SUMMARY

• Over 7 years of professional experience as a Business Analyst working on design, analysis process flows etc.
• Skilled in gathering business and application requirements, Business Processes, identifying risks, impact analysis, UML modeling, and Sequence and Activity Diagrams using Rational Rose and Microsoft Visio in Clinical and Health Information Management (HIM) processes.
• Experience in Client interaction and negotiating for requirements.
• Solid work experience with big team size and Clients.
• Experience working on 1095A form, Research errors on the form that consumers report to the FFM
• Supporting FFM by fixing enrollments that break and address discrepancies in reconciliation of enrollments.
• Extensively worked on analysis & compliance of ICD 9 to ICD 10 and HIPAA (Health Insurance Portability and Accountability Act) 4010 and 5010 EDI transactions.
• Experience with Medicare, Medicaid and commercial insurances in HIPAA ANSI X12 formats including 270/271,276/277,820, 835, 837, 997
• Proficient in authoring Business Requirement Document, Narrative Use Cases, creating Use Case diagrams, Sequence Diagrams, Activity Diagrams and other UML based diagrams using MS Visio, Rational Rose.
• Experience working in a matrix environment, enhancing UI applications, creating data sets, extracting and synthesizing data, conducting and interpreting quantitative and qualitative analyses.
• Excellent Knowledge in Electronic Medical Record (EMR) / Electronic Health Records (EHR) modules and process flow
• Extensive knowledge about the various types of health insurance programs such as: Medicaid, Medicare (Part A, B, C and D), PPO(Preferred provider organization), HMO (Health maintenance organization)
• Sound knowledge of Confidential t Protection and Affordable Care Act (PPACA), HIX (Health Insurance Exchange), Sarbanes - Oxley Act (SOX), ACORD, SOPs (Standard operating Procedures) and forms, GMP’s terms and Practices.
• Experience with claims process and adjudication in the Medicare, Medicaid & Private Insurance Sectors
• Extensive Experience in all the phases of Software Development Life Cycle including: Requirements Gathering, Feasibility study, Analysis, Design, Development, Testing, Deployment and Maintenance.
• Excellent knowledge and deep understanding of industry standard methodologies like Iterative Software Development Life Cycle Process as per Rational Unified Process (RUP), CMM (Capability Maturity Models), ISO9000 and Six Sigma and Rational Tools used during various phases of RUP such as Inception, Elaboration, Construction and Transition. Also worked using various methodologies such as Agile Software Development, Rapid Application Development (RAD), Joint Application Design (JAD) and Prototyping.
• Demonstrated skills in critically conducting the GAP Analysis throughout the projects in evaluating/ analyzing the existing standards and policies to determine the improvements
• Expertise in Business Modeling and UML Diagrams (Use Case Diagrams, Activity Diagrams, Sequence Diagrams) using MS Visio and Rational Rose.
• Strong knowledge of Business Intelligence, Data Warehousing, Data Modeling and Analytics concepts with expertise in grasping transaction flows and process management
• Good understanding on data and statistical data and worked on Data Modeling
• Expertise in Healthcare Data warehousing and BI tools (SQL server Reporting/Analytical tools)
• Knowledge of ITSM (Infrastructure Services Management) and ITIL (Information Technology Infrastructure Library) methods and processes.
• Expertise in reviewing Test Procedures, creating Test plans, defining System & Integration Test Cases, executing Test Cases, Test Data reviewing and maintaining and executing detailed Test scripts for User Acceptance Testing (UAT), analyzing bugs, interacting with team members in fixing.
• Extensive use of Mercury and Rational Tools for Functional and Performance Testing
• Expertise in Client site coordinator that involves understanding business requirements, day to day client interaction, offshore knowledge transfer (KT) activities, onsite status call coordination, project deadline keeping and worked as a team with business partners and end data customers
• Excellent Written and oral communication skills with ability to articulate requirements, process flows and relationships.

TECHNICAL SKILLS

Languages: C, C++, Java Script, SQL, HTML, WML, ASP, VB Script and COBOL

Methodologies: OOAD, RUP, UML, SDLC, JAD, Six Sigma, CMM, RAD, SCRUM

Databases: Oracle (10g & 11g), SQL, MySQL server, MS AccessTools MS Office (Word, Excel, Project etc.), Caliber, Visio, Adobe Acrobat Suite, Informatica. Rational Rose, Requisite-Pro, Clear case, Quick Test Professional, Clear quest, Crystal Report & Business Objects, Team Foundation Server (Started working on).

Quality Management: Quality Center, Load runner and ISO Concepts

Platforms: Windows (NT, 2000, XP), Unix, Mainframe

Reporting Tools: Business Objects, MS Excel, Crystal reports, Cognos

Other Tools: Clarity, EMC Documentum eRoom

PROFESSIONAL EXPERIENCE

Confidential, Virginia

EDI Analyst

Responsibilities:

• Created and reviewed BRD’s. for validating Form 1095-A
• Conducted interview & brainstorming and JAD sessions, to capture concise & feasible requirements.
• Created Use Cases, Activity Diagrams for process flow
• Reviewed and reconciled Health Insurance Casework System (HICS), for Track, Monitor and resolve 1095-A discrepancies.
• Closely working with Insurance Trading Partners and Contractors/Companies.
• Conduct daily meetings and sending reports on the progress, to project management team.
• Working with Team Leads, Team Managers and Technical staff to identify track and manage project issues as they arise.

Environment: MS Office, SharePoint, SQL Server, MS Visio, XML, Windows

Confidential - Lincoln, NE

Business System Analyst

Responsibilities:

• Acted as a liaison between Business area Subject Matter Experts (SMEs) & development team throughout all phases of SDLC; starting from Inception to Transition phase of Rational Unified Process (RUP) methodology
• Participated on meetings related to HIX impact on systems and the subsidies.
• Identified AS-IS process flow of ICD-9-CM and ICD-10-PCS compliance requirements using the gap analysis for the existing United HealthCare community Plan.
• Updated data processes, data reporting, data collection tools and other processes such as problem lists, writing orders, referrals according to ICD-10 code set.
• Ensured that ICD-9-CM procedure codes used for services and CPT codes were not outdated
• Contributed in ICD-10 Awareness Training Management Plan, created evaluation tool, and survey questions
• Reviewed state documents (policies, manuals, business processes, systems documents, banners, bulletins) from various divisions. Analyzed and performed quality assurance to determine areas impacted by ICD-9 related data
• Generated numerous Business Requirement Documents & Functional requirements specification documents, Use cases, system flow and work flow diagrams.
• Worked with the Managed Care Subject Matter Expert (SME) and Users to ensure that all the requirements for system change are covered.
• Extracted and refined user requirements by conducting JAD sessions, facilitating meetings & interview with Business Units and Technical Supports & Development team, identifying the business flows and process flows, conducting detailed and comprehensive business, functional & system analysis to determine High Level and Low Level artifacts & deliverables.
• Developed business and detailed functional requirements related to changes to be made to the claim entry screens, including Practitioner, Crossover Practitioner, Dental and Hospital Claim Entry Screens.
• Involved in remediation of the legacy MMIS to meet the minimal functionality necessary to electronically send, receive and process the HIPAA compliant standard transactions, and fully implement all components of NPI Compliance.
• Incorporated and updated all MMIS screens for NPI Implementation within the MPS1 subpart used for paying claims
• Created new screen layouts and identified locations for new fields being added and existing fields which are being moved.
• Developed business and functional requirements for the National Provider Identifier (NPI) Crosswalk and Crossover Claims Crosswalk solution.
• Developed Test Plans and Test Execution Procedure Document based on the Business & Functional Requirement Document and numerous Test Cases and Test Scenarios to cover overall aspect of quality assurance.
• Successfully tested all the test conditions, documented the defects and discussed with technical analysts the discrepancies between expected and actual results for the test conditions.
• Conducted knowledge transfer sessions which were used to make the users and other teams aware of all the changes being made in the system as part of various projects.
• Assisted End User in performing User Acceptance testing and performed testing of the end result files created by the development team to verifying whether all the User Requirements were catered to by the development effort.
• Worked with Team Leads, Technical staff and key users to identify track and manage project issues as they arise.
• Developed workflows that demonstrate current and proposed business requirements.
• Provided weekly status updates to project stakeholders on the progress of project development activities.

Environment: MS Office, SQL Server, MS Project, MS Visio, Unix, XML, Windows

Confidential - Long Beach, CA

Business System Analyst

Responsibilities:

• Reviewed, analyzed & created BRD’s identified Functional Requirements & Non Functional Requirements using Rational Requisite Pro.
• Conducted interview & brainstorming sessions, JAD sessions, presentation sessions to capture clear, concise & feasible requirements.
• Conducted GAP analysis & identified loop, segment, field additions/deletions, error conditions changes between As-Is process & To-Be process.
• Assisted in highlighting key aspects required for vendor solutions - HIPAA translators & testing tools & created vendor statement of work document.
• Identified & conducted mapping process for output from 5010 to proprietary UB92 & NSF formats for legacy payer systems.
• Captured key payer systems & HIPAA repository data flow issues & risks.
• Conducted Claim Adjudication (check for payer edits & rules), analyzed and identified any errors to generate 834.
• Conducted Gap Analysis & identified specific ICD 10 requirements & participated in development sessions capturing ERD diagrams, Workflows & Communication diagrams.
• Created Project Plan using MS Project identifying key resource constraints, deadlines & dependencies. Documented & created weekly project status reports.
• Created Current Process Flow (as-is process) & Future Process Flow (to-be process) using MS Visio.
• Created Use Cases, Activity Diagrams, System Context Diagrams entailing grandfathering process, preexisting condition exclusions, dependent coverage age increase & other required provisions.
• Made improvements and suggested innovative designs for the existing UI design of Confidential
• Created Test Case Prioritization as “critical/high/medium/low” & obtained TL approvals.
• Conducted positive & negative testing & produced test status reports for KIOT meetings.
• Used Ultra Edit Professional to format ANSI X12 EDI 837I,P,D files, identified & changed duplicates, changed loops, elements & segments, wrapped & unwrapped files.
• Used Ultra Compare Professional to do 3-way comparison among ANSI X12 EDI 837I,P,D files
• Logged defects using Rational Clear Quest & produced defect status reports to ensure quality standards

Environment: Mainframes, DB2, Rational Requisite Pro, Rational Clear Quest, Rational Test Manager, Oracle, UML, MS Office, IBM Lotus Notes, Windows.

Confidential, Tucson, Arizona

Business Analyst

Responsibilities:

• Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
• Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles.
• Built and customized SoDA for Word templates and extract information from information sources such as RequisitePro and Rose, and created a highly automated system for handling approvals, exceptions and priorities.
• Used the Agile methodology to build the different phases of Software development life cycle.
• Gathered Business Requirements. Interacted with the Users, Designers and Developers, Project Manager to get a better understanding of the Business Processes.
• Developed gap analysis document, logical and physical design and remediation plan for State.
• Responsible for mapping documents, creation of test plan, test scenarios, test cases for unit, system and system integration testing.
• Worked with business owners, content staff, IT and other stakeholders in creating a content management solution for managing the information in the supplier portal using WebSphere Application Server.
• Used the Rational Unified Process (RUP) to build the different phases of Software development life cycle
• Created Project management plans for managing on time delivery using MS Project along with writing test cases, unit and systems integration test plans in Win Runner and used Load Runner to check if application works fine with load.
• 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.
• Interaction with the business user and the IT team for understanding the requirements.

Environment: OO Modeling, Web Sphere, Rational RequisitePro, Rational Rose, Rational SoDA, RUP, UML, Win Runner, Load Runner, MS-Project, MS Visio, MS Office, Windows XP.