SUMMARY

• 7 years of experience in business process analysis, business requirements modeling and development of Web Based, and Client/Server applications in diverse business domains of Healthcare, Insurance and Service Industry Sectors.
• Proficient in gathering and converting User Requirements into Business Requirements and Functional Requirement Specifications FRS and use Modeling tools like Rational Rose and Microsoft Visio for requirements modeling.
• Good understanding of MITA and MMIS functional business areas which include claims, providers services, providers enrollment, recipient services etc
• Experience in Health Care and Insurance industries with solid understanding of Business Process Flows, Case Tools, and Business Analysis.
• 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.
• Worked with HL7, EDI ANSI 4010 Standards
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Expertise in Software Development Life Cycle SDLC , Use Cases, Business Process Modeling Notation BPMN , Object-oriented Analysis and Design, Rational Unified Process RUP and Rational tools used during all four phases of RUP: Inception, Elaboration, Construction, and Transition.
• Experience with health care Systems: FACETS, Medicare Part A, B, C, D, Medicaid systems
• Extensive hands-on and HealthCare management experience in a variety of projects involving the customization, design, development, implementation, and testing of automated systems to support the Medical Management Information System MMIS as well as day-to-day business operations.
• Strong knowledge of managed care payer requirements and procedures.
• Experience with QNXT 3.4, QNXT 4.6, Facets 4.71, Inbound Outbound interfaces, EDI configuration, and data mapping using ANSI X12 4010 and 5010 834,835,837 .
• Strong understanding of Data Modeling in data warehouse environment such as star schema and snow flake schema.
• Sound understanding of Gap Analysis, requirement management, risk analysis and project plans.
• Solid understanding of Rational Unified Process RUP using Rational Rose, Requisite Pro, Unified Modeling Language UML , Object Modeling Technique OMT , Extreme Programming XP , and Object Oriented Analysis OOA .
• Excellent understanding of Data Models and Information Architecture and sound skills in SQL.
• Familiar with HIPAA EDI transactions such as 835, 837 P, D, I 276, 277, 278 etc
• Used BEA BPM Tool to map Process flows and migrated Visio Process flows into BEA Tool.
• Experience in development methodologies like RUP, SDLC, AGILE, SCRUM and Waterfall.
• Expertise in Healthcare- domain. Hands on exp. in HL7 and PACS.
• Implemented automated COB processing of Medicare claims into Facets
• Experience in developing and conducted statewide HIPAA 5010 and ICD-10 awareness program for all IDS staff in Tenet.
• Worked on healthcare standards such as HIPPA 4010, 5010, DICOMM, CPT, ICD-9 and SOAP.
• Experience in Forward Mapping and Backward mapping analysis of ICD 9 ICD 10 Conversion for CM Diagnosis Codes and PCS Procedure Codes .
• Expertise in ICD-9 to ICD-10 Conversion
• Expertise in broad range of technologies, including business process tools such as Microsoft Project, Primavera, Promodel, MS Excel, MS Access, MS Visio, technical assessment tools, MicroStrategy Data Warehouse Data Modeling and Design.
• Excellent in designing business models using UML diagrams such as use case diagrams, class diagrams, activity diagrams, sequence diagrams and collaboration diagrams using Rational Rose and MS Visio.
• Experience in conducting Joint Application Development JAD sessions and White Board Sessions with end-users, Subject Matter Expert SMEs team, Architects and design group development and QA team for project meetings, walkthroughs and customer interviews commensurate with excellent communication skills.
• Creative and aggressive self-starter with integrative thinking skills, capable of communicating creative ideas through graphical analysis charts and statistical data display.

DISCIPLINES

Business Analysis, Business Architecture, Data Mapping, Data Modeling, Requirements Gathering, Functional Specification Design, Testing Test Cases Manual Testing Automated Testing tools , Quality Assurance QA , Documenting Process Flow, Process Re-Engineering, Process Mapping, Business Contingency/ Business Continuity Planning BCP , GAP Analysis, SDLC

Software/Hardware: Rational Team Test, OOAD OOA/OOD , RUP, UML, Rational Rose, Clear Case, Clear Quest, WinRunner, Load Runner and Test Director, C, C , Java, HTML, J2EE, VB 6.0, SQL, Windows 9x/NT/2000/XP, Facets, Access macros, Excel macros, Active Reports, Unix, Informatica, Six Sigma, Linux, Solaris, Oracle, SQL Server and MS Access, TSL, SQL Basic, IBM Mainframe, Shell Scripts, MS Visio, MS office, Adobe PageMaker, Adobe PhotoShop, MS Project 2002, Adobe workflow systems, Weblogic Server, iRise, Mercury Quality Center, MS Office Sharepoint Server 2007,Quick Development Case and Quality Review Tool QDQ ,

PROFESSIONAL EXPERIENCE

Confidential

Systems Analyst

Texas Health Resources is one of the largest non-profit health care delivery system in the United States. The Texas Health is continuously improving the quality of service through education, research, competent and innovative personnel, effective leadership and responsible stewardship of resources. The project aimed at providing enhancement of an internal Work Flow Management system to automate business processes based on preset business rules and conditions. The system was primarily aimed at handling insurance processes. Project encompassed online directory of local health care, insurance providers and involved in backend testing of reports with the operational data store in database.

Responsibilities:

• 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.
• Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies from Initiation to Deployment.
• Worked with FDA guidelines 21CFR , HIPAA Health Insurance Portability and Accountability Act .
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes
• PPerforming Impact analysis for readiness of ICD-10 conversion.
• Using MITA improved managing and monitoring of programs through the sharing of data.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD using UML
• Involved in HIPAA 5010 gap analysis of ANSI X12 4010 and ICD 10 initiatives
• Identified authoritative data sources specified business rules for data feeds utilizing HL7 protocol.
• nsured that ICD-9-CM procedure codes used for inpatient services and CPT codes for outpatient and physician services were not outdated
• 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.
• Participated in Forward Mapping and Backward Mapping analysis of ICD 9 ICD 10.
• Performed frontend configurations for Facets profiles in room type profile configuration build.
• Was responsible for data mapping of HL7 messages into relational database.
• Translated high level business / data requirements into Process, Workflow, and Data Flow Diagrams using Rational Rose / MS Visio / BPMN towards facilitating clear understanding of the business process.
• Utilized Agile/ SCRUM and PMI methodologies to monitor steer and develop project objectives.
• Extensive experience in using collaborative tools like Mercury Quality Center to facilitate development across disparate teams
• Works to assess and respond with corrective actions for control gaps found in the UAT for the HIX daily/monthly 834/999 enrollment transactional process as noted by self-assessments, and audit findings.
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOAD using UML and Business Process Modeling.
• Analyzed CMS comparison documentation highlighting changes of 5010 format and ICD10 diagnosis and procedure codes.
• Created automation Framework solution to automate provider contract migration to facilitate the pricing engine on NetworX Pricer Trizetto Product to apply the configured pricing rules to determine claim pricing and configured routing rules during claim processing from the mainframe systems.
• 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.
• Gathered Web Content Management requirements from business units, translated those requirements into wireframe designs, and delivered HTML and CSS wireframe prototypes to client for implementation.
• Mapped all as-is business processes using BPMN standards on MS Visio.
• Facets Product Configuration of new products and components including research, testing and trouble shooting in FACETs.
• Used Facets 4.71 to receive, store and send HIPAA-standard transactions 835, 837, 270, 271, 276, 277 and to administer HIPAA privacy rights.
• Worked with End-To-End implementation with Data warehousing team and Strong understanding of Data warehouse DW concepts Star Schema, Snowflake Schemas and Multi-Dimensional Models for query and analysis requirements
• Worked and involved in re-engineering the company's core claims adjudication processing following BABOK Business Analysis Body of Knowledge standards and extensive use of the BABOK guidelines and practices.
• Incorporated 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.
• Leading technical coordination efforts and leading on-site data-source HL7 Health Level 7 system architecture solutions.
• Wrote Use Cases, prepared use case diagrams using Rational Rose UML and followed Agile at every stage of the processes
• Performed data analysis for the existing data warehouse and changed the internal schema for performance.
• Worked with SQL queries using MS Access for data manipulations.
• Experience with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Developed executed several Optimized queries in SQL on this data.
• Implemented data access, storage and validation routines on the database server using Procedural Language/Structured Query Language PL/SQL .
• 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.

Environment:Requisite Pro, Rational Rose, Agile/Scrum, Facets 4.51/4.71, HL7Interfaces, PL/SQL, HTML, MS Office, MS Visio, EDI, WGS, STAR, Rational Clear Quest, Informatica, Six Sigma, Rational Clear Case, UML,RUP, Access macros, Excel macros, Microsoft Excel, Microsoft Word, Microsoft Power Point, Visio.

Confidential

Business Systems Analyst

Responsibilities:

• Confidential operates as a managed healthcare company in the United States. The company's Health Plan and Medical Services segment provides health plan commercial risk, Medicare advantage, and Medicaid products. It also offers commercial risk products, including health maintenance organization, preferred provider organization, and point of service products to individuals and employer groups. National in scope, yet local in focus, Coventry's Medicaid expertise helps communities around the nation support their Medicaid recipients gain control over their health challenges. The project was to upgrade the system that currently uses HIPAA 4010 to comply with HIPAA 5010.Gap Analysis was performed and changes were identified in HIPAA 5010 so as to upgrade the Medicaid Management information System MMIS to comply with the new standards mandated by HIPAA.
• Embrace agile principles. Support iterative user experience design, involving UX research and UX design at all stages of product development
• Defined and reviewed the Data Warehouse requirements with the business users for getting the right data from the source systems for reporting purposes. Performed a GAP analysis which involved understanding the reports in the old financial management system.
• Performed impact analysis on 5010 upgrades and ICD-10 conversions
• Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Created customized reports with complex calculations that were used to study the potential financial impacts of changes to Medicare and Medicaid payments.
• Participated in ICD 9 to ICD 10 codes conversion requirement gathering sessions and created high level business requirement document
• By using the BABOK approved processes for business requirements gathering
• Used HIPAA 4010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDI's 837, 835, and 834 and ICD-10 Code sets.
• Acted as a SME for the application team and the Infrastructure team.
• Analyzed HIPAA 5010 related to 837,835, 834. Transactions and performed gap analysis between the 4010 and 5010.
• Used RequisitePro for writing/analyzing project vision, goals, specifications and requirements.
• 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.
• Defined ICD-9 to ICD-10 mapping process using GEMs General Equivalency Mapping crosswalk file
• Extracted data from several databases to create a master list of the ICD-9 codes
• Conduced Joint Application Development JAD sessions and walk in interview with the business users to gather requirements.
• Created custom mapping between ICD-9 and ICD-10 codes
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in RationalRose for the Business Use Case and System Use Case.
• Conducted the FRS and URS reviews and walkthroughs with designers, developers and stakeholders. Also conducted feasibility and adaptability study.
• 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
• Created automation Framework solution to automate provider contract migration to facilitate the pricing engine on NetworX Pricer Trizetto Product to apply the configured pricing rules to determine claim pricing and configured routing rules during claim processing from the mainframe systems.
• Incorporated 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.
• Conducted JAD Sessions with Infrastructure management team, SME, policy holders and stakeholders for issues which were open and pending.
• Interacted with database developers for formulating the ER diagrams and data flow diagrams.
• Responsible for GAP analysis of ICD9-ICD10.
• Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.
• Involved in gap analysis and implementation of HIPAA 5010, ICD 10 and Claim Validations
• Created current and future state processes, along with prototype BPM solution at medical device company
• Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.
• Analyzed the mainframe reports for member/eligibility/claims and mapped the fields with FACETS batch jobs and reports.
• Extensively involved in testing Trizetto Facets and mainly involved in Enrollment and Eligibility modules.
• Performed configuration/ compatibility and user interface testing manually.
• Worked with QA lead in validating Test Plan and Test Scenarios.
• Used HP Quality Center for tracking Defects and tracing requirement functionality performances.
• Executed test cases manually. Compared and analyzed actual with expected results and reported all deviations to the appropriate individual s for resolution.
• Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models
• Assisted Business User during deployment in formulating User Acceptance Testing UAT for customized application and getting confirmation for product Release
• Review of high-level design document and low level design of classes and sequence diagrams.
• Ensuring that deliverables were delivered on time as scheduled.
• Used sessions, workforce for running and loading the data from source to target data warehouse.

Environment: UML, RUP, Rational Requisite Pro, Rational Rose, Facets, Rational ClearQuest, Excel, SQL, DB2, Crystal Report, HP Quality Center

Confidential

Business Systems Analyst

• Description: Health Corporation of America provides healthcare in North America and their goal is to provide quality healthcare and improved human life.
• As a Business Analyst Worked on the up-gradation of their database that has all the record of all the patients and customers. Including merging of several different data marts and building a new database so that managers can see all the information all together and then managed the database. Including managing their claims processing system plus managing the government funding part to support Medicare and Medicaid through the internal software system within the company.

Responsibilities:

• Converted business and user system needs into Vision Documents, Business Process Flows, Use Cases, and Non Functional Requirements
• Conducted user interviews, gathered requirements, analysed the requirements using RUP methodology and documented the requirements using Rational Requisite Pro.
• Followed the Business Rules, and ensured that HIPAA compliant Rules are followed to display minimum benefit information that the Provider is required to pass on the EDI transactions.
• Working within a growing knowledge of F4010 HIPAA 837 I, P, D, 835, 834, 820, 270, 271, 276, 277, and 278, EDI, Privacy, Security, and Medicaid.
• Involved in Six Sigma process analysis.
• Assisted the technical team in translating application functionalities into the application architecture and in producing a System Functionalities Document SFD based on gathering requirements and mapping available resources to these requirements.
• Provide inputs to development team in performing extraction, transformation and load for data marts and data warehouses.
• Defined Functional Test Cases, documented , Executed test script in Facets system.
• Utilized Excel Macros and VBA for automating the process of variance and trend analysis
• Responsible for the use of scarce resources through the development and sharing of reusable software making use of Medicaid Information Technology Architecture MITA.
• Analyzed the business requirements and produced a Business Requirements Document BRD Linked these BRD requirements to the system requirements using the System Requirements Specification SRS .
• Followed Agile XP Methodology for the release.
• rovide support in developing and maintaining ETL processes that extract data from multiple SOR's residing on various technology platforms then transport the data to various delivery points such as data marts or data warehouses.
• Experience working with Health Care Client Server Product TRIZETTO FACETS
• Utilized BABOK and RUP methodologies from Initiation to Deployment.
• Worked on Client/Server tools like SQL Server Management Studio to administer SQL Server.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Worked with developers and designers of BPM System to make sure development understands business process and detailed technical requirements.
• Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
• Used SDLC System Development Life Cycle methodologies like the RUP and the waterfall.
• Identified the impacts the HIPPA 5010 ICD 10 project had on enrollment Claims, FEP Medicare and Medicaid program .
• Authored business system analysis reports based on state regulations, HIPAA compliance and product business rules.
• Experience in configuration of claims adjudication systems, FACETS 4.51/4.71
• Interacted with the Tester while transporting the requirements to Mercury Quality Center.
• Utilized various Excel macros and measured concentrations to prepare samples for PCR based on each study's DNA microgram requirements and concentration ranges.
• Analyzed HL7 messages to track necessary information pertinent to solving Epic and Heat cases.
• Wrote detailed description of user needs, program functions, and steps required to develop or modify computer programs.
• Involved in Data Modeling of both Logical Design and Physical design of data warehouse and data marts in Star Schema and Snow Flake Schema methodology
• Defined Functional Test Cases, documented, Executed test script in Facets system.
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• Extensively involved in testing Trizetto Facets and mainly involved in Enrollment and Eligibility modules.
• Elaborated on high level schedule into a detailed work plan that incorporates all aspects of the testing initiative
• Used the CMMI Model to guide process improvement across a project
• Created DataStage jobs to extract, transform and load data into data warehouses from various sources like relational databases, application systems, temp tables, flat files etc.
• Created process flow for moving the claims related data from EDW to EDM.
• Interacted with clients and other members of the development and QA teams to ensure delivery.

Environment: IBM Mainframe , MS Access, MS Visio, RUP, OOAD, Informatica, , Facets 4.51/4.71, Scrum, Agile, MD 3270 Mainframe, MS Excel, COBOL, iRise Studio, Excel macros, Six Sigma, Ultra Edit, Oracle, MS Office, SQL, Windows XP

Confidential

Business Analyst

Boston Scientific improves the quality of patient care and the productivity of health care delivery through the development and advocacy of less-invasive medical devices and procedures. The Patient Management System integrated version of Patient Information System with EMR/EHR is intended to remotely communicate with a compatible pulse generator from BSC CRM and transfer data to a central database HIT EHR .

Responsibilities:

• Facilitated collection of functional requirements from system users, and prepared business and technical requirement specification documents.
• Facilitated review of Enrollment, Claims, Commissions, and membership portlets' designs with architects and developers to ensure that the goals of the portal requirements were satisfied
• Used UML, for gathering requirements, created Use Case Diagrams, and Use Case Specification document USD .
• Tracking and managing requirement changes using Requisite Pro.
• Assisted in building a Business Intelligence Process Model using Rational Rose and Visio.
• Used Prototyping method to gather additional requirements from the users in order to describe the business needs in terms of the system being created.
• Involved in validation of the HL7 messages between Epic and Ancillaries.
• Gathered user and business requirements through open-ended discussions, brainstorming and prototyping
• Developed various artifacts such as use cases, workflow diagrams, business process models and prototypes by interacting with end users, development personnel, project team and the subject matter experts.
• Worked with SQL queries using MS Access for data manipulations.
• Performs system administration duties related to the content management system Stellent . This would include developing process flows required for the development of workflows within Stellent that tracks all CMS-mandated content contributions.
• Designed, developed and tested data mart prototype SQL 2005 , ETL process SSIS and OLAP cube SSAS for Computer Maintenance Management System CMMS
• Reviewed Stored Procedures for reports and wrote test queries against the source system SQL Server to match the results with the actual report against the Data mart Oracle .
• Followed the RUP based methods using Rational Rose to create: Use Cases, Activity Diagrams / State Chart Diagrams, Sequence Diagrams.
• Formatted HL7 messages for interface applications to Cloverleaf interface engine.
• Worked with SQL queries using MS Access for data manipulations.
• Investigated faults within the application and interacted with the development team to resolve technical issues.

Environment: Windows 2000/XP, Microsoft Office SharePoint 2007, Rational Requisite Pro, MS Office, SQL Server, Oracle, PL/SQL, Agile, MS Project, MS FrontPage 2003, MS Access, EDI, Documentum 2.0.,UML.

Confidential

Business Analyst

Mercy is an organization dedicated to the delivery of quality health care plans and products working together with its customers, consultants, brokers, providers and employers. I performed pivotal role in multiple projects handling three releases at the same time. Release 1 2 was web-based service application developed for streamlining office workflow processes involved in Electronic Data Interchange EDI transactions and benefits in claims management cycle based on HIPAA Guidelines. Release three was based on reporting the policy premium. There were seven reports, which were generated in Brio portal.

Responsibilities:

• Gathered Business Requirements through brainstorming sessions on global calls.
• Documented the business logic and associated validation logic.
• Created screen-mockups using iRise to review the requirements and provide feedback on the screen design. Also, used Microsoft Paint to create ad-hoc screen mock-up to review with the users.
• Acted as a liaison between the development team, QA team and the Business team and resolved any conflicts due to change in requirements.
• Provided suggestions and ideas more from a strategic and long term perspective.
• Created Requirements Specification Document that translated business requirements into Technical specification including business and validation logic for ease of understanding to the development team.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. 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.
• Used the Agile methodology to build the different phases of Software development life cycle. SDLC
• Moreover, I also authored functional requirements documents FRD by interacting with development team for improving client's legacy system.
• Reviewed test scripts and made sure that the Test scripts covered all scenarios of the requirements.
• Conducted group JAD sessions with business units and stakeholders to define project scope and deliverables.
• Prepared UAT Materials, including the UAT Process, UAT Test document which would include step-by step process for UAT as well as all the tests that would cover all requirements.
• Interacted with the users and logged any defects, enhancements from the UAT.
• Worked with the Training Group to build training materials as well provided any suggestions/ tool tips to assist in User Training

Environment: Windows XP Professional, Oracle9i, Agile, MS Access 2000, MS Excel, Six Sigma, RUP, Oracle, UML, Rational Rose, Requisite Pro, Clear Case 2002, Rational Clear Quest 2002, MS Office suite, MS Visio 2003.