SUMMARY

• Over 7 Years of experience in the Field of Healthcare Industry as an EDI/Business/QA Analyst. Knowledge & working experience in HIPAA standards, EDI, Implementation & Knowledge of HIPAA code sets, FACETS, ICD - 9 & ICD-10.
• Thorough understanding and hands-on working experience with standards for medical transactions like 820 (enrollment), 834 (premium payments), 835 (medical claims payments), 837 (medical claims), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), and 277 (claim status response).
• Knowledge of HIPAA standards, EDI (Electronic Data Interchange), Implementation and Knowledge of HIPAA code sets, ICD-9 and ICD-10.
• Skilled in developing various UML Diagrams including Use Case diagrams, Activity Diagrams, Data flow Diagrams, and Process Flow Diagrams, Sequence diagrams, State diagrams, and Class diagrams.
• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus. Experience in BPM in claim management.
• Expertise in writing EPICS and User Stories using INVEST Technique. Experienced in Story Decomposition.
• Experienced in managing Product Backlog and Sprint Backlog.
• Involved in Business Process Management (BPM) activities like Process Design, Process Monitoring, and Process Execution.
• Expertise in Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of FACETS.
• Developed SQL queries for data extraction, analysis and reporting.
• Efficient in MS Project/MS Excel for planning/status reporting/writing test scenarios.
• Well versed experience in all EDI transactions like 820, 834, 837 P, 835, 27x and conversion of .
• Dealt with the complexity of migrating from the ICD-9 set of diagnostic codes to ICD-10.
• 3 plus years of FACETS version upgrade implementation project and worked extensively on 820(Payment Processing), 837i (Institutional Claim), 837p (Professional Claims) and 834 (Enrollments).
• EDI applications to process Health Care transactions as per the HIPAA guidelines.
• Experienced in performing Gap analysis by identifying existing technologies, documenting the enhancements to meet the end-state requirements.
• Experience in conducting User Acceptance Testing (UAT), SWOT analysis, Risk Analysis and GAP analysis.
• Extensive experience in various types of testing including Functional, Regression, Integration, System, Security, Database, Smoke/Sanity, & End to End.
• Well-versed with ICD-9 and ICD-10 guidelines, conventions and rules.
• Ability to conduct RAD, JAD sessions and carry out the entire process on my own.
• Possess strong skill to start from scratch and complete the requirement writing, testing, and analyses process.
• Experienced as a Business Analyst in a role of responsibility encompassing Requirement Gathering, Decomposition and Analysis besides Quality Assurance.
• Experienced in creating Use Case documents highlighting basic flow & alternate flows for specific functionalities.
• Hands on experience with Production Support, monitoring and maintaining multiple Applications in Development and QA and Production Environments.
• Ability to handle multiple tasks & work independently as well as in a team, with strong analytical & problem-solving skills. A good team player with excellent communication and interpersonal skills.
• Experience with Medicare, Medicaid, & commercial insurances in HIPAA ANSI X12 4010, 5010 formats including 834,835, 837 for interfaces & images to clearinghouses/ trading partners applications.
• Strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10, analysis & compliance experience from payers, providers and exchanges perspective, with primary focus on Coordination of benefits.

TECHNICAL SKILLS

Testing/Management Tools: Quick TestPro(QTP), Rational, ALM, EDI

Defect Reporting Tools: Quality Center (ALM), Rational ClearQuest, Global Remedy

Software/Operating Systems: Windows XP/Vista/7/8, UNIX, MS Office, Visual Basic

Languages: SQL, HTML, XML

Databases: MS SQL Server, Oracle, MS Access

Web Servers: IIS, Web Sphere

PROFESSIONAL EXPERIENCE

Confidential - Nashville, TN

EDI/BA Analyst

Responsibilities:

• Identify and remediate consumer data issues related to health insurance exchange coverage
• Apply appropriate research & technical knowledge in order to resolve outstanding issues in a timely & accurate manner
• Understand and follow escalation criteria to forward complex cases
• Identify and solve customer information and process problems
• Apply triage, research, collaboration, and technical knowledge to resolve transaction and process issues
• Analysis of discrepancies in the eligibility reconciliation process for multiple stakeholders
• Responsible for continuous process improvement of the reconciliation process.
• Provide content to and for collaboration with training staff on training stakeholders on triaging transactions and the reconciliation process.
• Responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges and performing root cause analysis.
• Responsible for accomplishing business objectives by identifying & solving customer information & processing problems.
• Participated in triage, research, collaboration, and technical knowledge to resolve transaction and processing issues.
• Responsible for analysis of discrepancies in the eligibility reconciliation process for multiple stakeholders and continuous process improvement of the reconciliation process.
• Provide content to and for collaboration with training staff on training stakeholders on the transactions and the reconciliation process.
• Provide training on the transactions and on the reconciliation processes.
• Worked on Claims system on Member modules for data validation and applied FACETS.
• Maintains updated and expert knowledge of the TennCare
• Assist Application Processors and Document Intake Specialists
• Trained with internal process and policy training of new and existing employees
• Served as Team lead in absence of Team Lead and Insured the work was communicated and distributed efficiently.

Environment: MS Visio, SQL Server, Oracle, SOAP UI, Facets, EDI 820,, 834, 835, 837, ICD-9 & 10

Confidential, Fairfax, VA

EDI/Business Analyst

Responsibilities:

• Analyzed and resolved all EDI issues in processes and maintain accuracy in all inbound and outbound documents and perform troubleshoot on processes and analyze all errors.
• Worked in Scrum Teams, sometimes performing duties of Scrum Master and/or Product Owner to ensure requirement backlog was maintained and prioritized properly, communication was fluent among scrum teams, and possible road blocks were resolved for sprint completion.
• Gathered requirements for impacted system and business areas for ICD-10 and their needs to embrace the changes.
• Carried out Risk Assessment, GAP analysis and Impact Analysis for the conversion project.
• Took an active role in determining the process flows for the Premium Payment and other new Call Flow types that were assessed as necessary for the Marketplace Plans
• Involved in one-to-one interview sessions and JAD sessions with stakeholders, SME’s and business owners to discuss the scope of the conversion.
• Produced for transaction sets EDI 820, 834, 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy.
• Implemented Agile throughout various project phases.
• Upgrade implementation project and worked extensively on 820, 837i (Institutional Claim), 837p (Professional Claims) and 834 (Enrollments).
• Involved in up-gradation of 4010 transaction to 5010 by conducting Impact Analysis and Risk Assessment and worked on the mitigation plan to avoid the risks.
• Tracking and addressing the problems on timely manner encountered on Acknowledgement 997, Remittance Advice 835, & Eligibility Inquiry/Response 270/271.
• Performed General Equivalence Mapping (GEM) to assist in converting any ICD-9-CM-based application to ICD-10-CM/PCS. Involved with ICD10 implementation testing.
• Worked as a liaison among stakeholders both business and IT side in order to elicit, analyze, communicate and validate requirements for changes to business processes.
• Facilitated various JAD sessions with Business User Groups, SMEs, and IT Groups.
• Used INVEST Technique to write effective User Stories. Evaluated User Stories for Complexity, Priority, and Data Analysis.
• Decomposed EPICS into smaller User Stories to provide more clarity on each Story.
• Assisted in identifying project scope, to conform to the regulatory compliance related to X12 837 (I/P) and 835.
• Responsible for soliciting and eliciting requirements for conversions.
• Involved in creating Reports and Documents like Requirements Documents, and Management Plan, Issue/Alternatives documents, Project Summary and Plans with formats like PDF, HTML, Excel and Word.
• Prepared UML diagrams (Activity diagrams, Sequence Diagrams, Use case diagrams) for Extensions.
• Involved with reviewing defects reported from UAT efforts and analyzed for root cause and took actions based on the findings.
• Created Use Cases diagrams and Activity diagrams to depict the interaction between the various actors (system users) and the system in Rational Rose for the Business Use Case and System Use Case.
• Actively involved in UAT Testing. Created detailed UAT Test Plan document as a road map for UAT Testers.
• Identified the master file changes and builds needed to enable the 5010 format to be utilized.

Environment: HIPAA X12, Quality center, QTP, SOAP UI, MS Office, SQL, SQL Server, EDI - 820, 834, 835, ICD 10

Confidential, New York, NY

Sr. EDI Business System Analyst

Responsibilities:

• Gathered user requirements and created use case model following Agile methodology.
• Wrote user stories to capture requirements. Outlined Acceptance Criteria and Test Data for User Stories. Prioritized User Stories for each sprint.
• Knowledge of HIPAA/EDI X12 5012 healthcare-related file formats including 820, 834, 835, and 837.
• Responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges and performing root cause analysis.
• Tested ICD-9 to ICD-10 mapping process using GEMs (General Equivalency Mapping) crosswalk file.
• Performed testing on functional areas impacted by ICD-10 codes.
• Monitor all EDI file processing and perform troubleshoot on processes to resolve all transaction file issues and perform tests on same and provide support to all client issues and maintain documents for all operational procedures according to data requirements.
• Performed General Equivalence Mapping (GEM) to assist in converting any ICD-9-CM-based application to ICD-10-CM/PCS. Involved with ICD10 implementation testing.
• Maintain knowledge on working of all HIPPA EDI protocols and map all data for various ERPsystems and applications and perform audit on all EDI processes to maintain accuracy.
• Provided accurate estimate for each User Stories using Story Points.
• Conducted different session with State SMEs to integrate the CIS system with the States MMIS system
• Involved to validation and mapping of different data sets for claims and enrollment of Medicare and Medicaid members with the states data sets.
• Identify/analyze/root cause discrepancies between enrollment/eligibility files (834 transactions) and payment files (820 transactions)
• Used the mapping tools to map 4010 and 5010 transactions along with ICD 9 and ICD 10 codes, and validated the HIPAA Syntax.
• Facilitated many JAD Sessions and used Requisite Pro for activities such as requirements definition and organization.
• Followed up with the SME in every module to ensure that HIPPA guidelines are being followed.
• Involved in testing HIPAA Database, which incorporates all the HIPAA (Health Insurance Portability and Accountability Act) transaction sets.
• Tested data to check HIPPA- eligible & participation check for individual coverage.
• Worked on HIPAA Transactions according to the test scenarios such as 837/835/834 transactions
• Involved in creating test scripts & test data files for the HIPAA transaction based on the ANSI X12N HIPAA standards.
• Involved in preparing use cases and business flow diagrams for the applications using UML.
• Traced requirements to high level design, test cases and product requirements.
• Worked with project manager and other users and created work flow diagrams using MS Visio/UML.
• Co-authored change management control plan, Created risk analysis documents and created risk management plan.
• Maintained Traceability Matrix and Test Matrix.
• Created and maintainedSQL Queries for back-end testing.
• Worked on method 1 template to cover all document deliverables & modified document deliverables for QA team.

Environment: VB Script, Java, J2EE, C+, Edifecs Specbuilder, SharePoint, SQL, SSRS, SQL Server, Quality Center (ALM), MS Office, Visio, XML, X12, EDI 820,, 834, 835, 837, ICD-10, ICD-9

Confidential, Iselin, NJ

EDI Business Analyst/QA Analyst

Responsibilities:

• Created test plans and test procedure templates and guidelines to be used by the QA team
• Collaborated with Offshore and Onshore QA resources.
• Responsible for assigning QA resources across Projects.
• Wrote test cases and tested Provider and Payor UI for healthcare.gov (marketplace).
• Involved in the testing of Regression Test Cases by QTP scripting.
• Actively involved in Source Driven Testing, Target Driven Testing, Business Cycle Testing, Business Scenario Testing and Data Integration Testing.
• Worked on different database like Oracle to check the data consistency.
• Involved in testing of various SaaS, web related and SOA based components of application.
• Involved in the Production Validation for each Release Project and also took part in post-production support.
• Wrote complex SQL queries on SQL Server were used to test and validate test data.
• Lead lessons learned sessions after each releases
• Participated in cross functional teams to developer a comprehensive functional and systems level solution test including cross functional review for such plans.
• Created EDI Export and Import processes and work with EDI Trading Partners, Payers or Vendors.
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet portals. This includes HIPAA 4010; 834, 837, 835. Prepared files for validation for EDI transactions, 834, 835, and 837.
• Provided healthcare provider problem resolution. Work as a medical coding SME, including ICD-9, HCPCS; Procedures and diagnosis testing
• Worked on 837 and 835 projects, including syntax and business rules for X12 HIPAA 4010 and 5010 validation for loops, segments, elements, qualifiers and code sets.
• Worked on Facets Claims Processing (Dental, Medial) and Subscriber/Member (Eligibility Inquiry, Enrollment) application groups.
• Wrote detailed specs to validate data updated in backend Facets tables when ICD 10 codes were used instead of ICD 9 codes.
• Wrote detailed specs to validate data updated in backend Facets tables when ICD 10 codes were used instead of ICD 9 codes.
• Involved in creating mappings for the conversion ofEDI X12 transactions code sets version and translation of ICD 9 codes into ICD 10 codes and Performed User Acceptance Testing (UAT) with the Business.
• Performed Functional, Integration, System Integration, Regression Testing.
• Extensively used complex SQL queries to extract data and also manipulate data during testing.
• Designed Test cases, test plan creation and Companion Guide development from stage to production
• Used Quality Center for defect tracking & reporting. Also used SharePoint for document sharing and defect tracking.
• Processed Testing files using Web services and make sure it’s converted into standard XML.
• Conducted Back-End Testing and Regression Testing using various phases of the application
• Completed several HIPAA 4010 and 5010 Projects, included Medicaid and Commercial entities. Projects include claims and enrollment testing as well as NPI and medical coding and ICD-9 EDI testing.

Environment: Quality Center, MS Visio, SQL Server, Oracle, SOAP UI, Facets, EDI 820,, 834, 835, 837, ICD-9 & 10

Confidential, New Brunswick, NJ

EDI Analyst

Responsibilities:

• Developed the QA strategy (what, how & when to test). Worked on timelines for deliverables as BA.
• Involved in the development of the test plan.
• Reviewed Test Plans, requirement documents and design documents to provide QA Sign off.
• Involved in writing Test Plan and implementing numerous test cases and scripts for the functional and GUI testing of the EpicRx® In Confidential t Pharmacy System.
• Worked on EDI transactions: 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.
• Created process flows and analyzed end to end processes.
• Conducted JAD sessions and requirement review sessions for EDI transactions, specially 834, and 837.
• Created projects using Quality Center. Created baseline scripts for Regression testing.
• Manually performed Front and End to End testing. Performed Positive/Negative testing manually.
• Performed Functionality, Front end, Negative and Positive using Manual testing.
• Performed Back End testing manually using SQL to ensure the data integrity of the application.
• Performed User Acceptance Testing before deployment.
• Involved in Configuration Testing. Developed Test Plan, Master Test Strategy, Test Agreement, and Test Scripts.
• Created Documents, this includes the Test Summary Results, Risk Assess and Testing Signoff.
• Performed database testing using SQL. Performed database integrity check using SQL.
• Performed User Acceptance Testing.
• Worked on Rational Clear Quest for defect submission and tracking.
• Actively participated in enhancement meetings.
• Conducted Security, Performance and Regression testing during the various phases of the development.
• Investigated software bugs and interacted with developers to resolve technical issues using Quality Center.

Environment: Manual Testing, Quality Center, SQL,Oracle, Windows, ASP, IE, EDI 820, 834, 835