SUMMARY

• 9+ years of professional experience as Business Analyst/Data Analyst/System Analyst with expertise in Software Development Life Cycle (SDLC) and Business Process Re - engineering in Health Care Sector with primary focus on claim adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Extensive experience in interviewing Business users & subject matter expert providing recommendations to resolve issues for various business/technical groups & defining strategic solutions to business problems in a multiple project environment.
• Experience as Business/Systems Analyst with expertise in Insurance, Healthcare processes, health insurance exchange HIX, meeting federal compliance and regulation, understanding client requirements and providing scalable infrastructure.
• Competent skills in developing detailed functional specs through JAD sessions, interviews with clients and business users, onsite meetings with business users & development team.
• Experience with PMO techniques such as Rational Unified Process (RUP), RAD, Agile(scrum meetings, user stories, sprints),Waterfall life cycle.
• Reviewed the data model and reporting requirements for Cognos Reports with the Data warehouse/ETL and Reporting team.
• Analysis & Design (Use Case, Sequence and Activity diagrams).
• Experience in documentation: BRD (Business Requirement Document), FRD (Functional Requirement Document).
• Writing (manual/automated test cases) and Conducting (Integration testing, Regression testing), Black Box, White Box testing, UAT (user acceptance tests).
• Proficient with data analysis, data mapping and dimensional modeling experience in decision support systems.
• Experience with Business intelligence tools like Cognos.
• Working experience in a cross-functional team environment/different geographical locations teams.
• Well versed in translating business requirements and user expectations into detailed specifications employing Unified Modeling Language (UML) diagrams using MS Visio and Rational Rose.
• Experience with Health Insurance Packaged Application likeQNXT.
• Providing US Health Insurance domain and Confidential 'sQNXT 2.6/ 3.4/4.7/4.81 /5.01 training & mentoring to other internal Business Analysts and Entry level fresher’s including knowledge of conversation from earlier versions ofQNXT.
• Experience with Medicare, Medicaid, and commercial insurances in HIPAA ANSI X12 formats including 277/275, 276/277, 835, 837, and NSF formats for interfaces and images to third party vendor applications.
• Experienced in HIPPA 4010/5010 EDI transaction. Experience with writing various test cases for FACETS interfaces and tracking/explaining bugs to development teams
• Experience in configuration of claims adjudication systems, QNXT 2.6/ 3.4/4.7/4.81 /5.01.
• Experience with Confidential QNXT System implementation, Claims and Benefits configuration set-up testing, Inbound/Outbound Interfaces and Extensions, Load and extraction programs involving HIPAA 834 and proprietary format files and Reports development.

TECHNICAL SKILLS

Process Methodology / Modeling Tool: SDLC, OOAD, RUP, AGILE, EXTEME Programming, & Spiral model & Prototype modeling. Rational Rose/Requisite Pro, Clear Case, Clear Quest, Quality Center, Test Director & ERWIN

Databases: MS Access, MS SQL Server 2005/2008, Oracle

Languages: C/C++, .NET, JAVA, VBA, XML, UML & HTML

Operating systems: Unix, Linux & Windows, Mainframe

Office tools: MS Office 2003/2007, Word, Excel, Power Point, Visio

Project management: MS Project 2003/2007

Reporting Tools: Business Objects Report, Cognos Report

PROFESSIONAL EXPERIENCE

Confidential, Naperville, IL

Sr. QNXT/System Analyst

Responsibilities:

• Worked with Business users and technical lead for gathering requirements and data transaction information.
• Created reports using Microsoft SQL Server 2005 Reporting Services and QNXT 4.81 tables
• I was involved in the system wide implementation of ICD-10 andQNXT 5.0upgrade.
• Act as a peer-leader for the testing efforts ofQNXTand FACETS Implementation and Upgrade projects.
• Expert in T-SQL programming to query the database for analysis, writing test scripts, designing reports, etc.
• Expert in designing complex reports such as drill-down, parameterized, sub-reports etc on an ad-hoc as well as scheduled basis.
• Coordinate with the data conversion team, stage agencies, and vendors during the development, test, and reconciliation process and post implementationQNXTand legacy systems data to ensure accuracy and consistency.
• Installation of major components for the TrizettoQNXT 5.01 medical record system including coordination of benefits for Dual Member and Dual coverage customers, Medicare Processing Refund, 837 EDI/ hardcopy claims input and 276/277 queries.
• DevelopedSQL scripts for extracting data and maintaining administration tasks.Tuned the SQL queries using SQL profiler
• Designed and developed UML diagrams such as use cases, activity diagrams and sequence diagrams.
• Involved with data migration team to gather requirements for data conversion from source system (Adaptis system) to new system ( Confidential ’sQNXT)
• Designed, built, tested, and assisted in Quality controltesting of test cases.
• Dealt with 834 import member lookup processes and resolving issues with member attributes, enabling multiple rules associated with member lookup process inQNXT.
• Used Process log browser to view different types of log history files to figure out issues with 834 transaction
• Dealt with the following tables heavily from QA perspective: member, enrollment, enroll keys, program, planprovinfo, provider type, relationship.
• Responsible for working with the State to review and modify process flows to increase productivity and effectively utilizeQNXTfeatures not provided by the legacy systems
• Participated in unit testing of the system that was currently being implemented. This initiative included the creation of testing scenarios, reviewing test cases and validating the various queues the claim processes to, tracking development issues and programming bugs.

Environment: QNXT 4.81/5.01, Informatica, Rational Rose, Rational Test Manager, MS Office Tools, UML, MS Visio, Windows XP, Oracle, SQL, MS Project 2003, SQL 2005/2008, Rational ClearQuest, Cognos, portNet/PowerPlay, Informatica 6.1, RUP, Mainframe,, QMF, Load Runner

Confidential, Long Beach, CA

QNXT Analyst

Responsibilities:

• Proposed Agile methodology to capture the Business Requirements.
• Interviewed business users asking detailed questions to gather business requirements, wants, and needs concerning the project and carefully recorded the requirements in a format that can be understood by both business and technical teams.
• Analysed existing provider setup and proposed new solution for Fidelis process flow.
• Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in QNXT.
• Used SQL to test various reports and ETL load jobs in development, QA and production environment.
• Experience with Confidential QNXT 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.
• Gathered requirements, elicited requirements, documented elicitation results for HIX Plan Management module defined by CMS and also performed testing on HIX
• QNXT Configuration and Maintenance/QA Activities included: Addition/Removal of CPT/HCPCS/Rev/ICD 9/Procedue codes/Custom fees/Restriction and Service Groups in a Benefit/Contract term. Also, addition and updating of Contract Terms (Change in reimbursement fees like daily rates) with the state specific revised rates of fee schedules.
• Worked with EDI analyst to setup 837 import & export process.
• Supported DBA to resolve QNXT data issues.
• Dealt with the following tables heavily from QA perspective: provider, contract, claim, claimdetails, member.
• Led JAD sessions with stakeholders to analyze system needs and integrate requirement to develop a consistent navigation structure
• Coordinate with the development team and vendors during the development, test, and reconciliation process and post implementation QNXT and ensure accuracy and consistency.
• QNXT Configuration and Maintenance/QA Activities included: performing the POC, testing and executing the setup.
• Dealt resolving issues with member attributes, enabling multiple rules associated with member lookup process in QNXT.
• Addition of a new provider, Attaching Pay to/PCP affiliations to a provider. Modifying Org Policy for an employer and fee tables i.e. making changes in fee amount, effective and terminate fields etc.
• Troubleshoot any problems found within QNXT/QMAC and when testing the SQL data database while validating against the business rules.
• Resolved issues like member duplicated in file, dealing with dependent transaction if subscriber is not found, failures in submissions in QNXT.
• Supported the business and the technical team in the product development and delivery process and successfully managed cross- departmental relationships by Coordinating & writing Test cases with the Development & Testing team.
• Responsible for working with the State to review and modify process flows to increase productivity and effectively utilize QNXT features not provided by the legacy systems.
• Implemented Change Control process for 1199 NBF.

Environment: C#, .net, Visio, MS SQL 2005, QNXT 3.4/4.7/4.81 , Cactus, Informatica, MS Outlook, MS Project, MS Word

Confidential, Atlanta, GA

QNXT/System Analyst

Responsibilities:

• Gathered requirements to build a new single data warehouse for information storage and retrieval.
• Extensively used Rational RequistePro.
• Deal with Business users to know their specification and coordinate with project manager in order to implement it.
• Validate codes inQNXTusing SQL Server.
• Import data intoQNXTfrom other Data source table and flat files using SSIS package.
• Unzip and Import national standard codes provided by CMS, FDB etc intoQNXTDB.
• Wrote, modified Store Procedures.
• Build code to extract data fromQNXTData Base and write into flat files.
• Used SSIS packages to integrate packages like source, destination, command lines etc.
• Responsible for testing the code and packages build.
• Unit tested the code, imported data and output flat files.
• Wrote test plan document and execute test cases to perform system test in Excel.
• Functioned as the primary liaison between the business line and the technical areas throughout the System Development Life Cycle (SDLC)
• Documented System Design Documentation (SDD) describing the systemsrequirement, operating environment, files and database design, input format, output layout, detailed design.
• Analyzed customer needs and existing functions in the area of HIPPA transactions to determine feasibility, consistency with the established scope of work.
• DevelopedSQL scripts for extracting data and maintaining administration tasks.Tuned the SQL queries using SQL profiler
• Designed and developed UML diagrams such as use cases, activity diagrams and sequence diagrams.
• Designed, built, tested, and assisted in Quality controltesting of test cases.
• Participated in unit testing of the system that was currently being implemented. This initiative included the creation of testing scenarios, reviewing test cases and validating the various queues the claim processes to, tracking development issues and programming bugs.

Environment: QNXT 3.4, Informatica, MS Outlook, MS Project, SQL 2005, MS Word, MS Excel, MS Visio, Agile Methodology

Confidential, Danville, PA

System Analyst

Responsibilities:

• Utilized Agile Methodology to configure and develop process, standards and procedures
• Conducted JAD sessions workflow diagrams, UML diagrams, process models, activity diagrams, use cases, for incorporating design changes in the order creation/ management system.
• Worked on Health Insurance Packaged Application like QNXT. Providing US Health Insurance domain and Confidential 's QNXT 2.6 training & mentoring to other internal Business Analysts and Entry level fresher’ s including knowledge of conversation from earlier versions of QNXT
• Actively participated on creating Migration strategy from existing PDE (Microsoft Access files) to Gold Data Repository.
• Clearly understood coding standards required for all Medicare Part D Users transactions involving electronic data interchange as provided by department of health and human services and incorporated at every stages of the project wherever found necessary.
• Prepared the Business requirement Document (BRD) and functional requirement document (FRD) for the enhancement of the existing services.
• Did data analysis, created data mapping and data interface documents and kept the documents updated with changes in requirements and functional specifications.
• Created reports using Microsoft SQL Server 2005 Reporting Services and QNXT 3.4 tables
• 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. Resolved issues like member duplicated in file, dealing with dependent transaction if subscriber is not found, failures in submissions in QNXT.
• Worked on modules related to Providers, Contract & Claims and worked with Claims, Provider attributes, enabling EOB & Remit rules associated with Provider configuration process in QNXT.
• QNXT Configuration and Maintenance/QA Activities included: Addition/Removal of CPT/HCPCS/Rev/ICD 9/Procedue codes/Custom fees/Restriction and Service Groups in a Benefit/Contract term.
• Coordinated with data architects and ETL team to understand/drill down on the data mart requirements. Came up with the plan to roll out data mart development efforts in different phases, coordinated efforts to analyze the data mart requirements between teams responsible for various source systems, scoped out the work required on behalf of different teams to adhere to the interface documents to provide data to the data-marts.
• Worked closely with business users and IT team in War room to solve the issues in time
• Provided Production support and post-production support/explained the changes to the business users/did one on one sessions/one to many sessions to make the business uses aware of the system changes.

Environment: QNXT 2.6, Agile, Requisite Pro, SQL 2005, MS Visio, MS office, MS word, MS excel Clear Case, Clear Quest, Quality Center

Confidential, Newton Ville, MA

Jr. System Analyst

Responsibilities:

• Elicited and gathered user and business requirements through JAD sessions and interviewing clients.
• Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non-functional requirements.
• Troubleshoot systems related issues regarding the functioning of core Part D Operations systems.
• Analyzed enrollment and billing workflows and procedures in order to assist in the development of new or modified systems.
• Provided technical assistance in identifying, evaluating, and developing systems and procedures.
• Performed gap analysis and root cause for the failure of letters send to the vendor.
• Prepared the Business requirement Document for the enhancement of the existing services.
• Prepared system Use case specification document with use case diagram.
• Created crosswalks for the letter values and codes.
• Worked with SharePoint to manage teams and companies data.
• Worked with business users to understand their requirements, worked with developer team to develop prototypes/Mockups, demonstrated prototypes to the business users.
• Worked TRR (Transaction reply report), accretion file.
• Mapped letters and their respective fields.
• Prepared and implemented test cases for System Testing as well as for User Acceptance testing.
• Conducted System Integration Testing and Regression Testing with developers in development and QA, also conducted user acceptance testing with UAT team. Safety reporting on system-based projects, acted as a liaison, writing documentation and increased project coordination.

Environment: MS Word, MS Visio, MS Project, MS Excel, MS PowerPoint