SUMMARY

• Business Analyst wif 7+ years of professional experience in business analysis, business process analysis, business requirements, database design, business process modeling, and strategic planning in teh field of Insurance.
• Hands - on experience as a Business Analyst in Healthcare Insurance, Medical Billing, Accounts Receivable, U.S. Health Insurance Portability, Accountability Act, EDI Transactions (834, 835, 837), HIPAA, MMIS, Medicare, and Medicaid.
• Extensive experience wif Health and Human Services programs, Medicare, Medicaid MMIS, Child Welfare, HMO, PPO, POS, Managed Care, Life, Health Insurance Exchange HIX, Health Information Exchange HIE, HIPAA regulations, Electronic Health Records EHR, Electronic Medical Records EMR, and Electronic Patient Records EPR, SHBP (STATE HEALTH BENEFIT PLAN).
• Extensive experience in business analysis, requirement gathering, and eliciting efforts for application development projects including DevOps practice involving Agile, Waterfall, and Agile - Waterfall Hybrid methodologies.
• Demonstrated experience and understanding of teh methodology testing in a DevOps environment, which includes experience in using Jenkins for auto-deployment of a build.
• Use Azure DevOps for raising defects, defect tracking, maintaining test results, System Test Plans, Designing SQLs, Test Scripts / Test Cases, Test Case Executions and Test Completion Reports for web applications & client-server applications, and status reporting
• Expert in all teh phases of SDLC methodologies like Waterfall, Iterative, Rational Unified Process (RUP), Agile/SCRUM, and Kanban throughout teh project life cycle.
• Experienced in interacting wif business users to identify their needs, gathering requirements, and authoring Business Requirement Documents (BRD), General system Design (GSD), Functional Requirement Document (FRD), and Software Requirement Specification (SRS) across teh deliverables of a project.
• Participated in Joint Application Development (JAD), brainstorming sessions, reviews, walkthroughs, and customer interviews to gather customer requirements.
• Worked wif multiple Relational databases like MySQL, Oracle, SQL server, and in-depth noledge in ETL tools (Pentaho, SSIS).
• High degree of computer literacy in MS Office: Word, PowerPoint, advanced Excel skills (formulas, pivot tables, VLOOKUP functionality), Visio, Project, Access, and SharePoint for document sharing/collaboration.
• Logs teh bugs in JIRA and assists teh developers in teh resolution of bugs.
• Proficient in developing & automating reports, iteratively building & prototyping BI dashboards using Tableau to provide insights at scale, and solving for analytical needs of business teams.
• Experienced in conducting GAP analysis, User Acceptance Testing (UAT), Risk Analysis and mitigation plan, Cost-benefit analysis, and ROI analysis.
• Skilled in designing and preparing monthly status reports, assisting in corporate projects in health care, health economics model, and evaluating all clinical trial data.
• Exposed to Medicare and Medicaid domains of teh healthcare systems and industry for inpatients, outpatients, Reimbursement Methodology, and Medicaid Management Information System MMIS.
• Worked in teh healthcare sector wif a prime focus on Claims Adjudication, Migration, Provider, Eligibility, and Prior Authorization for Medicare and Medicaid programs.
• Experienced in FACETS and its modules such as Claim, Member/Subscriber, Billing, Provider, Medicare, Medicaid, and experienced wif several Facets Batches.
• Well experienced as a Validation Consultant and as a Validation Associate by validating computer systems and software as per FDA regulations and GxP and GMP guidelines.
• Experienced in split claims in HB billing and performed scenarios for split claims.
• Knowledge of HIPAA standards, EDI (Electronic data interchange) Transaction syntax such as ANSI X12.
• Extensive noledge of Qualified Health Plans (QHP), Qualified Dental Plans QDPs, Health Insurance Exchange (HIX), and Affordable care Act (ACA).
• HL7 Standards, HIX, EHR - Electronic Health Records, EMR - Electronic Medical Records, CMS regulations, Health Care Reform, EMTALA, PPO, POS, and HMO.
• Adequate noledge in Health Administration - Claim processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Confidential, Medicaid, CDHP (consumer-driven health plans).
• Excellent noledge of Medicare Part A, B, C, and D and Medicaid Health Insurance Policies like CHIP, Personal Injury Protection PIP insurance, billing experience in life and disability in health plans, etc.
• Extensive Claim experience for providers, Payer, Clearinghouses, Pharmacy Expert level noledge of healthcare industry applications and processing, EDI transaction sets, and formats.
• Experienced in EDI and HIPAA wif multiple transactions involving claims handling and processing, wif HealthCare payer and provider experience (270 & 271, 276 & 277, 820, 837 P/me/D, 834, 835) Proficiency in documenting Test Cases, Test Plans, Test.
• Varied experience including Medicaid (MMIS, MITA, MECT), Medical Billing, Medicare, and General Insurance (Health Claims).
• Strong analytical, problem-solving, and interpersonal skills; acquired credentials in teh medical profession having teh zeal to treat patients wif empathy and compassion.
• Outstanding communication skills, self-motivated and goal-oriented wif a high degree of flexibility, creativity, commitment, and optimism.

PROFESSIONAL EXPERIENCE

Sr. Business Analyst

Confidential - Phoenix, AZ

Responsibilities:

• Gathering requirements as well as scheduling a daily scrum meeting to elicit, analyze, verify, and manage teh needs of teh project stakeholders, customers, and end-users.
• Organized and facilitated Agile and Scrum meetings, which included Sprint Planning, Daily Scrums or Standups, Sprint Check-In, Sprint Review & Retrospective.
• Worked on Data mapping, and logical data modeling used SQL queries to filter data wifin teh Oracle database tables
• Created SQL Queries using Oracle and SQL Server in validating data into Data Warehouse/ETL applications
• Responsible for overall documentation development and editorial cycles for DevOps and other IT Infrastructure groups using Confluence Wiki.
• Worked wif Senior Developers, Architects, Project Managers, DevOps Engineers, Release Managers, SCM Team Leads, and other Infrastructure team members on and offshore.
• Conduct JAD sessions to gather and document requirements that enhance a wide range of functionalities including claims processing, eligibility and enrollment, provider networks, and electronic data interchange.
• Responsible for analyzing Eligibility for State Welfare Program, Children’s Health Insurance Program (S-CHIP), Food Stamps (SNAP), Child Care and Temporary Assistance to Needy Families (TANF) (CHIP, SNAP, and TANF).
• Worked on electronic Medicaid eligibility verification system and teh Medicaid and Medicare intermediary along wif their roles in claim processing.
• Performed Gap Analysis for 5010 enhancements using teh TR3 implementation guides and side-by-side HIPAA 5010 guides provided by CMS (Center for Medicare & Medicaid Services).
• Experience in working wif CMS and Medicaid Programs. Experience in implementing Healthcare Compliances like ACA, HIPAA, and MOOP.
• Good Understanding of teh EDI (Electronic data interchange), Implementation, and Knowledge of HIPAA code sets
• Participated in Requirement gathering, Business Analysis, and User meetings wif both onshore and offshore teams, discussing teh issues to be resolved and translating user inputs into ETL design documents along wif capturing specific data and analysis of teh root cause of teh problem.
• Analyzed Service Requests and Change Requests available in JIRA and pertaining to everyday business needs
• Knowledge of several functionalities available in teh Facets several applications such as Billing, Member/Subscriber, Accounting, and Utilization Management.
• Worked wif providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 834, 837, 835, and 270/271
• Proficient in Developing and executing Test Plans, Test cases, FRD, Trizetto Facets 4. x and Medical Billing, Test Scenarios, also performing functional, and usability testing and ensuring that teh software meets teh system Requirement.
• Worked as liaison between software developers and users of EMR systems to create better electronic medical record systems.
• Maintained a proactive stance wif business relationship(s) to ensure teh business needs are always met wifin GxP Quality guidelines.
• Tested claims adjudication and group and enrollment for new Medicare advantage members.
• Medical Claims experience in Process Documentation, Analysis, and Implementation in 835/837/834/270/271/ Standards processes of teh Medical Claims Industry from teh Provider/Payer side.
• Serve as an active member of teh PDP team, interacting wif developers, business users, and subject matter experts SME to analyze and configure PBM Web-Portal functionality based on Business requirements.
• Documented teh UAT Plan and worked wif teh UAT Team to ensure teh acceptance criteria for every requirement have been included in teh UAT task plan.
• Collaborating wif teh IT Data Modeling team to ensure data model design is consistent and accurate wif teh business requirements.
• Responsible for Medicaid Claims Resolution/Reimbursement for state healthcare plans using MMIS.
• Managing and Billing Medicare, Commercial HMO/PPO claims daily.
• Worked on teh claims related to Medicare (Part A, Part B, Part C, Part D)

Confidential - Oak Brook, IL

Sr. Business Analyst

Responsibilities:

• Validated Active Renewals and Passive Renewals for “Qualified Health Plan (QHP)” and “Medicaid” (MCD) Members based on their effective plan dates.
• Gathered requirements for making changes to teh existing Electronic Medical Records (EMR), Electronic Health Records (EHR), and Ambulatory Services for teh existing Epic Interfaces.
• Administered HMO, PPO, HSA, POS, EPO, FFS, DSNIP, and Medicare Supplemental (Medigap) contracts.
• Developed EDI specifications and applications structures for data feeds and mappings for integration between various systems, including XML, and performed back-end testing on teh Oracle database by writing SQL queries
• In-depth noledge of Medicare/Medicaid Claims processes from Admin/Provider/Payer side which were later part of teh training program to vendors.
• Agile projects designed to improve teh current claims adjudication processing application MQ Direct.
• Used HIPAA Gateway to comply wif HIPAA standards (270/271, 276/277 & 837) for EDI transactions
• Well-versed wif HIPAA, Facets, CHIP claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source, and providing corresponding solutions.
• Analyze federal and state regulations/ policies for Medicaid and Children’s Health Insurance Program (CHIP) reimbursements.
• Scaled Agile Framework for teh Enterprise SAFe Leading transformation. Rally Dev Agile Tools. DevOps.
• Worked on Medicaid and CHIP program requirements, including a complete end-to-end life cycle data flow of eligibility, enrollment, claims, encounters, payment, and post-payment.
• Conducted multiple JAD sessions between various organizations such as DHS, DCCA, and OIMT to elicit system requirements using stakeholder analysis, RACI charts, and prototypes.
• Well-coordinated wif teh team and maintained independent workload of several Programs including Medicaid, SNAP, TANF, CHIP, Presumptive eligibility, and ACA.
• Responsible for delivering recommendations in establishing data exchanges between teh State's Medicaid Management Information System (MMIS) and teh Federally Facilitated Exchange (FFE) via teh Federal Health Information Exchange (HIX) Hub for Affordable Care Act (ACA) requirements.
• Committed to establishing FFM / FFE (Federal facilitate Exchange) under HIX (Health Insurance Exchange) that meets teh functional requirements of teh Patient Protection and Affordable Care Act (PPACA).
• Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions related to providers, payers, subscribers, and other related entities.
• Used FACETS to provide seamless transactions between teh provider, members, and teh plan.
• Did GAP analysis by comparing teh past HIX reports wif present Contractual Reports to create teh Future Reports.
• Validated member Eligibility, benefit, and claim status in a system and parallel testing.
• Worked and supported EDI Translators to analyze EDI file submission for Professional, Inpatient, Outpatient, pharmacy claims, and dental claims.
• Firm understanding of HIPAA regulations and experience working in all phases of healthcare insurance processing like defining Membership Eligibility and Enrollment and various Medical Claims processing.
• Strong Knowledge of Medical Billing Rules and Regulations to bill teh claims to teh Insurance offices to get paid.
• Expertise in teh EPIC Medical software application (EMR, HER) as it relates to hospital workflows and setting up teh infrastructure for software implementation in a clinic environment.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Developed and presented CMS stakeholder presentation to share MDM solution before deployment to production.

Confidential - Bloomfield, CT

Business Analyst

Responsibilities:

• Completed Agile/SCRUM project to allow a direct exchange method to send and receive secure patient EMR data between care providers to support coordinated care.
• Responsible for analyzing Eligibility for State Welfare Program, Children’s Health Insurance Program (S-CHIP), Food Stamps (SNAP), Child Care, and Temporary Assistance to Needy Families (TANF) (CHIP, SNAP, and TANF).
• Organized and facilitated JAD sessions as part of Requirement elicitation sessions based on User Stories and identifying Business and Functional Requirements and detailed discussions
• Assisted wif DHS complaints and resolution by effectively communicating wif key stakeholders and working wif internal departments
• Gathered teh Requirements for Medicare Systems as part of teh Patient Protection Affordable Care Act (ACA)
• Extensively used SQL queries for data validation in both Medicare/Medicaid and commercial HIX
• Develop, test, modify and manage EDI (x12 standard) maps using B2B mapping tools in teh Healthcare industry.
• Involved in project planning, coordination, and QA methodology in teh implementation of teh Facets in teh EDI transaction of teh claim module.
• Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999 HIPAA EDI Transactions using MS Word, MS Excel, MS Access and Facets PROD PPMO
• Strong HIPAA EDI 4010 and 5010 processes for a member, payers, and providers including Coordination of benefits, Copays, benefits, etc.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid, and other payers of government carriers.
• Served as a liaison between teh internal and external business community (Claims, Billing, Membership, Capitation, Customer service, membership management, provider management, advanced Healthcare management, provider agreement management) and teh project team.
• Developed business and functional requirements for teh National Provider Identifier NPI Crosswalk and Crossover Claims Crosswalk solution.
• Acted as a liaison between business staff and technical staff to articulate needs, issues, and concerns as per GxP and IRB department requirements.
• Maintained a proactive stance wif business relationship(s) to ensure teh business needs are always met wifin GxP Quality guidelines
• Working on Pharmacy Claims/Rx claims, Claims adjudication, Eligibility, Prior Authorization, Accumulators, Drug Step edits, PHI, and different managed care products like POS, HMO, and PPO.
• Worked wif ACS X12 5010 and ASC X12 4010A including teh various Claims Transactions such as 837 submit medical claims, 835 medical claim payments, 270 benefit/eligibility inquiries, 271 benefit/eligibility responses, 276 claim status requests, 277 claim status notification, 820 premium payments, and 834 enrollments.
• Expertise in teh EPIC Medical software application (EMR, HER) as it relates to hospital workflows and setting up teh infrastructure for software implementation in a clinic environment.
• Develop implementation guidelines and principles for practice-based clinical applications, including various practice management and EMR systems.
• Involved in developing teh new child-only pediatric QHP compliant QDP plans and adult dental insurance products for teh IU65 segment on and off teh exchange.
• Analyzed teh impact of new HIPAA standards on targeted systems, processes, and business-associate relationships
• Worked on Medicare Advantage (A, B, C), Medicare Part D (MA-PD), Medicaid Options (Under 65 and Over 65), and Managed Care (Care, Disease & Case Management, and in Insurance regulations & Claims Processing).
• Worked as a liaison between teh business client and teh development team for teh implementation of 5010 transitions in compliance wif HIPAA standards.
• Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid, and Medicare.
• Validation of connectivity between teh external systems and CMS Confidential database for electronic submission of documents by verifying teh gateway logs and SAML assertions.

Confidential, Bethesda, MD

Business Analyst

Responsibilities:

• Successfully collaborates wif business stakeholders and Sponsors to capture requirements for new development projects. Manages requirements and resources through teh SDLC.
• Extensive noledge of Medicaid Management Information Systems (MMIS), National Provider Identification (NPI), Electronic Data Interchange (EDI), Health Level -7 (HL7), HIX (Health Information Exchange), EMR/EHR, Health Care Reform, and Patient Protection and Affordable Care Act (PPACA).
• Assisted JAD sessions to identify teh business flows and determine whether any current or proposed systems are impacted by teh EDI x12 Transaction, Code set, and Identifier aspects of HIPAA.
• Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Develops business requirements and related technical documentation based on teh needs of various Divisions and Offices wifin DHS via industry-standard techniques such as data modeling, workflow analysis, reverse engineering, or requirements decomposition.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding, and HL7.
• Created Use-Cases and Requirements documents to document business needs and was involved in creating use cases based on HIPAA standards.
• Analyzed Medicaid Eligibility Determination System for Children’s Health Insurance Program (CHIP) and enrollment transaction 834 submitted to program administrator for HIPAA 5010.
• Worked wif teh implementation and ongoing support of teh Health Insurance Exchange (HIX) and compliance wif teh Affordable Care Act (ACA) mandate and Health Care Reform Act.
• Practiced agile methodology, led sprints, and prioritized line items based on key business initiatives wif respect to teh Affordable Care Act (ACA) mandate and Health Care Reform Act.
• Involved in projects to design a state-customized Financial Management solution for Health Insurance Exchange (HIX)
• Committed to establishing FFM/FFE (Federal facilitate Exchange) under HIX (Health Insurance Exchange) that meets teh functional requirements of teh Patient Protection and Affordable Care Act (PPACA)
• Expertise in payer domain System Integration wif Health plans eligibility and claim information. Strong understanding and Claims Processing/adjudication, Membership, and other standards.
• Tested claims adjudication and group and enrollment for new Medicare advantage members.
• EDI Claims Processing documented enhancements to teh EDI Claims Processes EDI 837, 835, 276, 277 to ensure accurate processing of claims of members.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain an up-to-date list of payer contacts.
• Tested teh billing and rendering provider, member subscriber, and payment modules of FACETS in teh UI as well as in terms of database validation through SQL Queries.
• Wrote Standard Operating Procedures (SOPs) for all aspects of teh validation life cycle, in accordance wif FDA regulations, particularly 21 CFR Part 11 and GxP regulations.
• Assisted teh implementation in teh GXP environment to adhere to regulatory and risk management compliance.
• Medical Claims experience in Process Documentation, Analysis, and Implementation in EDI X12 Standards processes of teh Medical Claims Industry from teh Provider/Payer side.
• Designed and Developed various Business Intelligence reports against ODS, Claims systems such as Facets, HER systems such as NEXTGEN and Care Management systems, Network Management systems, and Revenue Cycle Management systems.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Involved in Medicaid and Medicare claims to process along wif CMS, MITA, MMIS, Electronic Medical Health Record (EMR/EHR), and Pharmacy Benefit Management (PBM).
• Setting up Fee Definition and Fee Calculation in FACETS for QHP Individuals, Grandfathered/ Transitional Small Group, QHP Small Group, and Large Groups
• Involved in Testing teh various results generated by teh reports against teh data present in teh database tables and used UAT on that data involving teh users.
• Assisted in managing and billing Medicare, and Commercial HMO/PPO claims on a daily basis.

Confidential

Business Analyst

Responsibilities:

• Worked extensively on Claim adjudication and Claims Payment functional area wif teh Subject Matter Experts and gained strong noledge.
• Good Understanding of teh EDI (Electronic data interchange), Implementation, and Knowledge of HIPAA code sets.
• Developed Traceability Matrix including BRD and FRD to track down different defects related to Member enrollment eligibility, Claims adjudication, and Clinical requests from members.
• Gathered requirements for Medicaid and CHIP insurance coverage and performed data analyses.
• Participated in defining new processes for interfacing wif DHS for Medicaid claims submission.
• Knowledge of Patient Protection and Affordable Care Act (PPACA).
• Monitor all Affordable Care Act regulations to create client briefs and libraries for PPACA compliance.
• Gathered teh Requirements for Medicare Systems as part of teh Patient Protection Affordable Care Act (ACA).
• Business Analyst for a large Electronic Health Records EHR System and Design project related to State of California HER and HIX standards - DHCS.
• Analyzed issues wif EDI transactions and fixed IDOCs to be submitted into SAP for order fulfillment.
• Medical Claims experience in Process Documentation, Analysis, and Implementation in EDI X12 Standards processes of teh Medical Claims Industry from teh Provider/Payer side.
• Adjudicated medical claims for correct pricing to administer payment to medical providers.
• Involved in assembling, organizing, and analyzing patient information, including medical history, symptoms, examination results, test results, and prior treatments for HER (HL7) software development.
• Performed business analysis, software validation, and testing for client/server, multi-tier and web-based applications for EMR, and commercial business for managed healthcare plans and Industries.
• Developed Health Plan Issuer Accreditation Mapping to Qualified Health Plan (QHP) and Qualified Dental Plans QDPs.
• Followed teh Agile Scrum SDLC (System Development Life Cycle) methodology, Validated QHP Benefits, Rates, Network Adequacy, Essential Community Providers, Prescription Drugs, and Service area Information wif their templates for data submission by insures.
• Experience in Claims Processing, claim encounters, and Claims Scrubbing in HMO, PPO, DSNIP, Medicaid, and Medicare.
• Worked on Facets including Claim processing online and batch adjudication, Case management, Customer service, Member/subscriber administration, Provider network management, and reporting.
• Responsible for teh development and implementation of HIPAA EDI Map sets 270, 271, 276, 277, 820, 834, 835, 837, and 5010.
• Worked closely on adherence to HIPAA compliance, meeting CDC and CMS requirements to meet teh needs of implementation projects.
• Ensured all EDI Claims are received from Trading Partners and are processed and loaded into its appropriate claim systems daily.
• Active member for teh policy review to implement teh blueprint requirements for Medicaid/MMIS, Medicare, CHIP, and Tax Credits benefits per CMS guidelines.
• Designed and Developed various Business Intelligence reports against ODS, Claims systems such as Facets, HER systems such as NEXTGEN and Care Management systems, Network Management systems, Revenue Cycle Management systems.
• Used noledge of Healthcare Information Systems EMR model to develop proposed workflow in MS Visio.