SUMMARY:

• Senior Business Analyst with 8 years of experience in business process analysis/modeling, data requirements gathering, database design and development of Web Based, and Client/Server applications.
• Extensive experience in conducting Market Research, Feasibility Studies, Data Analyses, Data Mapping, Data Profiling, Gap Analyses, Risk Identification, Risk Assessment, Risks Analyses, and Risk management.
• Good knowledge of Health Insurance Plans and experienced in determining the FACETS Eligibility, Claims, Billing experience within life and disability in health plans with thorough understanding of CPT coding, CMS - 1500 claim forms and reimbursement forms.
• Excellent knowledge and deep understanding of industry standard methodologies like Software Development Life Cycle (SDLC), Iterative Software Development Life Cycle Process as per Rational Unified Process (RUP), CMM (Capability Maturity Models), Market Prominence automated solution.
• Research, track, parse and interpret EDI files 999, Transaction Acknowledgement records, and enrollment and claims files in EDI FECS data repository and UNIX server and analyze them according to the request.
• Gained good experience on Configuration of QNXT followed by business rules around adjudicating claims, member eligibility verification, and authorizations.
• Experience with TriZetto's FACETS, QNXT Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member
• Excellent Knowledge in Healthcare Medicare Part D implementation using Market Prominence.
• Extensive knowledge of Medical Management Information Systems (MMIS) and HL7.
• In-depth knowledge of creating use case, activity, logical, component and deployment views with rational tools to extract business process flows and workflows thereby helping development and quality assurance teams in understanding the requirements.
• Expertise in testing Enrollment, Billing and claims processing in FACETS.
• Sound Knowledge of data architecture concepts, data warehouse and datamarts.
• Results-oriented Joint Application Development (JAD) facilitator and meetings coordinator with excellent interpersonal skills.
• Analytical, methodical, and resourceful approach to problem solving, identifying and documenting root causes and corrective actions
• Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements
• Experience in Change Management Process (Identify, Analyze, Evaluate, Plan, Implement, Review and Close).
• Strong oral and exceptional written business communication skills
• Hard working, positive thinking, self starter with a strong goal orientation
• Excellent meetings facilitator with excellent inter-personal and conflict resolving skills.

TECHNICAL SKILLS:

Programming Languages: C, C++, C#, VC++, VB, VB.NET, C#.NET, ASP.NET, Java, SQL

Development Methodologies: RUP, AGILE, Waterfall

Databases: MS-Access, MySQL, SQL Server, Oracle, Teradata, DB2, Sybase

Internet: HTML, XML, VBScript, ASP, JavaScript, JSP, J2EE.

Bug Tracking Tools: Mercury TestDirector, Rational ClearQuest

Utility Tools: MS Office Suite, MS Project, TOAD, Adobe Photoshop

Reporting Tools: Crystal Reports, SQL Server Reports (SSRS)

Data warehousing Tools: Informatica, Business Objects, Cognos, Erwin

Testing Tools: Quick TestPro (QTP), TestDirector, WinRunner, LoadRunner

PROFESSIONAL EXPERIENCE:

Confidential, Englewood, CO

Sr. Business Analyst

Responsibilities:

• Gathered, analyzed, documented business and technical requirements from both formal and informal sessions and validate the needs of the business stakeholders.
• Analysis of inbound and outbound interfaces and extensions to Trizetto FACETS Claims Processing system.
• Facilitated JAD sessions with SMEs and business analysts from other feeder systems for a detailed analysis and a better understanding of impact of various projects on each other.
• Extensively worked on Facets Modules such as, Claims processing, Eligibility and Capitation.
• Worked on user interface design processes, standards, and best practices for web distributed applications.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the Compliances/Regulations and HIPAA Regulations.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Prepared Data Flow Models for code sets validating in FACETS and Claim Process Engine.
• Created Mapping Documents, Report Mock-ups and modified existing report mock-ups and finalized for development.
• Acted as a mentor and provided coaching and guidance to Stage-I and Stage-II SAs on work related issues.
• Tested claims adjudication and group and enrollment in Amisys for New Medicare advantage members.
• Supported major projects involving configuration changes to Facets (4.8V-5.01V)
• Worked on ensuring the configured TriZetto products and services are functioning as expected and will meet end user requirements.
• Participated in interdepartmental workgroup sessions designed to facilitate effective solutions to ongoing systematic transaction processing problems.
• Created job aids such as; materials and workflows for configuration and related tasks.
• Demonstrated good judgement in defining methods & techniques for obtaining solutions and worked on advanced problems of diverse scope and complexity where analysis of situation and data requires a review of a variety of factors.
• Used SQL to test various reports and ETL load jobs in development, QA and production environment
• Worked with testing team to create the testing scenarios, Queries and helping them to understand the logic.
• Provided recommendations for improving testing approaches, processes and procedures

Environment: Windows XP (SP-3), Caliber,HL7, -Data Modeler, HP Quality Center, MS Project Plan, MS Visio, Microsoft SQL Server, SQL Server Management Studio (SSMS), SQL Server Integration Services (SSIS), TSQL, Oracle 10g,MS Office Suite, SharePoint 2010.

Confidential, Tampa FL

Business Analyst

Responsibilities:

• Helped to communicate business priorities to the organization to effect business solutions
• Created and maintained BRD to assist PM close basis while managing multiple projects
• Converted Business Requirements to the Functional Specification
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
• Provide MarketProminence product support for Medicare Enrollment and Member Services.
• Involved in gathering clinical data and supported application development. Data includes Confidential t’s admission status, discharge details and transfers. Also tested claims and diagnosis reports of the Confidential t
• Used Requisite Pro for the Requirement Documents Preparation
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Tested conversion activities to ensure proper convert of claims and enrollment from legacy system to QNXT.
• Prepared Business Process Models that includes modeling of all the activities of business from the conceptual to procedural level
• Responsible for all MarketProminence system configuration changes.
• Translates and implement business requirements and project components into the Medicaid Management Information System (MMIS).
• Participated in process of preparing verification master plan to describe clearly and concisely the company’s philosophy, expectations, and approach to be followed. Met with users to generate and review business test cases.
• Analyzed and reviewed the claims processing in QNXT and monitor the efficiency, and auditing of the claims and process.
• Create and modify truth table dependent queries within MarketProminence.
• Conducted JAD Sessions to develop an architectural solution that the application meets the business requirements, resolve open issues, and change requests. Implemented and monitored Individual Development Plans focusing on total performance, including both quality and productivity.
• Designed and implemented HIPAA 835 Payment Advice Transaction, 837 Health Care Claim Transaction. Populated ICD-9, EDI X-12 transaction sets 835, 837, 270, 271, 276 and 277 responsible for Claims processing, coordination of benefits and pricing process
• Documented the Functional Specification for ETL and reporting requirements.
• Wrote Test Cases, performed unit testing and integration testing
• Monitored client expectations through client involvement and communication throughout the lifecycle of the project; educate clients and stakeholders on the benefits and risks associated with the project.
• Worked with the Quality Management team to ensure that requirements documentation can be easily translated into test plans, and ensure that the proper testing plans have been completed.

Environment: Rational Unified Process, Rational Rose, SSIS Visio 2003, MarketProminence,Office 2003, QNXT, MS Project 2002, Ms FrontPage, Windows XP,SQL,SAS.XML

Confidential, Irvine, TX

Business Analyst

Responsibilities:

• Played key role in System Development Life Cycle Process consisting of: Design and Gap Analysis, Business Requirements, Systems Requirements, Test Criteria, and Implementation to have the outputs of project dealt with the automation of correspondence directed to insurance policy owners.
• Performed analysis on enterprise data/report integration & provided functional specification to development team to build Enterprise Reporting Systems.
• Collected business requirements to set rules for proper data transfer from Data Source to Data Target in Data Mapping. including claims and enrollment testing as well as NPI and medical coding, ICD-9 and ICD-10 EDI testing
• Involved in FACETS System implementation, Electronic Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPPA 835 and proprietary format files and Reports development.
• Defined Functional test cases, documented, executed test script in FACETS system.
• Performing data mapping for the application, confirm and vacillating the requirement at time of testing.
• Worked on HIPAA Transactions and Code Sets standards according to the test scenarios such as 837 health care claims transactions.
• Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Analysis and Design of the Trizetto FACETS Data Model to ensure optimal system performance and tuning.
• Researched the existing client processes and guided the team in aligning with the HIPAA rules and regulations for the systems for all the EDI transaction sets.
• Gathered requirements and modeled the data warehouse and the underlying transactional database.
• Perform Gap Analysis of the processes to identify and validate requirements.
• Scheduled Business Object reports using Broadcast agent.
• Involved in the testing phase right from the Unit testing to the User Acceptance testing.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• 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.
• Use Cases and other Process Flow Models were designed using Visio and Rational Rose.

Environment: RUP, UAT, GAD (Gap Analysis Document), Microsoft Office 2003 Professional (Outlook, Word, Excel, Visio, Access), Microsoft SharePoint 2003

Confidential, Baltimore, Maryland

Business Analyst

Responsibilities:

• Conducted detailed Requirement gathering and Analysis with end users and other stake holders to gather business requirements. Studied the pre-existing model and proposed enhancements.
• Facilitated JAD sessions with stakeholders, SMEs, and IT team discussing the integration of new features in a pre-existing system.
• Worked on Batch Processes in FACETS for enrolments and claims.
• Co-authored Business Requirement Documentation (BRD), Mapping documentation, Functional Requirement Documentation (FRD)
• Performed gap analysis and designed high level workflows on QNXT Enterprise Core Administration System
• Designed various UML diagrams (Activity diagrams, Component diagrams, Sequence diagrams) using Microsoft Visio.
• Worked on FACETS modules:, Claims, and Provider, Product setup.
• Developed and executed test strategies, test plans and test cases. Conducted Integration testing and regression testing with a team of IT members and QA.
• Create reports and queries from Data Warehouse, enrollment system (MarketProminence), and other system tools to accurately track all Medicare activity.
• Exposed to using ICD 9/ICD 10 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for Institutional, Professional and Crossover (Medicare Part A/B) Claims.
• Writing SQL queries to extract and analyze data from QNXT (company database) and produce weekly and monthly reports. Created tables and reports using TSQL.
• Worked intensively with Medicare & Medicaid claims and claims processing for transactions.
• Got signoff from UAT team and business users before scheduling the release of the product.
• Requirements Management using Rational Requirements Composer tool (RRC)
• Customized screens/reports related to Member, Enrolments, Product Setup and Providers in FACETS.
• Resolved issues with unpaid/unprocessed claims and generated reconciliation reports.
• Worked with ICD 9 encoding for in Confidential ts services and referrals to verify the validity of incoming claims documented ICD 9 codes presently used by the system.
• Validated and verified the claims adjudication process in FACETS through SQL Queries.
• Conduct analysis of medical policy for product setup according to the current documentation.
• Wrote use cases for diagnosis code and procedural code usage in Product setup/ Enrollment/ Eligibility/ Utilization management.

Environment: MS Project, HPQC, RUP (Rational Unified Process), SQL, QNXT, SASMS Word, MS Excel, RRC, MS SharePoint, MS Visio, Oracle 9, Unix, FACETS 4.7/5.1

Confidential, Philadelphia, PA

Business Analyst

Responsibilities:

• Facilitated JAD sessions introduced use cases into application development methodology and created client approval process for project methodology.
• Prepared & presented weekly and monthly business operations review before the senior leadership team.
• Responsible for conducting meetings & providing sessions for Suppliers for improving External Balance Score Card.
• Prepared High-level design for customization of payroll and inventory module.
• Created bi-weekly reports and conducted client meetings to track the progress and timely delivery of final deliverable.
• Plan, schedule, initiate, and follow up with quality engineering procedures to improve and maintain product quality
• Created detailed functional specifications for development team
• Documented the Use Cases and prepared the Use Case, Activity, Logical, Component and Deployment views using MS Visio and Rational Rose for a clear understanding of the requirements by the development team. Coordinated with testers in using Rational Clear Quest for defect tracking
• Reviewed Integration Test Plan for integration between modules.
• Documented project processes and procedures and version controlled them using Rational Clear Case.
• Created Artifacts and defined Milestones and iteration plans for Inception and Elaboration phases of SDLC
• Assisted the Account Management people in reviewing the account of the customers.
• Used Test Director with QA team for testing.
• Developed supplier payroll system with the provisions of dynamic salary structure/increments/ annual leave, gratuity calculation, staff overtime, report generation module and salary posting to GL.
• Worked closely with project manager in handling whole project.
• Identified and managed issues, risks, constraints and change requests for projects as well as those applications that could affect projects resulting in successful implementations
• Worked independently using a pre-defined project plan and maintained detailed level records for all phases of the application systems and programming activities