SUMMARY

• 7 years of extensive experience as EDI Analyst with 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.
• Knowledge of 837, 835, 277, 270, 271, 275, NCPDP, 5010 and ICD-10.
• Extensive experience on MMIS Medicaid Systems, HealthCare Industry including supporting efforts including response to RFP, Requirements Analysis Documentation, General System Design and Detailed System Design Documentation, conducting JAD and JAR sessions of project life cycle
• Extensive knowledge of Object Oriented Analysis and Design (OOAD) using Unified Modeling Language (UML), Rational Unified Process (RUP), Waterfall model, Rational Rose, Requisite Pro, Rational Clear Case and MS Visio.
• Expertise in the use of tools such as Caliber RM, Rational Rose, Requisite Pro, Starteam, Test Director
• Experienced in facilitating and conducting Joint Application Development (JAD), Rapid Application Development (RAD) and Joint Requirement Planning (JRP) sessions, interviews, workshops and requirement elicitation sessions with end-users, clients, stakeholders and development team.
• Experienced in training and mentoring team members with product knowledge and business processes.
• Strong work ethic, taking ownership of all duties and responsibilities and meeting management objectives.
• Strong business acumen, analytical, problem solving, interpersonal and presentation skills.
• Excellent written and oral communication skills to keep executive staff and team members apprised of goals, project status, and resolving issues and conflicts.

TECHNICAL SKILLS

Business Skills: Business Process Modelling, 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 4010A1/5010, ICD-10, ICD-9, ANSI X12, HL7, CPT and CMS

Languages: C, C++, MySQL, MS SQL Server, PL/SQL, HTML and XML, JAVA

Visual Modeling Tools: Rational Rose, Requisite Pro, Clear Quest, Clear Case and MS Visio.

Testing Tools: HP Quality Center, Win Runner, Load Runner and TOAD

Web Servers: Microsoft Internet Information Server (IIS) 4.0/3.0, SunOne Server 5.2.

Office tools: MS Office 2003 (Word, Excel, Power Point, Outlook), MS Visio, MS Project

PROFESSIONAL EXPERIENCE

Confidential, Des Moines, IA

Lead EDI Analyst/Sr. Business Analyst

Responsibilities:

• Extracted the business requirements from the end users keeping in mind their need for the application and documented it for the developers following the HIPAA Guidelines for individual functional areas.
• 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.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Performed System testing of the Claims processing systems (Pricing Rules, Duplicate/Limits validation, Member Eligibility, Provider Enrollment, et al).
• Responsible for creating test scenarios, scripting test cases using testing tool and defect management for Policy Management Systems, Payables/Receivables and Claims processing.
• Completed the documentation of Claims Scenario’s for the source system
• Developed business process models in RUP to document existing and future business process
• Conducted Joint Requirement Planning (JRP) sessions with clients and technical team to create a list of must have and nice to have requirements.
• Categorized and prioritized the requirements using the Rational Requisite Pro.
• Created Business Requirement Document (BRD) and Functional Requirement Document (FRD) based on the information gathered from clients.
• Actively involved in developing, executing and managing User Acceptance Testing (UAT).
• Coordinated various kinds of User Acceptance Testing (UAT) including regression testing, system testing, integration testing, functional testing, alpha & beta testing.
• Wrote PL/SQL statement and stored procedures in Oracle for extracting as well as writing data.
• Created RUP activity diagrams and sequence diagrams to analyse the requirements and recommend solutions
• Prepare presentation slides in MS Project, which was extensively used in different JAD sessions and to track progress
• Managed the team of consultants responsible for developing on-demand Medicaid Management System reports.
• Analyzed Business Requirements and segregated them into high level and low level Use Cases, Activity Diagrams / State Chart Diagrams using Rational Rose according to UML methodology thus defining the Data Process Models.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Managed Scope and change throughout the SDLC process of the product.
• Analyzed, designed, and coded several online subsystems for the Medicaid System.
• Developed Use Cases, Activity diagrams, Sequence diagrams, and Deployment diagrams using MS Visio for a clear understanding of the requirements by the development team.
• Transformed Business requirements into functional specifications, focused on user interface design, created mockup screens.
• Incorporated Rational Unified Process (RUP) to create Requirement Document Specifications using Visible Analyst.
• Participated in Black Box Testing, Usability Testing, Load and Performance Testing and Integration Testing.
• Designed the business requirement collection approach based on the project scope and SDLC methodology.
• Involved in preparation of Requirement Traceability Matrix (RTM), Defect Report and Weekly Status Reports.
• Authored progress and completion reports, which were then submitted to project management on a weekly basis.

Environment: RUP Methodology, TOAD, SQL, Microsoft Word, Microsoft Visio, Microsoft Excel, Microsoft Power PointRational Requisite Pro, Rational Rose, Win Runner, Load Runner, Test Director, Informatica Power Center, Cognos.

Confidential, Des Moines, IA

Lead EDI Analyst

Responsibilities:

• Facilitated interview sessions to identify business rules and requirements and then documented them in a format that can be reviewed and understood by both business people and technical people.
• Led projects to develop and enhance claims adjudication, eligibility, formulary, prior authorization and reporting applications internal user experience as well as expanding client product offerings
• A web application was reengineered to make it compliant with the EDI standards. Integration of this web application with the third party administrator’s applications (TPA) was achieved.
• The developed application is complaint with the HIPAA standards.
• Identified the impacts the HIPPA 5010 & ICD 10 project had on enrollment Claims, FEP (Medicare and Medicaid program).
• Worked in processing 270, 271, 276, 277, 275, 8230, 834, 837 in NPS system
• Tested claims adjudication and group and enrollment in Amisys for New Medicare advantage members.
• Tested HIPAA Gateway Application Interface for all inbound and outbound messages (Healthcare Eligibility 270 and 271, Healthcare Claim Status request 276 and 277, Healthcare Claim 837 and 835)
• Understood and articulated business requirements from user interviews and then converted requirements into functional specifications.
• Created UAT plans with several test cases for each project to ensure that the system runs smoothly after the proposed enhancements or changes have been made.
• Created Business Requirement Document and Functional Requirement document.
• Developed UML Use Cases using Rational Rose and developed a detailed project plan with emphasis on deliverables.
• Transformed business requirements into functional specifications, focusing on workflow analysis and design, business process reengineering, user interface design, portal design, and process flow modeling.
• Used MS Visio for Process modeling, Process mapping and Business Process flow diagrams
• Developed test scripts using QTP for existing test case and Unit tested.
• Extensively used Test Director & Quality Center to write Test Cases and for reporting. All the Scripts are maintained using Test Director & Quality Center.
• Extensively uploaded test cases from MS Excel, MS Word to Test Director & Quality Center.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Involved in interactions with Subject Matter Expert, Project Manager, Developers, and the end-users in more than one JAD sessions. MS Project proved useful in coordinating activities with project manager and various other team
• Develop and maintain sales reporting using in MS Excel queries, SQL in Teradata, and MS Access
• Converted various SQL statements into stored procedures thereby reducing the Number of database accesses.
• Involved in creating automated Test Scripts representing various Transactions, Documenting the Load Testing Process and Methodology.
• Created meaningful reports for analysis and integrated the Performance Testing in the SDLC.
• Conducted user interviews, gathered requirements, analysed the requirements using RUP methodology and documented the requirements using Rational Requisite Pro.
• Created and managed Project Templates, Use Case Project Templates, Requirement Types and Traceability Relationships in Requisite Pro.
• Analyzed the impact of new HIPAA standards on targeted systems, processes, and business-associate relationships.
• Used SDLC (System Development Life Cycle) methodologies like the RUP and the waterfall.
• Identified solutions to close gaps in HIPAA compliance.

Environment: Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Microsoft Project, Rational Rose, Rational Requisite Pro, HIPAA Desk Tool, TOAD, Adobe Captivate 3.0 and Windows XP.

Confidential, Chicago, IL

EDI Analyst

Responsibilities:

• Testing various change orders of Medicaid applications received from the System Engineer’s
• Regression Testing of Web applications and applications dealing with MEDICAID and MEDICARE Services
• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Conduct complex documentation and user needs analysis. Interface with team and staff to develop HL7 integration
• 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
• Worked on electronic (HIPAA X12 standards-270, 271, 275, 276, 277, 278, 835, 837, and 997) and paper claim forms such as UB04, HCFA-1500, CMS1500, etc.
• Lead Business Intelligence reports development efforts by working closely with Microstrategy, Teradata, and ETL team
• Analyze and prepare specifications for the improved functionality of the Nasco.
• Developed the strategy for developing and implementing new EDI (HL7 and X12) interfaces and converting historical clinical and data.
• Reviewed administrative and clinical practices and procedures: point of care, scheduling, registration, clinical documentation, patient care, and charge entry, medical coding and diagnostic testing procedures associated with multiple business units.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.
• 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
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to followICD 10Code set andANSI X12 5010formats.
• Conducted Gap Analysis, and Gathered User Requirements by Interviews, user meeting, JAD session, and Requirement Elicitation Sessions
• Utilized corporation developed Agile SDLC methodology. Used ScrumWork Pro and Microsoft Office software to perform required job functions.
• Assisted to develop the Test Plan, Test Cases and Test Scenarios to be used in testing based on Business Requirements, technical specifications and/or product knowledge.
• Prepared graphical depictions of Use Cases, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using Microsoft Visio.
• Analyzed trading partner specifications and created EDI mapping guidelines

Environment: RUP Methodology, Microsoft Word, MS Visio, Microsoft Excel, Microsoft PowerPoint, Rational Requisite Pro, Rational Rose, SQL, Win Runner, Load Runner, TOAD, Test Director, HIPAA Desk Tool