SUMMARY

• Have 6 yrs of experience as a Business Analyst in all phases of Software Development Life Cycle with solid understanding of Business Requirement Gathering, Business Process Workflow and Business Process Modeling.
• Good understanding of health care industry, Claims Management process, Medicaid and Medicare Services.
• Proficient in all phases of Requirement Management, including gathering, analyzing, detailing, and tracking requirements.
• Involved in Test Planning, Test Preparation, Test Execution, Issue Resolution and Report Generation to assure that all aspects of a Project are in Compliance with the Business Requirements.
• Familiar with HIPAA Standards and Compliance issues, HIPAA Privacy policy, requirements gathering in compliance with HIPAA standard.
• Proven ability to analyze complex problems, identify risks and develop effective solutions to improve productivity, reduce cost and track progress through all phases of SDLC
• Strong experience in all phases of Software Development Lifecycle (SDLC) using Waterfall, Agile/Scrum, RUP (Rational Unified Process) and Software Testing Life Cycle (STLC).
• Expert in analyzing, elicitation and management of requirements. Highly experienced in creating Business Requirement Document (BRD) and Functional Requirement Specifications (FRS) document.
• Facilitated one on one interviews, Joint Requirement Planning (JRP) and Joint Application development (JAD) sessions
• Experienced in methodologies like Agile, Waterfall Model and Data Modeling; Creating Process mapping, Use Cases, Sequence diagrams, Activity diagrams
• Solid understanding of Membership, Claims Processing, Billing, Benefit/Eligibility, Authorization/Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions.
• Involved in maintaining performing GAPanalysis, Requirement Analysis, Document Analysis.
• Exceptional ability to maintain and build client relationships with business owners to identify, prioritize and document business requirements.
• Extensive experience in Healthcare/Claimsadjudication with knowledge of industry compliance standards like HIPAA and EDI X12 transactions (834, 837, 835, 270/271, 276/277).
• Proven ability to support multiple complex projects under tight deadlines, often with competing priorities.

TECHNICAL SKILLS

Microsoft Technologies: MS Project, Visio, Excel, Word, Outlook, PowerPoint

Requirements Management Tools: Rational Requisite Pro, Rational Rose, MS Visio, HP ALM

Operating Systems: Windows 2000/7/XP, DOS

Languages/Standards: SQL, HIPPA, ICD

Methodologies: Agile, Waterfall

PROFESSIONAL EXPERIENCE

Confidential, Richardson, TX

Business Systems Analyst / Tester

Responsibilities:

• Coordinated with the developers and IT architects to design the interface of the new system according to the X12 (834, 835, 837 (I, P, D) standards.
• Created document and diagrams for membership enrollment according to HIPAA 834 compliance standard for membership enrollment.
• Responsible for system integration testing of 837 claim files, 834 eligibility files and 270/271 interface files to ensure required interactions are met during the SDLC process.
• Involved in handling HIPAA/EDI Medical Claims, design and documentation.
• Performed validation of X - 12 270, 271, 835 and 837 Professional and Institutional format files according to EDIFECS engine.
• Worked on requirements of the 835 HIPAA project, the 820 report project, on 835 7 and HIPAAEDITransactions across enterprise
• Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting any errors with the process of EDI inbound and outbound files
• Monitored and Analyzed activity report and transaction monitoring.
• Worked on improvement of Claims Reimbursement User Interface for a better experience and in corporate changes as per HIPAA guidelines using the gap analysis.
• Conducted meeting with the development team to discuss any requirement changes.
• Active participant of all the scrum meetings, and helped maintain the product backlog and scrum backlog. Co-ordinated with scrum team for efficient delivery within designated sprint cycle.
• Experience in Health Care Insurance Industry with exposure to Electronic Medical and Health Records (EMR & EHR)/Automated Health Care Systems.
• Extensive experience in Health Care and well versed with HIPAA compliance, HL7 standards, CMS HCPCS, ICD 10 coding multispecialty, e.g. Interventional Radiology, Respiratory Therapy, Nuclear Medicine, and Breast Center.
• Expert on US Health Care Industry, Electronic Data Interchange (EDI), Health Level 7(HL7) and Health Insurance Portability and Accountability Act (HIPAA).
• Involved in Manual Testing and UAT testing.
• Performed felid-by-field mapping of interface between parent EMR system and downstream system.
• Prepared BRDs (Business Requirement Documents), Functional requirement documents, supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze data requirements fromData ware house.
• Performed GAP analysis of business rules, business and system process
• Designed Activity, Sequence and process flow diagrams using MS Visio to simplify and elaborate certain selection and filter condition.
• Documented requirement using Use Case analysis.
• Conducted JAD session, meetings, and information sessions to gather the requirements from the clients.

Environment: UML, RUP, Rational Requisite Pro, Rational Rose, Excel, SQL.

Confidential, Boise, ID

Business Analyst / Quality Analyst

Responsibilities:

• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure a consensus.
• Participated in review and analysis of business requirements, adding additional cases as needed, insuring they are complete and testable.
• Worked on requirements of the 835 HIPAA project, the 820 report project, on 835 7 and HIPAAEDITransactions across enterprise
• Tested the ANSI X12 /EDItransactions (HIPAA) like 270, 271, 276, 277, 837P, 837I, 837D, 835.
• Wrote Test scenarios and test cases for testing and processing of member enrollment and benefits, batch jobs corresponding to the claims (837) and real time transactions like 270/271/276/277.
• Did the forward and reverse data mapping between the fields in mainframe andQNXT.
• Tested the changes for the front-end screens inQNXTrelated to following modules, test theQNXT batches (member load, Billing, Provider)
• Worked with HIPAA Team for RIMS Companion Guide of X12 ANSI 270/271 and 276/277 Companion guides for Professional and Dental claims. Cross-functional team member in the implementation of the ANSI X12 involving 837HIPAA compliance and 835 Remittance Advice.
• Analyzed the front end Customization requirements onQNXTapplications (Member, Group/Subgroup application, Member maintenance)
• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, plan codes, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc from Legacy system (AIM) toQNXT.
• Involved in impact analysis of HIPAA and 837P transaction sets on different systems.
• Performed GUI testing, Integration testing, Regression testing, Ad-hoc testing, Negative testing, End to End testing, Smoke testing Load testing, User Acceptance testing and Pilot testing.
• Wrote Test Scenarios, Test cases in excel sheet and imported them to Rational Manual Tester/Test Manager.
• Logged defects in Rational Clear Quest, re-tested defects, analyzed defect with Users and Developers.

Environment: QNXT, MS SQl Server, Rational Reqpro, Rational Clearquest, Rational Manual Tester, Rational Test Manager, MS SQL Server Reporting Service (SSRS), MS Share Point.

Confidential, Virginia Beach, VA

Business Systems Analyst

Responsibilities:

• Involved in handling HIPAA/EDI Medical Claims, design and documentation
• Monitored and Analyzed activity report and transaction monitoring.
• Created document and diagrams for membership enrollment according to HIPAA 834 compliance standard for membership enrollment.
• Conducted meeting with the development team to discuss any requirement changes.
• Checked inbound/outbound HIPPA regulated EDI transactions
• Involved in Manual Testing and UAT testing.
• Prepared BRDs (Business Requirement Documents), Functional requirement documents, supporting documents containing the essential business elements, detailed definitions, and descriptions of the relationships between the actors to analyze data requirements fromData ware house.
• Performed GAP analysis of business rules, business and system process
• Designed Activity, Sequence and process flow diagrams using MS Visio to simplify and elaborate certain selection and filter condition.
• Documented requirement using Use Case analysis.
• Conducted JAD session, meetings, and information sessions to gather the requirements from the clients.

Environment: .UML, RUP, Rational Requisite Pro, Rational Rose, Excel, SQL

Confidential, Colorado Springs, CO

EDI Analyst

Responsibilities:

• Conducted AS-IS and TO-BE analysis and assisted in developed process models and systems integration structure.
• Knowledge of the complete EDI format used in electronic documentation which was part of the knowledge transfer program to the vendors as per the requirements.
• Provided Pharmacy expertise to Pharmacy SME's to supplement and expedite research and discovery of business processes and requirements
• Coordinated with lead Pharmacy SME's in gathering and documenting information, requirements, and workflows
• Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.
• As part of the data mapping procedures, assisted in writing requirement document for ETL - Data Extraction, Data Analysis and Loading process of collected data.
• Involved in various types of Audits and the Financials involved through different stages.
• Gained Compliance audit experience due to exposure to the legal/audit consulting groups.

Environment: RUP, MS Office, Rational Quality Manager, SQL Server, MS Project, MS Visio, Java, XML, Jira, Rally, Rational ClearQuest, ClearCase, Windows XP