SUMMARY

• Over 7 years of IT and Management experience in Software Development Life Cycle (SDLC) and Project Life Cycle working as Business Analyst mainly in Healthcare sector.
• 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.
• Competent skills in developing detailed functional specs through JAD sessions, interviews with clients and business users, onsite meetings with business users & development team.
• Detailed Analysis of the HIPAA 4010, 5010 along with the 6020 version of the 834 and 820 Companion guides.
• Experienced in gathering and documenting test Scenarios and ability to train users to translate technical requirements and translate them to a business audience
• Expert in compliance with HIPAA 4010 and 5010 standard.
• Strong knowledge of X12 format files and its structures including Loops, Segments and Data Elements.
• Strong experience with different project methodologies including Agile - Scrum Methodology, Waterfall, Modified-Waterfall, RUP.
• Strong Knowledge and experience of EDI transactions, ASC X12 Transaction sets: 834(Benefit Enrollment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 820(Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271(Explanation of Benefits (EOB)/Response to EOB), 276/277(Claim Status/Claim Status Response)
• Experience with Medicare, Medicaid, Medigap/Medsupp & commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 270,271, 276, 277, 835, 837, 997, NPI, ICD 9,ICD 10, NDC, DRG, CPT, NCPDP codes & NSF formats for interfaces & images to clearinghouses/ trading partners applications.
• Proficient with various modules of IDX.
• Proficient in writing test cases for both front end and the back end.
• Proficient with mocking up data to test when actual test data are not available.
• Experience web based application development and maintaining wikis.
• Experience with healthcare fraud and abuse problem and solution development
• Writing Use cases, test plans and test cases, System/Application testing and creating Business process flow diagrams
• 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
• Have a wide range of experience as a healthcare business analyst in Hospitals, Third party Billing companies, and Bio-Medical companies.
• Knowledgeable in HIPAA, Joint Commission and ISO Standards.
• Have good experience in Process Management, Client Relationship Management and Project Co-ordination skills.
• Have strong knowledge of Rational Unified Process (RUP) and Agile (Scrum) methods of SDLC.
• Strong knowledge of requirement Elicitation Techniques like Joint Application Development sessions (JAD), Interviewing, Questionnaires, Brainstorming, and Surveys for enhancing features of the Application.
• Strong Management Skills, demonstrated proficiency in leading and mentoring individuals to maximize levels of productivity, while forming cohesive team environments.

TECHNICAL SKILLS

Business Tools: Retalix, Proxis Store Manager Classic, TeleTracker Business Suite, PRAPP

Microsoft Tools: MS Project, MSP Professional, MS Visio, MS Office, MS Outlook, MS FrontPage

Databases & Languages: Oracle, MS Access, .NET, MySQL, SQL, HTML, Java, XML

Testing Tools: HP Quality Center, Mercury Test Director, WinRunner, Load Runner, Rational Robot, Quick Test Professional

Methodologies & Standards: RUP, Six Sigma, SDLC Agile, QA, HIPAA, Medicare Software, ezclaim, Medicaid

Operating System: Windows 95/98/NT/2000/XP, UNIX, Linux

Tools: Adobe Acrobat, Business Explorer, Toad, Data Warehousing,Lotus Notes

Skills: Rational Rose, Rational Requisite Pro, Rational Clear Quest, Snagit, Rational Unified Process, UML, SOA, ESB, ITIL, Business Process Modeling, HPQC, ALM, MS Visio, MS Word, MS Excel, PowerPoint, MS Project, MS Access, MS Outlook, ERWin 4.5, SharePoint, Cognos, Crystal Reports Visual Basic 6.0, Java, Object Oriented Programming, C++ .Net, UNIX, Windows NT/ 2000/ XP, MS SQL Server, BlueChip, FEP Express, VDR Data System, BlueSource, Coordinator Mouse.

PROFESSIONAL EXPERIENCE

Confidential, NY

Business Systems Analyst

Responsibilities:

• Conducted GAP Analysis in understanding how the upgraded system carries out the business functions and assists in ensuring the timely and effective implementation and conducted feasibility study and performed impact analysis for proposed enhancements.
• Worked with the internal and external technical teams (development and infrastructure) to translate business and technical requirements in to high quality, cost effective solutions that meet the long term goals and strategies of the organization.
• Worked on changes for HIPAA Transaction and proposed changes to be made in the current system for an easy transition from version .
• Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicare/Medicaid Claims.
• Assisted the IT team to develop service oriented architecture (SOA), and data warehouse system to utilize data mining for data analysis.
• Designed and developed Use Cases, Use Case Diagram, Activity Diagrams, Sequence Diagrams, Data Flow Diagrams using Object Oriented Design (OOD) concepts and UML using Rational Requisite Pro.
• Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies from Initiation to Deployment.
• Performed End to End testing for the member, provider and claims modules as per the MITA business process
• Worked with (ACS) X12 5010 and (ASC) X12 4010A including the various Claims Transactions such as: 837 (submit medical claims), 835 (medical claim payments), 270 (benefit/eligibility inquiry), 271 (benefit/eligibility response), 276 (claim status request), 277 (claim status notification), 820 (premium payments), and 834 (enrollment).
• Involved in the claims adjudication process of Facets.
• Worked on Facets extensions mapping attributes.
• Created Use Cases diagram and Activity diagram to depict the interaction between the various actors and the system in Rational Rose for the Business Use Case and System Use Case. Worked on FACETS batches like XPF and MMS to upload bulk data into the FACETS system through the HIPAA gateway by generating keyword files to enroll, modify or terminate providers and members Analysis of the data using SAS retrieving data MS Excel Sheets.
• Responsible for architecting integrated HIPAA,Medicare solutions, Facets.
• Documented the detailed business as well as technical requirements to upgrade the current system to 5010 transactions. Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches (membership, Billing, Provider, etc.).
• Involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837,835, 270, and 271. Experience with TriZetto Facets Application Groups: Claims Processing, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management.
• Develop Logical and Physical data models that capture current state/future state data elements and data flows using Erwin.
• Evaluated and analyzed EDI transaction sets 276/277 (Claim Status Request/Response), 270/271 (Eligibility Inquiry/Response), 837 (Claim Transaction) and 278 (Healthcare Service Review Information)
• Analyzed HIPAA 5010 related to 835, 837, 270, 271, 276 and 277 transactions (both inbound and outbound) and performed gap analysis between the 4010 and 5010.
• Worked with Source system Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying. Experience in configuration of claims adjudication systems, FACETS 4.51/4.71
• Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
• Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
• Completed a review of existing documentation for orders, referrals and reports and compared it to the clinical details needed for HIPPA 5010.
• Developed the project schedules, milestone tracking and resource allocation using MS Project. Developed timelines for project delivery and managed projects and resources to successful completion.
• Created, maintained and updated a weekly Detailed Milestone Report (DMR) for presentation to senior management, executives, business sponsors and Compliance officers on a weekly basis.
• Coordinated and liaised with the QA and UAT teams for bug and defect tracking, created test cases and assisted with test plans.
• Managed/modified the web interface for the support website including content management on a daily/weekly basis and interacting with the technical writers.
• Conducted Training sessions for users and compiled the User Manual.
• Provided the recommendation to adoptTest Driven Development (TDD) methodology for testing the business scenarios in the back-end.
• Create and track project plan using MS Project and ensure on-time and high quality deliverables to the client.
• Assign the front end development and QA tasks to the offshore team and get the requirements compliant deliverables from them for final customer delivery.

Environment: SQL Server, .NET, Windows XP, Informatica,, Facets 4.51/4.71, Requisite Pro, UML, SQL, Use Cases, Developer Notes, Share Point, HTML, Quality center, Load Runner, QTP, MS Visio, MS Excel, MS Project, MS PowerPoint, MS Word, MS Excel, iRise tool, Adobe Photoshop.

Confidential, Fall River, MA

Business Analyst

Responsibilities:

• Interacted with clients to gather all requirements to formulate business specifications and translate those into application functionality, decide when to advocate and when to compromise to arrive at a mutually acceptable solution.
• Served as the SME for supporting EDI transaction for Enrollment and Billing area. Evaluates business impact for any EDI integration with Trading Partners and Public Health Benefit Exchanges.
• Used Tibco application to manages Billing information, decisions, processes and applications in real-time with south coast.
• Conducted controlled brainstorming sessions with project focus groups for collecting business requirements through used stories based on the project scope on Agile Methodology.
• Worked at different stages of the Software Development Life Cycle (SDLC) with business users, developers, and stakeholders.
• Assisted the technical team in translating application functionality into application architecture and the production of a System Functionality document.
• Performed GAP analysis by understanding the AS-IS system and the TO-BE system by having discussions with the SMEs.
• Communicated the business directives, goals and needs to the technical team, and serve as client interface from managing user expectations and client satisfaction.
• Corrected and Updated the Requirements Traceability Matrix after completion of the UAT testing.
• Conducted training sessions of doctors and nurses on Electronic Data like Electronic Medical Record
• Involved in the full HIPAA compliance requirements and HL7 Standards.
• Worked with Member systems on the Enrollment and benefits validations and audits
• Worked as “Tech Support” for end users to assist them with Remedy and Test Director during UAT testing phase.
• Verified the functionalities of the application manually and analyzed Test Scripts to check if it has covered the functionalities, which need to be in compliance with rules set by FDA.
• Documented Test Plans that contains test scripts, test cases, test data and expected results for the User Acceptance testing

Environment: SQL Server, Web Services, HTML, Quality Center, Agile, JAD, Share point, Tibco

Confidential, Raleigh, NC

Business Analyst

Responsibilities:

• Studied existing business application and processes, current source system, collected end user requirements and suggested the improvised business process model.
• Analyzed the "As is" and "To be" system documents to show the current and proposed functionalities of the system using MS VISIO.
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Involved in defining and documenting the vision and scope of the warehousing project.
• Worked with ACES and Facets claims data for claims subject area, Enrollment and billing data for member/Subscriber, and Product subject areas.
• 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 for the attribute mapping purpose
• Conducted interviews with management team
• Conducted and participated in the JAD session with the SME's and project team members.
• Worked as a liaison between the business and technical side to convey the business needs to the system architects.
• Participated in weekly status meetings to present status and in corporate any digressions from the original scope.
• Designed Use Cases using UML and managed the entire functional requirements life cycle using SDLC.
• Created and managed project templates, Use Case project templates, requirement types and traceability relationships in Requisite Pro.
• Carried out a thorough target data model assessment and risk analysis.
• Involved in cross-functional teams, developing new ways to boost efficiency and delivering results in a fast changing environment to achieve company goals.
• Participated in the walkthroughs and meetings specifically for Claims and Membership modules.
• Coordinate with Development and Business team to develop high level Business and Technical documents.
• Worked with the clients on the verification process for the requirement phase documents
• Implemented Standardized process throughout the Software Development Life Cycle (SDLC).

Environment: Windows XP, UNIX, Facets, Rational Requisite Pro, MS Office, MS Visio, UML

Confidential, Chicago, IL

Business Analyst

Responsibilities:

• Gathered and documented User Requirements and Business Requirements (BRD) using MS Word & MS Visio.
• Developed process models and business process flows and also Designed the data mapping procedure as Data Analysis.
• Proposed and conducted Risk Management Process to discuss the critical issues with the process and to steps to be taken to reduce the critical factors involved posing treat to the business process.
• Analyzed HIPAA compliance against the new HIPAA 5010 version & ICD-10 codes
• Analyzed EDI transactions sets and also created new set of EDI Transaction using HIPAA 5010 principles.
• Conducted GAP Analysis for AS-IS & TO-BE process flow analysis of the business process.
• Defined the scope of the project to develop a prototype of the entire system.
• Created Requirement Traceability Matrix (RTM) for the changes requested by the stakeholders
• Facilitated and conducted Joint Application Development (JAD) Sessions for faster navigation of information among the team members and stakeholders and to discuss critical issues with the project.
• Proposed strategies for testing team guidelines in the quality center.
• Conducted data mapping of the extracts using Source System Subject Matter Expert (SME) along with SQL.

Environment: Windows XP,MS Office,MS Project, MS Excel, Quality Center, SQL Server, Facets 4.21, MS Project, SQL Server, MS Visio, Java, Unix, J2ee, XML, Rational ClearQuest, Rational ClearCase, Mainframes, GAP analysis and SWOT analysis.