SUMMARY

• Over 7+ years of experience as Healthcare Consultant with specialization in HIPAA and Affordable Care Act (ACA), HL - 7, EDI Transactions (820, 834, 835, 837), MMIS, Medicare and Medicaid.
• Strong experience on CMS, Health Assessment Systems, Medicare and Medicaid Insurance Billing, Hl7 Standards, Compliance issues, HL7 Message Validation, ICD 9, ICD 10, Electronic Health Records, Electronic Medical Records.
• Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS.
• Knowledge on Medicare, Medicaid, MMIS, HIPAA EDI transactions 278, 820, 834, 835, 837, HL7, HMO, PPO, ANSI X12 Procedural and Diagnosis codes.
• Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrolment).
• Strong experience in managing Claims management process, Knowledge of Medicaid and Medicare in the Data Analysis, Design, Development, Implementation and Testing of Data Services.
• Good experience in writing MDX queries while creating and customizing Cubes using SQL Server Analysis Services (SSAS) and Converting Data from MDX to Tableau.
• Hand on experience on Data Warehouse ETL Processes and interacting with the data analysts and the end users for informational requirements.
• Specialized in Data Warehouse, Business Process Modelling, Data Analysis, Data Mapping.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Medicare, Medicaid, CDHP (consumer driven health plans).
• Ability to develop business rules, context data flow diagram, entity relationship diagram, workflow diagramming, prototyping and document current state, gaps and future state processes.
• Experience in Conducting and facilitating JAD sessions and brain storming sessions with key user groups emphasizing the scope of the project in order to provide key initiatives in working with users in identifying and defining project and system requirements.
• Proficient in all phases of Requirement Management; including gathering, analyzing, detailing and tracking requirements using RTM, create Business Requirements Document (BRD) and Functional Requirements Document (FRD).
• Strong experience in data cleansing, data translation, data mapping using MS Excel.
• Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects of both ETL jobs and Reporting jobs.
• Extensive knowledge on performing process reengineering by documenting and evaluating existing business processes.
• Strong working experience in the Data Analysis, Design, Development, Implementation and Testing of Data Warehousing using Data Conversions, Data Extraction, Data Transformation and Data Loading (ETL).
• Experience in SQL ad-hoc queries to extract data from various database for data analysis and generating reports per the format specified Subjects Matter Experts (SME's).
• Skilled in translating business requirements and user expectations into detailed specifications and building business process flow charts using MS Visio and Enterprise Architect to communicate project functionality to the development team employing designing techniques like OOAD and Unified Modelling Language (UML).
• Sound proficiency in analyzing and creating, Use Case Diagrams, Sequence Diagram, Activity Diagram, Data Flow Diagrams, Business Flow Diagrams, Wire Frames and Mock-ups using MS Visio and Rational Rose to communicate business and functional requirements to clients and developers.
• Performed AS-IS and TO-BE business process flow for clear translation of Functional to system requirement specification.

PROFESSIONAL EXPERIENCE

Confidential

Healthcare Consultant

Responsibilities:

• Developed test scripts for new billing software, submission of EDI claims and incoming ERA files.
• Validated the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice or payment) claims adjudications.
• Provided various strategies to implement HIPAA 4010 in the new MMIS system and ultimately move to HIPAA 5010.
• Developed intuitive reports in SSRS, Report builder and Tableau to support pre-assumed business questions.
• Developed data field mappings. Provided programming and support for claims processing functions and auto-adjudication.
• Manually loaded data in FACETS and worked on Facets Business rules.
• Exposed to using ICD 9/ICD 10 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, reimbursement methodology.
• Worked on developing the Business requirements and use cases for FACETS batch processes.
• Facilitated IT, Technical, and workflow transition of large group practice to hospital linked ACO with HL7 and SQL data flow.
• Coordinate with state stakeholders on Medicaid Management Information System (MMIS) portal development.
• Involved in Adjust Business Rules, Processes, and Data Transformation Language code, modifying, testing, and troubleshooting HL7 interfaces as needed.
• Designed, Developed and supported interactive Tableau Dashboard reports and
• Involved in creating Dashboards and needed using Tableau Desktop and published them to Tableau server.
• Involved in designing and customizing data models for Data warehouse supporting data from multiple sources
• Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
• Analyzed data using MS Excel pivot tables, formulas, VOOKUP, and Power Query.
• Performed UAT, regression testing on EDI 835 and 837 X12formats in Facets.
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X10 Transaction, Code set and Identifier aspects of HIPAA.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Analyzed, and documented business and functional requirements via uses cases for Medicare billing transaction-based middleware/database layers with SOA & XML.
• Facilitated JAD sessions for Requirement Validation with HIPAA to gather requirements for the new MMIS.
• Designed and developed Use Cases using UML and Business Process Modeling.
• Maintained project plans, task, defect and issues lists, lead meetings to discuss all aspects of the project's execution, developed test scripts, executed UAT, participated in the QA process, and developed training materials and system documentation.
• Analyzed and interpreted the test results of the monthly regression test cycle using MS Excel.
• Designed and developed Detailed Technical Specifications for several Use Cases.
• Used MS-Visio for flow-charting, process model and architectural design of the application.
• Designed and developed project document templates based on SDLC methodology.
• Gathered requirements for medical data that needed analyzing then extracted data (metadata) from databases (SQL, MS Excel, MS Access), systems.
• Participation in Product Review Board (PRB) process and CR's data management in JIRA.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology.

Confidential

Healthcare Business Analyst

Responsibilities:

• Involved in migration of HealthCare ICD9 to ICD10 diagnosis codes which is the key aspect in healthcare domain.
• Assisted with building the EDI 837, 835, 270/271, 276/277, 278, 820 and 834 transactions processing flow from the Trading Partners to the translator.
• Actively participated in the designing of the EDI transactions using the new HIPAA 5010 version also including the use of ICD-10 codes.
• Worked on HIX member's enrolment, billing claims and customer services process that are required to participate in the federal health insurance exchange (HIX). This exchange was according to the compliance with Patient Protection and Affordable Care Act (PPACA).
• Extracted data from appropriate source including data warehouse /BiQuery Capture external & internal customer needs for analysis and interpretation & manage customer relations pertaining to analytics / Track & analyze issues to identify trends.
• Worked on Data mapping of EDI Segments from 834 FFM (Federally Facilitated Marketplace) to Facets database and vice-versa.
• Adhered to the HIPAA Compliance Plan and the Privacy Standards Confidentiality Agreement.
• Performed data analysis on large data sets using SPSS analytics, MS Excel, and MS Access.
• Provided enrollment for all Medicaid providers along with the Medicaid Member. This includes the files and data conversion and migration of all application functionality from the legacy MMIS system to the client-server application.
• Acted as a liaison between the company and the business partner in support of gathering and documenting requirements, developing process flows, writing use cases, specifications and in writing user guides to meet project objectives.
• Performed Gap Analysis to compare the existing system with the proposed new system.
• Modeled data using MS Excel, Access, SQL, SAS, and/or other data warehouse analytical tools.
• Created Use Cases, various UML Diagrams and Data Flow Diagrams to determine the data flow via various systems.
• Followed the UML based methods using Rational rose to create use cases, activity diagram, sequence diagram, collaboration diagram that include functional and non-functional specifications to hand off to development teams.
• Worked with MS Office (MS Word, Outlook, Excel, PowerPoint, and Project) and MS Visio.
• Communicated and lead the Business Analysis team to ensure process, definitions, metric designs, and metadata are used consistently, and that documentation is updated accurately and available for all team members.
• Possess high-level understanding of JIRA admin activities like creation of user, sprints, epic, bulk upload, confluence content creation and data movement across screens etc.
• Data mapping, logical data modeling, created class diagrams and ER diagrams and used SQL queries to filter data within the Oracle database Maintained the requirements traceability matrix and ensured that the requirements were consistent after changes.
• Worked as a Business Analyst for multiple module wise development teams. The project followed full project life cycle as per the SDLC specifications using MS Project.
• Communicated twice a week with business SMEs and Project managers to solidify requirements and associated deliverables.
• Interacted with the SME's to gather information about the health care enrollment, eligibility and health care claims processing and created Use cases/FRS traced to use cases.
• Worked extensively on Gap analysis, Root Cause Analysis and Impact analysis of issues to requirements to meet the gap and redesign of the user interface.
• Involved in mentoring specific projects in application of the new SDLC based on the Agile Unified Process, especially from the project management, requirements and architecture perspectives.
• Worked on many Change Requests, Parking Lot items, Action Items, Process Flow Diagrams (UML), Pain Points, and Use Cases.

Confidential - Brentwood, TN

Healthcare Business Analyst

Responsibilities:

• Analyzed current MMIS and EDI claims and documented the requirements to implement new MMIS automated system.
• Validated 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response) and 834 (Enrolment/Dis-enrolment to a health plan)
• Used Facets Analytics for fast and easy retrieval, display and grouping of information for performing queries and generating reports.
• Interacted with Claims, Payments and Enrolment hence analyzing and documenting related business processes
• Worked with the SMEs (Subject Matter Experts), IT managers, software architects to identify the key changes pertaining to HIPAA, and participated in Health Management to communicate effectively with them.
• Performed Requirement Analysis, Impact Analysis and documented the requirements using Rational Requisite Pro.
• 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.
• Involved in creation and execution of manual test cases in HP quality center and automated Test Cases in QTP and analyzed the Test Results.
• Assisted in Change Management and Release Management by requesting, implementing and evaluating changes to the system using Rational Requisite Pro and recording defects using Quality Center.
• Reviewed the Joint Requirement Documents (JRD) with the cross functional team to analyses the High-Level Requirements
• Created Use Cases and Business Requirement Document after accessing the status and scope of the project and understanding the business processes.
• Authored business system analysis reports based on state regulations, HIPAA compliance and product business rules.
• Designed and managed Oracle database having functions, procedures, views, indexes and triggers using Toad.
• Extensively used Toad for SQL scripts and worked on SQL for enhancing the performance of the conversion mapping.
• Performed Unit Testing and User Acceptance testing (UAT) assisted in developing Test Plan and Test Cases to be used in testing based on Use Cases and Functional Specifications.
• Involved with all the phases of Software Development Life Cycle (SDLC) methodologies throughout the project life cycle which involved gathering, analysis and documenting business and technical requirements from both formal and informal sessions.
• Tested the application manually by executing Test Cases in Quality Centre prior to Automation and Involved in automated testing.
• Performed functional testing with the development team as well as User Acceptance Testing and Regression Testing of the application using Quality center and JIRA for prioritizing defects and assigned it to the developer to fix the bugs.

Confidential - Stuart, FL

Business analyst

Responsibilities:

• Documented functional specifications and validated Test books, thus ensuring all business requirements are included.
• Directed and managed the Change Control Process for the project as a whole by facilitating group meetings, one-on- one interviews and corresponding with work stream owners to discuss the impact of change request on the project.
• Conducted User Acceptance Testing (UAT) and collaborated with the QA team to develop the test plans, test scenarios, test cases, test data to be used in testing based on business requirements, technical specifications and/or product knowledge.
• Worked closely with the Developers and Engineering Teams in the review and modification of the product and its specifications.
• Developed use cases from requirements and created UML diagrams such as use case diagrams, activity diagrams and sequence diagrams
• Created Test Plan with list of test cases to be developed and test strategy and scope and executed test cases manually and identified bugs.
• Conducted gap analysis sessions for new or existing setup so as to interpret customer business needs and translate the same to operational requirements.
• Actively involved in client management, client interaction and business development by making sure that the clients are utilizing the full benefits of using our system; and made sure to procure new requirements from clients to promote business.
• Delivered the comprehensive Functional Specifications and System Design Specifications (SDS) and System Requirement Specification (SRS).
• Performed GAP and Risk analysis of existing system and evaluated benefits of new system and validated technical designs created by IT developers against functional specifications.
• Communicated defects to the developers and participated in bugs and enhancement review meetings.
• Performed user acceptance testing (UAT), interacted with users for execution of test cases in UAT.
• Supported the development, tuning, and debugging of database servers (MS SQL & MS Access), stored procedure, triggers, functions and backup recovery procedures and control procedures.
• Conducted detailed Enterprise Analysis- defined Business need by analyzing existing control documentation, standards and policies; assessed capability gaps by thoroughly documenting processes; determined solution approach through enabling stakeholders to reach decisions and agree proposed solutions.
• Extensively used rational tools for UML, tracking and reporting and applied the Rational Unified Process in all areas of a software development life cycle.