SUMMARY

• 7 years of extensive experience in the field of QNXT Business Analysis, working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Combined experience in Software Development Life Cycle and Business Analysis: experienced in gathering user requirements, documenting requirements, technical writing, business analysis, system analysis, testing, and implementation of projects.
• Experience in Healthcare Payer and Provider Operations, re - engineering claims, benefits, enrollmentand eligibility processes Experience with different modules within healthcare (Sales, Membership, billing, enrollment, claims, capitation, and providers).
• Strong knowledge of managed care payer requirements and procedures.
• Experience in preparation of Deliverables, Business Requirement Documents (BRD), detailed Functional Specifications and Non-Functional Specifications, developing Use Cases and Test Cases
• Extensive experience working in back end tester by writing SQL Queries and PL/SQL scripts on large data warehouse systems involving Terabytes worth of data.
• Familiar with HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278 etc
• Experience with Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Oversees the execution and completion of information technology solutions projects for the Healthcare/Payer Solutions area.
• Extensive experience in Strategic development of a Data Warehouse and in Performing Data Analysis and Data Mapping from a Operational Data Store to a Enterprise Data Warehouse
• Experience with TriZetto QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.
• Good knowledge of Health Insurance Plans (Medicare Part A, B, C and D), managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS-1500 claim forms and reimbursement forms.
• Excellent knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax like ANSI X12, Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Experience in coordinating UAT by developing test plans, UAT test scenarios, test cases, test data to be used in testing based on business and user requirements.
• Highly skilled in creating, writing, and executing Test Cases, Test Scripts from Business User Requirement documents and Functional Design Documents.
• Strong business knowledge of Healthcare sector and very good knowledge about HIX and proven experience with ICD9-ICD10 conversion.
• Interacted and involved with Business users to gather requirements and support them with Business Intelligence solutions and products.
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Solid understanding of Business Process definition, Risk Analysis and SDLC methodologies
• Good working knowledge of Claims processing, HIPAA Regulations and 270, 837P, 837I, 837D EDI Transactions for health care industries.

TECHNICAL SKILLS

• RUP
• UML
• SDLC
• Agile/Scrum
• Waterfall
• ETL
• QA
• MS Access
• SQL Server
• MySQL
• PL/SQL
• Oracle
• DBA
• DB2. Windows 98/2000/XP basic UNIX
• HTML basic DHTML basic XML
• Sharepoint
• MS Office Suite-Excel Macros
• Project
• Visio
• Adobe Photoshop
• Flash
• Rational- Rational Rose
• Rational XDE.

PROFESSIONAL EXPERIENCE

Confidential, Chicago, IL

QNXT Business Analyst

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.
• Acted as a liaison between the development team, QA team and the Business team and resolved any conflicts due to change in requirements.
• Involved in gap analysis and implementation of HIPAA 5010, ICD10 and Claim Validations
• Designed, developed and maintained system configurations, such as Procedure Codes, Pay Codes, Payor/Benefit Plans, Follow-Up Workqueues, Charge Entry and Claim Edits
• Involved in testing the ICD-10 codes by sending the test transactions to clearing houses or payers
• Used MS Sharepoint for the purpose of managing documents and for hosting websites which was used to access shared work spaces and documents.
• Analyzed and worked with HIPAA specific EDI transactions for claims, member enrollment, billing transactions.
• Work on fallouts from various applications, journalize manual billing requests, process payments, and customize miscellaneous activities.
• Write SQL scripts for adding, changing or deleting various benefit or contract data to or from QNXT that would take several man hours to complete via the front end software.
• Planned the UAT testing, test plans, test cases and worked with the business users for UAT test execution & assisted in developing the training documentation.
• Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application.
• Provide in-depth business knowledge and advanced technical support to Encounters Operations team (root cause analysis, data quality, validation).
• Met with individual departments to communicate SharePoint purpose, application and vision for the future.
• Perform billing compliance audits and manage billing projects. Collaboratively analyze results to develop reports/recommendations.
• Provide timely and relative support to cash applications and senior leadership in regards to the settling of outstanding invoice payments due various utilities.
• Responsible for integrating with QNXT. Designing test scripts for testing of Claims in Development, Integration and production environment.
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
• Maintain all applicable HIPPA, Billing Compliance and safety policies and guidelines.
• Identified defects and perform root cause analysis by analyzing data quality issues.
• Conducted HIPAA4010A1 to 5010 upgrade JAD sessions and documented the outcome on QNXT and FACETS platform.
• Worked in mainframe environment and used SQL to query various reporting databases.
• Involved in all phases of SDLC that covered elaborating, configuring and testing of the various applications
• Responsible for conducting gap analysis as is to be for ICD9 and ICD10. Prepared Data Flow Models for code sets validating in Facets and Claim Process Engine.
• Involved in testing QNXT Member, Provider, Claims Processing, Utilization Management, Accumulators, Contracts and Benefits.

Environment: Windows 2000/XP, MS Office, SQL Server, Agile, Oracle, MS Project, MS Access, XML, Sharepoint, TestDirector, LoadRunner, Rational Rose, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.

Confidential, Minnetonka, MN

QNXT Business Analyst

Responsibilities:

• Analyzed the existing claims process and specific business rule logic will be applied in the ACP model.
• Gather detailed business and technical requirements and participate in the definitions of business rules and data standards.
• Acted as a liaison between client and payer/intermediary. Experienced in payer rules, requirements, governmental regulations and HIPAA compliance.
• Developed a comprehensive object oriented data model for healthcare eligibility, claim and accounts for the entire product suite.
• Created the SQL scripts for demonstrating the prototypes and for verifying the result sets
• UsedFACETSAnalytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Defined Functional Test Cases, documented, Executed test script in QNXT system.
• Participated in Defect review, incident Management, Root Cause Analysis and High Risk reviews.
• Performed in-depth testing of the service development system by documenting requirements and specifications for a world-wide deployment of SharePoint personal sites, workgroup portals and shared data repositories.
• Created and maintained the insurance coding and fee tables along with the contracts in the electronic billing system and prepared annual budget recommendations.
• Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
• Use guidelines and artifacts of the RUP to strategize the implementations in different phases of SDLC.
• Involved in creating sample mappings for the conversion of EDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes.
• Assists application developers perform root cause analysis on systems and applications
• Worked with Claims, enrollment, eligibility verification for members and providers, benefits setup, and backend payment cycle in facets.
• Interact with the Subject Matter Experts (SME's) to gather information about the health care enrolment, billing and health care claims processing and checked if they are processed correctly or not.
• Assisted with development of strategy for managing SharePoint permissions in conjunction with Active Directory and future implementation of Identity Lifecycle Management functionality
• Analyzed the change detection process on QNXT database tables to capture the daily changes done by Users through Online QNXT Application.
• Ensure data integrity through effective configuration of fields and tables; proficiently review and correct 837 rejected files as well as evaluate 835 files to determine optimal solutions for creating payor matches.
• Performed functional, regression and performance testing in user acceptance test (UAT) environment and approval of the application.
• Deflected the impact of multiple report requests from the Business Intelligence users.
• Analyzes benefit and contract configurations and processes to ensure information is entered correctly in QNXT
• Design, develop and went live after migrating several MS Access & SQL Server databases for corporate developers, resolving typical database issues.

Environment: Ascential DataStage, (Designer, Director, Manager, Parallel Extender) Debugger, Oracle, MS Word, Excel, Visio, Access, and Project, Mercury TestDirector Agile, Waterfall.

Confidential, Pittsburgh, PA

Business/Systems Analyst

Responsibilities:

• Wrote Business Cases after conducting meetings with business users, risk team and finance team.
• Used HIPAA 4010 transactions to support the analysisof current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes forHIPAA 5010 transaction processing EDI’s 837, 835, and 834 and ICD-10 Code sets.
• Involved in impact analysis of QNXT adjudication system as a result of change in EDI transactions.
• Mapped all as-is business processes using BPMN standards on MS Visio.
• Responsibilities include developing initial design requirements and documents to migrate the ITS system to NASCO ITS system.
• Act as liaison between the billing office and the clinical areas for coding and billing compliance deficiencies
• Conducted JAD sessions and created functional and technical requirement specification for application development based on Solution Delivery Process.
• Updated/Modified Facets Fee Schedules
• Performed root cause analysis on model errors and alerts and identified steps for resolution.
• Designed High level design, for New process, integrating with legacy and QNXT
• Analyzing data, generating reports and collecting appropriate data to support evaluation of billing operations.
• Identifying technical needs and projects for IT staff.
• Utilized Facets Data Model to document, map and query data required for the 271 benefit response
• Created a test plan and a test suite to validate the data extraction, data transformation and data load and used SQL and Microsoft Excel.
• Experience with Trizetto Facets System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 837 and proprietary format files and Reports development.
• FacetsProductConfigurationof new products and components including research, testing and trouble shooting inFACETs.

Environment: Rational Rose and Requisite Pro, MS Visio, MS Office, MS Project, Agile, UML, XML, Windows XP, NT/2000, DB2, SQL Server 2000.

Confidential, Woodland Hills, CA

Business Analyst

Responsibilities:

• Understanding the current business process, defining scope of the project along with vision statement.
• Met with users and stakeholders to understand the problem domain, gathered customer requirements through surveys, interviews (group and one-on-one) along with JAD sessions.
• Applied Unified Modeling Language (UML) methodologies to design Use Case Diagrams, Activity Diagrams and Sequence Diagrams in Rational Rose.
• Coded the ETL and Business Intelligence Batch and On line PL/SQL Packages.
• Developed Use Case diagrams, business flow diagrams, Activity/State diagrams and Sequence diagramsso that developers and other stakeholders can understand the business process.
• Analyzed and tested various Common Eligibility Outbound Interface Process and other Inbound/Outbound QNXT interfaces.
• CAssure that all Artifacts are in compliance with corporate SDLC Policies and guidelines
• Analyzed the change detection process on Facets database tables to capture the daily changes done by Users through Online Facets Application
• Exposed to & working knowledge of all the phases of the SDLC cycle & worked in both Waterfall and Agile models like Daily Scrum, Sprint Planning and Sprint Review.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to followICD 10Code set andANSI X12 5010formats.
• Direct contact with the payer on behalf of the provider to discuss claim rejection reasons concerning claims and enrollment
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database.
• Parsing high-level design specification to simple ETL coding and mapping standards.
• Designed and facilitated the implementation of data warehouses required by application systems.

Environment: Windows, MS Office(MS Word, MS Excel, MS Powerpoint, MS Visio), RUP, UML, Visual Basic, SQL, Win Runner

Confidential, Tampa, FL

Business Analyst

Responsibilities:

• Responsible for defining the scope and implementing business rules of the project, gathering business requirements and documentation.
• 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.
• HIPAA EDI transactions such as 835, 837 (P, D, I) 276, 277, 278.
• Experience in EDI automated first-pass claim adjudication, requiring thorough understanding of claim processing, both front and backend operations.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Involved in creating sample mappings for the conversion ofEDI X12transactions code sets version and translation ofICD 9codes intoICD 10codes.
• Conducted business-impact assessment and the results were compared with the new HIPAA 5010 standards to determine the current level of compliance and developed an action plan for approval by the project steering committee.
• Involved in designing and developing Data Models and Data Marts that support the Business Intelligence Data Warehouse.
• Used Query Analyzer, Execution Plan to optimize SQL Queries

Environment: Requisite Pro, Rational Rose, Agile, PL/SQL, MS Office, MS Visio, EDI, Rational Clear Quest, Rational Clear Case, UML,RUP, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.