sturdy knowledge to handle the 835 and 837I, 837P claims Data Analysis and Strong Experience in Provider Credentialing. Good Hands on Experience with EDI Systems. Have good Experience with Facets Claims Processing. Have good Hands on Experience working with Physician Claims (HCFA or CMS1500) and Hospital claims (UB04). Validated EDI X12 transactions like EDI 834 (Benefit Enrollment and Maintenance), 277/275(Health Care Claim Request for Additional Information and Response), 276/277(Health Care Claim Status Request and Response), 835(Health Care Claim Payment/Advice), 837 and (Health Care Claim: Professional, Institutional and Dental) as per HIPAA 5010.
• Experienced in Business and Technical writing: Business Case, Scope Document, Business Requirement Document (BRD), Functional Requirement Document (FRD), Non Functional Requirement Document (NFRD), Use Case Scenarios, Test Plans, Test Scenarios, Test Cases, AS-IS and TO-BE Workflows. Excellent knowledge of Health Insurance Exchange (HIX) health Insurance Portability & Accountability Act (HIPAA) standards, Electronic Data Interchange (EDI) X12. Strong knowledge and experienced with Health Care Reform and Patient Protection and Affordable Care Act (PPACA). Validated EDI X12 transactions like EDI 834 (Benefit Enrollment and Maintenance), 277/275(Health Care Claim Request for Additional Information and Response), 276/277(Health Care Claim Status Request and Response), 835(Health Care Claim Payment/Advice), 837 and (Health Care Claim: Professional, Institutional and Dental) as per HIPAA 5010.
• Having Good knowledge in US Healthcare Industry end to end (Billing Rules and Regulations, Hospital Claims, DME Claims, Physicians office Claims submission and Insurance office all type of Claims adjudication). Good Hands on Experience to use ICD 9 codes and Good and Strong Experience on EMR files. Good Knowledge of ICD 10.
• Collabrated with Business users, stakeholders and PO product owners in-order to break down business requirements gatherings into Epic stories,User stories create user stories, mockups, wireframes, documentations in confluence JIRA to understand code by Developers team,test by QA team in each sprint planning and updating SI Service Items, LOB Line of business and migrating RDD requirement design documnet in Atlassian confluence. GBD Facets Government Business division Medicare & Medicaid for all forms of Health insurance.
• Reviewed requirements for business rules with Product Manager & Product Owner and identified any additional information required for Rule Design. Participated in Feature Refinement & User Story Grooming sessions. Participated in PI Planning and Build Rules. Rule Testing (Unit Testing with mocked data and production data) & Demo results. End to End Testing Support & Support Parallel Test. Supported defect resolution for any defects related to rules. Supported defect analysis for any production issues related to rules. Supported maintenance requests for updates to business rules post deployment. Documentation updating Atlassian confluence, migrating RDD to confluence Atlassian.
• Well versed in the product, process and technology aspects. At the intersection of business strategy, client and implementation vendors and responsible for translating abstract visions into reality while managing client's expectation as well as vendor's work efficiency. Also proficient in all aspects of the agile deliverables required for a technology team to build beautiful products. This includes hands on development of storyboards, wireframes, product backlog, user stories and user acceptance criteria.
• Worked within Agile squads directly supporting Legal, Enterprise Compliance, Enterprise Risk, Information Security, etc. Participated in multiple technology and/ or business releases and play a key role as subject matter expert for successful implementation. Drove User Story generation across business and technology teams to support a healthy backlog of capability development within assigned domain.Identified potential new and improved technical directions, develop strategic options/ approaches to recommend to management.
• Acted as liaison and primary contact to Business Units, Integration/Infrastructure, Architecture and PMO, providing an advocate for technology initiatives within assigned domain. Assisted managers in change management efforts related to organization, and short- and long-term strategic plans and goals. Proficient in business analysis concepts (business process modeling (BPM), context diagrams, use cases, user stories).
• Acted as critical adviser to the team, providing deep functional expertise in the work plan, standards, process and procedures, and change management efforts. Conducted all phases of complex analysis to prioritize making recommendations toward solutions, and manage resources to achieve unit, division and corporate goals..
• Worked closely with the IT Governing Groups to ensure Development Standards are met. Provided, analyze, recommend, negotiate, and direct work as subject matter expert on complex, technical issues. Facilitated successful delivery for assigned releases - Ensure internal IT and business needs are clearly identified, designed and constructed to meet quality standards. .
• Worked closely with the Business units and IT partners to create, identify, and evaluate deliverables such as user stories, business process models, user manuals, test plans and test results, as well as release plans. Created, evaluate, and present complex technical business cases, as-is and to-be business processes, current and future technology integration design recommendations to colleagues, management, business customers and vendors.
• Collaborated with Business units and IT partners to provide effort estimate / user story points. Assisted managers in developing annual and multi-year department objectives and strategies. Understand the future direction of business, IT impact on the business, the role IT plays, and communicate these trends to the business and IT colleagues.
• Worked directly with the business and technical teams to deliver high quality functional IT specifications, gathering and creating specifications from the business teams. Worked to make User Stories and responsible to complete the stories on time. Developed and implemented data cleansing, data security, data profiling and data monitoring processes. Involved in UAT and Integration testing, Requirement Gathering, creating source of Work, preparing the documents as per the Business request. Gather Data from Help Desk Ticketing System and write Ad-hoc reports and, charts and graphs for analysis. Performed User Acceptance Testing (UAT) to ensure that proper functionality is implemented.
• Responsible for support, enhancement and implementation software applications used within the Healthcare organization. Identified opportunities to leverage technologies in areas that improve and enhance the business practices by designing and implementing application/product enhancements. Worked with/liaison to customers and end-users, appropriate IT personnel and software vendors on a regular basis to align technology functionality to operational processes. Facilitated project implementations. As an individual have doing project implementation. Also performed day to day review of contracts, redefying, and understanding what the client is asking for.Took great notes in regards to what the customers requirements are.
• Possesses and routinely provided broad knowledge of business system analysis processes and procedures. Had the ability to provide solutions to most business system problems and serves as a resource to others in the resolution of the more complex issues. Had the ability to drive processes and improvement initiatives. Problems encountered are frequently diverse in scope where experience and judgment is relied upon for obtaining solutions. Applied a detailed knowledge of business system analysis concepts, practices and procedures to determine most effective business system applications.
• Have the knowledge and skills in delivering requirements design document (RDD) and functional design for internally developed products and 3rd party applications requiring customization. Requires an individual who has the ability to gather and document user requirements and translate or breakdown into User story the information collected to functional requirements including scoping documents, mock-ups, functional requirements and technical specifications.
• Having Good Hands on Experience about Healthcare revenue cycle and accounts receivable management, including payment cycles, key trends, and critical success criteria.