SUMMARY:

• Over 7+ years of professional knowledge in Software Development Life Cycle SDLC and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, migration, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Documented Non - functional requirement documents, Business Requirement Document BRD and Functional Requirement Document FRD.
• Comprehensive experience in different SDLC methodologies: Waterfall, Agile and Rational Unified Process.
• Interacted with the Stakeholders, End Users to understand and gather stakeholder requirements and create the Business Requirements Document BRD and Functional Requirement Document FRD and communicating it to the entire team involved
• Expertise in performing GAP analysis and Impact analysis driving internal and external requirements.
• Functional knowledge in developing and implementing Claim Processing Systems.
• Test case writing manual/automated and conducting different tests Integration and regression testing, UAT User Acceptance Testing.
• Knowledge of Analysis Design Use Case, Sequence and Activity diagrams using Unified Modeling Language.
• Writing Manuals System guides, training material for business users and Deployment guides.
• Good knowledge in RDBMS, Oracle, SQL along with MS SQL administration, SQL Enterprise Manager, Data analysis and reporting.
• User training on the changes being released and conducting post production activities like getting feedback from users.
• Good understanding of EDI Transactions270/271, 278, 837I, 837P, 835, 834, 820, 276/277.
• Strong understanding of FACETS and Facets Data Model working on data model and data extracts.
• Experienced working in Facets online modules such as Billing, Provider, Claims and Membership modules.

TECHNICAL SKILLS:

Business Skills: Business Process Analysis Design, Requirement Gathering, Use Case Modeling, JAD/JRP Sessions, Gap Analysis and Impact Analysis.

Methodology: RUP, Agile, OOAD and Waterfall.

Standard and Codes: HIPAA, EDI, ANSI X12, HL7, CMM, ISO, CPT and CMS form.

Management Tools: Rational Rose, Requisite Pro, Clear Quest, Clear Case, Serena Team Track and MS Visio, MS Project.

Testing Tools: Test Director, Win Runner, Load Runner and TOAD.

Database: Oracle 8i/9i/10g, DB2, MS SQL Server.

Operating Systems: UNIX, Windows 95/2000/NT/XP.

Office tools: MS Office 2007 Word, Excel, Power Point, Outlook, MS Visio, MS Project

PROFESSIONAL EXPERIENCE:

Confidential, New York, NY

Facets Business Analyst

Responsibilities:

• Followed Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
• Created SQL Queries using Oracle, SQL Server and DB2 in validating data into Data Warehouse/ETL applications.
• Work on project documentation that defines the process requirements required to implement Facets.
• Configure provider demographics, billing information and contract information in claim system while maintaining departmental quality and production goals and objectives.
• Involved with Data team to extract data from Data Warehouse and generate report.
• Configure Facets Procedure Codes application on Application Support Application by setting up the table and populating the Table name, Field name, and Field Description.
• Internal review of user stories with management for scenarios/test data/screen shots prior demo.
• Single-point contact for issues encountered by the client which were managed & coordinated via JIRA system.
• Documented various key elements of HIPAA compliance and made sure that they were understood by the development teams and ensured that the test cases written for the project were HIPAA complaint.
• Worked on EDI transactions: X12, 835, and 837 P.I to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes
• Tested the billing and rendering provider, member subscriber, and payment modules of FACETS in the UI as well as in terms of database validation through SQL Queries.
• Created use cases that defined the role of customers, medical practitioners, clearing house Administrators and healthcare plans such as: Medicare, Medicaid insurance plan.
• Gathered requirement for SSIS, SSRS, OLAP Cube and used advanced Excel Power Pivot, SAS, Tableau Visualization tool to deliver actionable KPIs, measurable metrics and indices in support their operations, sales development for Enterprise Information Management.
• Analyzes and resolves problems and complaints about payment of claims for Health services provided to Medicaid recipients. Prepares letter responses and answers inbound and outbound telephone inquiries from Medicaid providers.
• Analyze change requirements for Providers, Contracts and Claims processing modules configuration in Facets system for Medicaid and Medicare Advantage Plans.
• Worked closely with ETL and BI teams during project implementation and actively suggest ways and means to share and optimize work.
• Involved in HIPAA EDI transactions such as 270, 271, 837 (P, D, I), 276, 277, 834, 820, 278, 999/TA1, and 277 CA.
• Adding scenarios, test data and screen shots used for testing to Test Ready User Stories in JIRA.
• Document all data mapping and transformation processes in the Functional Design documents based on the business requirements
• Worked in FACETS Reconfiguration of member/subscriber, Data Element Definition and Usage with values and completed configuring FACETS Applications like Related Entity, Parent Group, Group, and Subgroup.
• Involved in GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. Worked on EDI transactions: 270, 271, 835, and 837 to identify key data set elements for designated record set.
• Good experience and understanding of dataware house database design, relational integrity constraints, OLAP, OLTP.
• Experienced in software development life cycle such as Waterfall, Agile-SCRUM methodologies, Business Analysis and Modelling.
• Instructed and modeled core Agile principles of collaboration, prioritization, team accountability and visibility, ensured consistent application of SCRUM methodologies across the enterprise
• 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.

Confidential, Jacksonville, Florida

Business Analyst

Responsibilities:

• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses.
• Experience in X12 EDI Transactions (834 enrollment, 820 payments, 270/271 eligibility/response, 837I and 837P institutional and professional claims, 835 Healthcare Claim Payment Advice, 277CA Claim Acknowledgement, 999 transactions)
• Modification or enhancement related to MMIS Medicaid Management Information System security.
• Built business requirements into the Medicare Advantage MA requirements database and created the Project Requirements Document for the three functional areas.
• Worked closely with Data Architects and ETL Leads/Managers and was responsible to perform detailed data requirements analysis and create design specifications and operational documentation.
• Understand rules and regulations of HIPAA as imposed during Electronic Data Interchange EDI.
• Used JIRA to perform test management activities and used JIRA tool to track and maintain different versions of the project documentation.
• Conducted one-on-one sessions with business users to gather data warehouse requirements.
• Expertise in implementing the agile, Rational Unified Process and Waterfall Methodologies throughout the Software Development Life Cycle of the project.
• Managed the evaluation of ETL and OLAP tools and recommended the most suitable solutions depending on business data warehouse needs.
• Develops and execute testing strategies for MMIS system changes. Strong background in testing entire systems life cycle and skilled in testing various Medicaid software.
• Extensively designed Data mapping and filtering, consolidation, cleansing, Integration, ETL, and customization of data mart.
• Active involvement in ETL design for data integration and master data management
• Worked with claims and configuration departments to resolve and reduce provider issues by analyzing and researching Medicare and Medicaid guidelines, fee schedules, and provider credentialing, contracting and licensing requirements
• Managed the team of consultants responsible for developing on-demand Medicaid Management System MMIS reports.
• Experience in an outsourced healthcare insurance operations environment and understanding of MECT and MITA.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.

Confidential, Minneapolis, MN

Business Analyst

Responsibilities:

• Facilitated interview, one on one and brainstorming sessions with SME's User's in understanding the requirements pertaining to billing Origination to billing Processing.
• Assisted and written System Requirements Documents SRD, including Functional and Non-Functional requirements.
• Gathered business requirements through interviews, surveys, prototyping and observing from account managers, finance manager, and independent advisors and got an accurate understanding of their needs.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Experience on configuring Hospital Claim Processing application on Claim Processing application by creating the lay out on excel sheets and populate Fields name, Section/Subsection, description, and table and columns name.
• Developed Test Cases for Deployment Verification, ETL Data Validation and Report testing.
• Analyzed with business users and software developers to improve OLAP functions on cube, dimension/level and measures for health care reporting
• Develop implementation guidelines and principles for practice-based clinical applications, including various practice management and EMR systems.
• Defined frameworks for Operational data system (ODS), Brokerage data warehouse (BDW), Central file distribution (CFD) and Data Quality (DQ) and created functional data requirement (FDR) and Master Test Strategy documents.
• Writing Epics and user stories, managing sprints and backlog grooming, and tracking project progress in JIRA.
• Created UML-based feasibility studies and Use Case Models to communicate those ideas to the developers.
• Conducted brainstorming sessions with the business users and SMEs to elicit requirements and worked in the creation of Agile Epics, user stories, Acceptance criteria documents.
• In-depth knowledge and experience in full SDLC with Agile/SCRUM and waterfall methodologies.
• Followed the UML based methods using Microsoft Visio to create: Use Cases Diagrams, Activity Diagrams, and Sequence Diagrams.
• Worked with SME's and business users to gain in-depth understanding of the business' mission, objectives, purpose and processes.
• Responsible for sales and marketing specializing in practice management, managed care systems, thin-client technology, Electronic Media Records EMR/EHR/PHE/PMR, ASP technology, and full integration tools.
• I nvolved in defining the source to target data mappings, business rules, business and data definitions
• Collaborated with the QA testing team to develop the test plan, test conditions and test cases to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Conduct project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.

Confidential, Miami, Florida

Business Analyst

Responsibilities:

• Implemented and maintained all EDI payer files for private, Medicaid and Medicare insurance plans.
• Involved in complete SDLC process in upgrading Facets system, system analysis, system support, migration support, profile changes, security tracking, and code deployment.
• Knowledge of the entire Systems Development Life Cycle (SDLC) with experience in the design, implementation, and maintenance phases.
• Extensively involved in HIPAA User Acceptance Testing UAT. Defined and maintained Test Cases for EDI transactions.
• Participated in frequent agile team meetings (Scrum planning, daily stand-ups, retrospectives) to provide guidance to an agile product development process.
• Converted MS Access database to MS SQL database using MS SQL Server Enterprise Manager. Created SQL scripts for uploading procedures.
• Conducted business validations covering the following deliverables: Facets Providers, Claims, Finance and Membership.
• Vast experience of working in the area of data management including data analysis, gap analysis and data mapping.
• Ability to analyze engineering product support issues described within a bug-tracking system (JIRA) and provide guidance to other Client Services members in an advisory capacity
• Analysis of Business requirements & Design Specification Document to determine the functionality of the ETL Processes.
• Extensive Claim experience for Provider, Payer, Clearinghouses, Pharmacy Expert level knowledge of healthcare industry applications and processing, EDI transaction sets and formats.
• Proposed strategies to implement HIPAA in the new MMIS system eventually move to HIPAA. Facilitate HIPAA integration and applied ANSI ASC X12 standards for 837 P, I, D, 270/271, 276/277, 278, and 835 transactions.
• Prepared client process maps for the consumer, broker, employer and provider transactions for the Facets process.
• Created PL/SQL packages to extract, transform and load data into data warehouses from various sources like relational databases, application systems
• Review and understand CMS regulations, data files and requirements that support Medicare billing processes.
• Produced Initial Medicaid Information Technology Architecture MITA State Self-Assessment Report to support the current Medicaid Management Information System MMIS Replacement Project.
• Determine primary, secondary and tertiary coverage on accounts for Managed care and Medicaid payers.
• Work on Rapid SQL to get access to Sybase Data base to see impacted table and column that is affected by upgrade
• 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.