SUMMARY

• Over 6 years of consistent experience in the following areas: Ability to Elicit, Analyze, gather and document Business Requirements, experienced in writing Use Cases. Proficiency in SDLC life cycle, understands the workflow concept, ability to gather and document the 'As - Is' and 'To-Be' processes
• Requirement gathering through interviews, workshops, JAD sessions with clients, developers and QA Analysts and referring to existing system documentation and procedures
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
• Worked in a software development IT shop, created quality documentations such as Requirements Documents, Design Document, Test Plan, and User Acceptance Test Plans.
• Self starter with excellent time management skills
• Strong data analysis skills, experienced in data warehousing.
• Strong experience with different project methodologies including Agile, Scrum Methodology, SDLC, RUP.
• Strong experience and understanding of claims management process
• Strong experience and understanding of health care industry, claims management process, Knowledge of Medicaid and Medicare Services
• Strong knowledge and experience with claims associated with payers, claims by providers and member/subscriber claims
• Strong knowledge of EDI Claims, member enrollment, and billing transactions
• Understanding of HIPAA Standards and Compliance issues, HIPAA Privacy policy, opt in/opt out policy.
• Well versed with BPM domain and has good knowledge of Pega RULES Process Commander (PRPC).
• Requirements gathering in compliance with HIPAA 4010 and 5010 standard.
• Experience web based application development and maintaining wikis.
• Experience with healthcare fraud and abuse problem and solution development
• Writing Use cases and producing Behavioral diagrams (Sequence diagrams, Collaboration diagrams) and Class diagrams based on UML Methodology & creating Business process flow diagrams
• Writing & documenting Business Plan, Requirements Document, Functional Specification Document, and Test Cases
• Defining Test Cases, analyzing bugs, interaction with team members in fixing errors and User Acceptance Testing (UAT)
• Using project management tools like MS-Project for status reporting and planning.
• Creative and aggressive self-starter with integrative thinking skills, capable of forming and maintaining positive and productive working relationships in internal, external, independent, and team environments
• Highly motivated, organized and results and detail oriented with excellent interpersonal, communication and presentation skills. Proven capability of adapting to new and fast changing technologies

TECHNICAL SKILLS

Project Methodologies: SDLC, Agile, Rational Unified Process (RUP), UML

Business Modeling Tools: Rational Rose, MS Visio, UML, mind map

Requirement Management Tools: Rational RequisitePro, Rally, Direct Capture of Objective (DCO) of Pegasystems

Defect Tracking Tools: Rational Clear Quest, Quality Center, Test Director

Operating Systems: Windows NT/XP/2000, UNIX

Database: Oracle, SQL server, DB2, Teradata

Quality Assurance: Software Application Testing Life Cycle

Business Applications: Microsoft Office Suite, MS VISIO, MS Project, RSM

BPM Packages: Pega RULES Process Commander, Aqua Logic BPM

PROFESSIONAL EXPERIENCE

Confidential - Alexandria, VA

System Analyst

Responsibilities:

• Gap Analysis of DOI approved PDF’s
• Participate with project manager to develop project plan and design charter documents.
• Authored Technical Requirements documents and maintenance document including detail functionality for enhancement of the application
• Analysed the data elements to be stored in IES database that are used for underwriting processes.
• Invloved in establishing conncetion between internal wellpoint systems and vendor operated applications such as eHealth, Connecture and Online Insight.
• Delivered data flow operations to IES middleware team for sending application to Ultera, which is an imaging system.
• Gained knowledge on billing page changes as part of Audit compliance mandated SSCR and implemented Billing page to be secured for all PlanFinder states.
• Successfully implemented WI uniform application which is part of State mandated project.
• Analyzing all the IES middleware impacts, requirements, and defects.
• Interacted with Business users and Technical team in providing clear solutions to Requirements.
• Involved in listing and updating the Supplementary requirements for the projects.
• Assisted with documentation updates, BRD updates, FDD, materials required for project review meetings and meeting minutes.
• Coordination and implementation of a QA methodology for the application.
• Authored Test Plans, Test Scripts, Validation Protocols & technical doc
• Analyzed the business requirements and directed on writing Test Cases.
• Worked on defects, analyzed it and assigned to the development teams.
• Carried out weekly team meetings for defect tracking and updates on outstanding defects.
• Involved in Process Flow Diagrams to illustrate the flow of IES/PlanFinder application.
• Authored GO Live documents and achieved approvals.
• Gathered SOX approvals from Business owners on all the documentations. Also gathered UAT sign off from Business owners.
• Supported on production release checkouts.
• Participate in Lean IT enablement approaches which involved designing Use cases for IES system and using rational software tools.

Environment: MS Visio, MS Office, Test Directory, Clear Quest, Requisite Pro, RSM, SharePoint, IES Admin Tools, Application’s: PlanFinder, MUWS, SECA.

Confidential - Austin, TX

Sr. Business Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model
• Assisted Project Manager with the creation project timelines and milestones and resource planning
• Analyzed the “As is” and “To be” system documents to show the current and proposed functionalities of the system using MS VISIO
• Creating GANT charts to monitor and analyze the progress of the project
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts
• Scheduled experience with managing multiple schedules across single program(s) and ability to roll-up schedule
• Involved in defining and documenting the vision and scope of the warehousing project
• Assisted with documentation updates, BRD updates, resource allocations / assignments, materials required for project review meetings and meeting minutes
• Backed-up associate on preparation and updates to all project status reports
• Preparation of RFI and RFP for requirements in SAP PP, SFDC, Siebel, Pega and BPM solutions across the globe for the clients.
• Assisted with training of associates on small enhancement processes; worked with ACES claims data for claims subject area, Enrollment and billing data for membership subject area
• Conducting business validations covering the following deliverables: Facets Providers, Facets Claims and Facets Membership areas
• NASCO uses MetaVance for Auto enrollment process. We have proposed a solution to increase the first pass rate. Then new application which shall be developed in Pega would act as an intermediary, by analyzing the reports generated from Metavance and auto updating the data.
• Provide client with a platform to transition smoothly to an onshore-offshore model for Pega engagements
• Involved in the development of Business and Technical Requirements Document (BTRD) and Business System Design (BSD) document for the project
• Involved in identifying and studying the ACES and Facets system data and field by field analysis of Facets system for the attribute mapping purpose
• Analyzed the data in the Facets source system to map into the correct field and attribute in the target storage
• Conducted interviews with management team and other stakeholders
• Conducted and participated in the JAD session with the SMEs and project team members
• Worked as a liaison between the business and technical side to convey the business needs to the system architects
• Primary technical point of contact for client and to coordinate with a team of Doctors, Bio-medical engineers and Domain experts

Environment: MS Windows, FACETS, MS Visio, Pega Systems Rule engine, MS Project, MS Office (PowerPoint, MS Word, MS EXCEL), Web 2.0, SQL, Oracle, SDLC, Agile

Confidential, Philadelphia, PA

Sr. Business Analyst

Responsibilities:

• Involved in updating and/or reworking previous documentation on their Membership Enrollment System for Florida to get them in sync and up to date with their current new system in place.
• Involved in System Integration, Compliance and User Acceptance Testing and Validation of Medicaid claims processing and Electronic Data Interchange (EDI) translation in compliance with the 4010A and 5010A Health Insurance Portability and Accountability Act (HIPAA) transactions 837 I/P, 835 and 997 Acknowledgement.
• Resolution of HIPAA compliance failures in inbound (837 I/P) and outbound (835, 997) medical claim adjudication transactions.
• Worked with ICD 9 and 10 Procedure and NDC codes used in HIPAA transaction code sets.
• Gained understanding of Medicaid policy and billing requirements and documented needed changes to policies and billing manuals related to ICD10 through facilitation with internal KMHP program areas.
• Analyzed and documented Medicaid reimbursement issues related to implementation of ICD10 and ensured that these issues are documented and addressed in the approach to ICD10 conversion process.
• Analyzed and documented ICD10 requirements related to data elements, data exchange and data transmission.
• Documented business needs for ICD10 resulting from the HIPAA 5010 gap analysis.
• Worked on the ICD9 to ICD10 crosswalk and coordinated the development of the crosswalk solution.
• Determined the requisite ICD10 training for both internal staff and Medicaid provider groups and assisted in the development of training materials.
• Involved in bi-weekly workgroup sessions to complete various sections in the functional specification document like Business Rules Definitions, Processing Rules, Pre-Edit Errors, etc. and weekly status meetings for updates.
• Involved in manually testing the application from the backend to carry out data validation.
• Attended Joint Application Mapping (JAM) Sessions with my team to map the business needs.
• Used requirement elicitation techniques such as JAD Sessions and Document Analysis to gather information regarding the application from the KMHP SME and EDS along with the State of Florida people.
• Involved in bi-monthly Technical and Operational Issues (T&O) Conference Calls with AHCA, EDS and various providers who worked with AHCA to answer and resolve issues pertaining to a smooth transition from AHCA’s previous fiscal agent ACS to EDS.
• Maintained open and clear communication with the team on change requests.
• Gathered and documented functional requirements for testing and verification of HIPAA Administrative Simplification X12 standards, 837 Institutional and Professional HIPAA standard transactions and EDI messages (837) Healthcare encounter claim and coordination of benefits (COB) - claim payment and remittance advice835 - Healthcare claim status (276/277), Eligibility for a health plan (270/271), Referral certification and authorization (278), Enrollment & Withdrawal in a health plan (834), Premium payments (820) and Future transactions (identified in HIPAA).
• Co-authored and reviewed Operational Guidance Documents along with Design Documents and Deployment Plan Documents.
• Extensively involved in multiple teleconference calls on a weekly basis with NaviMedix to resolve all the open issues so that the Business Requirements Documents, Functional Specification Documents, Technical Specification Documents, Operational Guides, etc. could be completed, approved and sent for a successful sign off in order to be able to build the application and deploy it.
• Created UI Documents as supporting documents for the Business Requirements Documents.
• Involved in Data Flow/Business Process Diagrams to illustrate the flow, input and output of data.

Environment:, MS Office, MS Visio, JAVA, SQL Plus, Sybase SQL Mercury Quick Test Pro, Mercury Quality Center, MS Outlook, iHealth Claims Inquiry Tool, Crystal Reports, XHTML, File Manager, Tracer, FACETS 4.2.1

Confidential - Burlington, NC

Business Analyst

Responsibilities:

• Analyzed, designed, and implemented web applications for Risk Managers to assess insurance applications
• Responsible for the functional study and analysis of the business requirements, UML state chart diagrams, flow charts, business process and designing data elements
• Presented to large groups to review all analysis, ad-hoc reports and made suggestions for new processes that would benefit the organization
• Responsible for streamlining business processes through analysis, design, and documentation of new processes and applications including risk assessments and mitigations, and creation of process flows (VISIO flow design) and change enabling quality controls
• Gathered Business Requirements, interacted with the Users, Designers, Developers, Project Manager, and SMEs to get a better understanding of the Business Processes, and analyzed and optimized the process
• Created UML Diagrams including Use Cases Diagrams, Activity Diagrams/State Chart Diagrams, Sequence Diagrams, Collaboration Diagrams, Deployment Diagrams, Data Flow Diagrams (DFD), ER Diagrams, and Web Page Mock-Ups using Rational Rose and MS Visio, and defined Business Process Model and Data Process Model
• Involved in gathering requirements about Provider Implementation and Claim Submitting Details about specific Providers
• Involved in Provider Implementation module and NPI Implementation
• Conducted JAD/RAD sessions to understand the unique demands and Needs of Providers
• Worked on Conversion of claim records to include new NPI fields
• Involved in X-12 270, 271,277, 835 and 837i and 837p Transactions
• Used the Unified Change Management (UCM) tool, Rational ClearQuest to maintain and track the Stakeholder-requested enhancements and changes
• Used Rational ClearCase, a Configuration Management tool, to maintain different builds of the application with description about all changes and versions
• Integrated Rational RequisitePro with Rose, ClearQuest, and ClearCase to provide visibility to teams, maintain tractability among requirements, use cases, change requests, and configure changes
• Developed Project Status Metrics for weekly evaluation of Project Status, and analyzed the impact of the open issues and Change Request on the Project Plan
• Identified and documented Issues, Risks, and Gaps, and their descriptions and impact, and provided recommendations and alternatives

Environment: Rational Suite (RUP, UML with Rational Rose, Rational RequisitePro, ClearQuest, ClearCase), MS-Visio, SQL Server 2000, Oracle Server 9i

Confidential, Malvern PA

Business Data Analyst

Responsibilities:

• Worked on validating customized Enterprise Labeling Information System (ELIS) that was designed to process labeling of controlled documents
• Worked with VMDM and made it able of the metadata & data management systems to manage & track master data relationships, as well as hierarchy changes.
• Worked with account managers and business users to gather requirements.
• Interacted with various teams to gather requirements for new Confidential Security products.
• Wrote requirements for pricing methodologies of new Security products.
• Worked with the Management during the Scope and Blueprint stage in creating Business Process and Procedures. Mapping the integrated scenario of client's Business process. Organization Structures of Company with Manufacturing Plants, Divisions and storage location.
• Involved with Business groups on clean and harmonized business process data for the global fields requirement analysis in the Material master (be clean and stay clean philosophy).
• Involved with DATA Management team in developing the SCOPE doc for DATA rules to be followed regarding project requirements and designing the rules for Global data requirement for CORE.
• Created process flows for servicing and acquisition processes.
• Erwin& Model manager Architecture, Implementation and administration
• Erwinbest practices and standardization and automation of physical design usingErwinmacros, development ofErwinFW scripts for Netezza Appliance, Data model Report template design and development and administration.
• Involved in getting the required Business requirements for all global plant operations from Functional Managers in Purchasing, Inventory Management, Vendor management of stocks and Customer Master team
• Wrote documentation for all aspects of the computer systems validation lifecycle, in accordance with FDA regulations, particularly CFR 21 Part 11, including: Validation Plan and Protocol, Installation Qualification (IQ) Specification, Operation Qualification (OQ) Specification, Performance Qualification (PQ) Specification
• As part of AGILE, worked with SCRUM teams for formal daily face-to-face communication between team members.
• Followed AGILE during different software development phases.
• Extensively used ReqPro for requirements
• Documented all the changes in the initial templates
• Used Visio to create pricing flow diagrams.
• Updated the existing business process diagrams and created new business process diagram.
• Wrote requirements for report enhancements (System reports and Crystal Reports).
• Created templates for new reports.
• Coordinated with the developers and QA team during the development process.
• Created Test Scripts & Test Scenarios to check report content, layout, and parameters.
• Tracked the defects in legacy reports as per account managers and end users. Compared the results and tracked the differences in excel.
• Integrated Quality Center and QTP for automation during regression.
• Carried out UAT to make sure that the results were accepted by account managers and users.
• Wrote test SQL queries for UAT.
• Wrote test cases in Quality Center for manual testing and created scenarios for UAT.
• Worked on defects through Quality Center.
• Carried out weekly team meetings for defect tracking and updates on outstanding defects.
• Worked as a liaison between the Business and Technology Department.
• Enhanced communication lines between executives, managers, and peers.
• Lead team meetings and attended walkthroughs with team members and management

Environment: EDMS, Documentum, Quality Center, Quick Test Professional (QTP), OLAP, OLTP, GxPharma, Trackwise, eRoom, Oracle, SQL and PL/SQL, HTML, Windows

Confidential, Miami, FL

Business Analyst

Responsibilities:

• Participated and organized requirement gathering sessions with the stakeholders to elicit and analyze requirements.
• Assisted in preparing Scope Document by analyzing - various business domains interdependencies, end to end business processes of claims adjudication, various business domains scope statement, current business process flows and current system documentations.
• Worked with all Facets Provider of software development from requirements gathering to testing, configuration and international deployment.
• Followed Workgroup for Facets Electronic Data Interchange standards for testing that need to comply with the HIPAA guidelines.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Coordinated and worked with Project Manager to prepare Project Plan in MS Project for Process Claim Domain.
• Executed complex integrated systems planning and solution alternative analysis and design.
• Executed business process analysis “As-Is” system & “To-Be” systems & perform gap analysis.
• Deeply involved & being a part of the solution delivery life cycle of enterprise solutions, including software and vendor selection, package implementation, and vendor management.
• Organized and participated in JAD sessions with the system architect, SMEs & project sponsor for a faster & effective system development.
• Developed solutions in compliance with the industry models / standards and implementation of Quality Management Systems & HIPPA regulation.
• Experienced creating design documentation related to system specifications including user interfaces, security support and control, performance requirements and data conversion.

Environment: Windows NT,, MS-Visio, FACETS 4.21, Oracle, Requisite Pro, MS Project, Mainframe