SUMMARY:

• Around six years of professional experience as EDI Analyst with expertise in Software Development Life Cycle (SDLC) and Business Process Reengineering in Health Care Sector with prime focus on claims adjudication, provider, eligibility and prior authorization for Medicaid and Medicare programs.
• Experience in all phases of software development life cycle (SDLC), including Requirement gathering and documentation, Analysis and Design, Quality Assurance, Testing and End user support working as Business Analyst mainly in Healthcare sector.
• Experience in developing detailed functional specs through JAD sessions, interviews, on site meetings with business users and development team.
• Documentation: BRD (Business Requirement Document), FRD (Functional Requirement Document) and Non - functional Requirement Document.
• Experience with PMO techniques such as Rational Unified Process (RUP), Agile & Waterfall life cycle.
• Have extensive knowledge in Insurance products like HMO, PPO, POS and HIPAA and Regulations.
• Worked on Affordable Care Act (ACA), FFM/FFE
• Worked on requirement change management to upgrade integration process of revised warehouse system and involved in planning, analysis, UX design, development and testing.
• In depth knowledge of Requirements Traceability Matrix (RTM).
• Extensive experience in developing use cases, creating screen mock ups, conducting GAP analysis, SWOT Analysis, Report Requirement Specification and Risk Analysis.
• Strong knowledge of EDI Claims, member enrollment, Eligibility as well as ICD9 and ICD10 conversion.
• Experienced in various Healthcare areas like Enrollment, Benefits, Claims, Medicare, and implementation of HIPAA key EDI (ANSI X12) transactions.
• Well versed experience in all EDI transactions like 834, 820, 837 P, 835, 27x and conversion of 4010 to 5010.
• Developed expertise in claims processing and direct clearinghouse for claim processing and billing to insurances companies nationwide all on a SQL backend.
• Involved in testing QNXT Member, Provider, Claims Processing (with proper ICD - 9 and ICD - 10 and HCPCS/CPT codes), and Utilization Management, Contracts, and Benefits modules.
• Good Knowledge of Medicare, Medicaid, claim process and Pharmacy Benefit Management (PBM).
• Well versed in all EDI ANSI X12 files, such as 834, 820, 837, 835, etc.
• Expertise in performing Back End Testing by writing SQL queries for the purpose of database integrity in MS SQL Server.
• Familiarity with current industry standards such as HIPPA guidelines (4010 & 5010) and EDI Transaction. Extensive experience in EDI implementations (Real and Batch Processing).Excellent experience in EDI transaction like 270, 271, 276, 835, 837
• Extensive experience in Healthcare systems: FACETS, QNXT, Medicare part A, B, C, D and Medicaid system.
• Strong skills in back-end testing using SQL Queries
• Expertise in impact analysis on the key application systems (claims processing, reporting, payments) and business process of health insurance companies.
• Writing Manuals (System guides, training material for business users and Deployment guides).
• Working experience in a cross-functional team environment/different geographical locations teams.
• Experience with HIPAA compliance (4010 & 5010) and Healthcare systems
• Experience with health care Systems: FACETS.

TECHNICAL SKILLS:

Requirement tools: IBM doors, SharePoint, requisite pro

Forecasting tools: HUMMER, EXCEL

Financial Platform: Bloomberg Terminal

UML tools: Visio, EP, Rose

Works flow tools: JIRA, Clear Quest, Share point

Database: Oracle, SQL Server

Testing tools: Bugzilla, HP ALM

Healthcare Tools and modules: FACETS, McKesson, QNXT configuration, Billing, Claims

Other tools: MS project

PROFESSIONAL EXPERIENCE:

Confidential, Mclean, VA

EDI Analyst

Responsibilities:

• Responsible for preparing the Software Requirement Specifications (SRS) document, Standard Operating Procedures (SOPs) for 1095A project.
• Involved in daily scrums and writing meeting notes.
• Experienced in running parallel BUU project as lead to Submit Updated BUU template.
• Experienced in full process of updated form submitted to OPERA.
• Responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges and performing root cause analysis.
• Performed manual testing by building 837 claims, converting them into EDI file, uploading them into mainframe region and doing error resolution.
• Responsible for projects involving the integration of the new Affordable Care Act rules into the current Medicaid systems processing for Washington DC, whereby saving time and resources for the state
• Worked collaboratively with project team including development, business analyst, and QA resources in Affordable Care Act - FFM Obama Care - Center for Medicare and Medicaid (CMS), Active participant in Eligibility and Enrollment EE modules
• Experience working in ANSI x12 837-835 EDI Transaction.
• Involved in configuration of Member and Provider Module in QNXT.
• Managed the testing and verification of HIPAA standard transactions, and EDI messages (837),
• Involved in several deep dives to find a solution for road blocks.
• Involved in testing the Web APIs that fetch end user data for Federal Facilitated Marketplace Enrollment (Affordable Care Act/"Obama Care")
• Involved in creating architecture view/BRD/FSD for the ICDN 10 mapping for Affordable Care Act (ACA) and also well versed with ICD10, Facets.
• Skilled in knowledge of HICS to close out cases. (Hospital Incident command system).
• Involved in training new EDI analyst on project with one on one session and using power point slides.
• Troubleshoot any problems found within QNXT and when testing the SQL data database while validating the business rule.
• Actively involved in testing ANSI X12 834 EDI- Benefit Enrollment and ANSI X12 837EDI Health Care Claim EDI
• Gathered and documented Requirements on New Obama Care Health Insurance exchange pool and Laws governing the implementation.
• Extensively used SQL queries for data validation in both Medicare/Medicaid and commercial HIX
• Expert in reporting bugs using Bugzilla and HP ALM.
• Validate the date from EDI transaction.
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to follow ANSI X12 4010 formats including 270 Eligibility/Benefit Inquiry, 271 Eligibility/Benefit Information, 276 Claim Status Request, 277 Claim Status Response, 810 Invoice, 820 Payment Order/Remittance Advice, 834 Benefit Enrollment, 835 Remittance Advice and 837 Claims and Encounter, to meet and exceed HIPAA requirements set forth by the federal government.
• Performed Backend testing by extensively using SQL queries to verify the integrity of the database.
• Create internal reports using Dashboard and basic SQL queries in the tool to track activities of the teams.
• Incorporated FDA guidelines (21CFR) and HIPAA (Health Insurance Portability and Accountability Act).

Environment: - MS Office, JIRA, Confluence, Remedy, Oracle 10g, Oracle Forms, Share Point, ROAR, PAP, TOAD, HP ALM

EDI Analyst/ Business System Analyst

Responsibilities:

• Analyze change requirements for Providers, Contracts and Claims processing modules configuration in QNXTsystem for Medicaid and Medicare Advantage for AL, FL, GA, IL (ICP &MMAI), IN, MD, MS, NC, SC, PA and TN plans.
• Created Use Case diagrams using UML and Business Process Models using MS-Visio.
• Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems.
• Responsible for Business Process Management (BPM) for development of various projects.
• Created Data Mapping documents for data transfer from Claims Processing System to EDW (Enterprise Data Warehouse)
• Developed Use Cases, Sequence Diagrams, Activity Diagrams and Class Diagrams.
• ICD 10(Affordable Care Act): Involved in performing gap analysis, mapping, and gathering requirement for the upgrade of ICD9 to ICD 10.
• Analyzed the impacts of HIPPA 5010 project on inbound 837 claims.
• Performed manual testing by building 837 claims, converting them into EDI file, uploading them into mainframe region and doing error resolution & testing for 5010 requirements & NPI crosswalk.
• Executed SQL statements to check if the data integrity has been maintained.
• Worked on configuration of Providers and Contract - Provider demographics, Provider Contract and Contract Info using QNXT.
• Verifies the plan's pricing and illegibility of policy holders in regards to ACA (Affordable Care Act).
• Created and maintained SQL scripts and UNIX as a part for back-end testing on the oracle database.
• Used provider-credentialing module in QNXT to change the status of the provider.
• Conducted Functional, System, Integration, Regression, UAT and Smoke Testing of Public welfare Public Sector application with specific focus on Affordable Care Act (Obama Care), eligibility application.
• Executed SQL queries to test the database for records that detect and submit functional acknowledgement and remittance advice in the claims application.
• Recommend ways and workarounds for HIPAA 5010 (EDI X12 837,834,278,270) upgrades.
• Worked with providers and Medicare or Medicaid entities to validate EDI transaction sets or Internet web portals. This includes HIPAA 4010; 837, 835, 270/271, and others.
• Involved in testing of FACETS Implementation, involve in end-to-end testing of FACETS Claims Processing module, Membership and benefits.
• Identified and logged defects while using SQL for DB verification as part of QA Analysis for development team.
• Involved in Data Analysis for the data warehouse and data mart system for the Configuration of Benefits with Members.
• Worked on affiliating provider with new groups & service locations & adding required contracts, Plan affiliations using QNXT.
• Worked on EDI Transactions (837/834/835/276/277 ) for Verification and Validation as part of System Testing.
• Validated data integrity and quality checks during ETL, using SQL queries.
• Conducted series of meetings, joint sessions, and interviews with the health insurance experts, operations experts, subscribers, and technical people to properly identify and understand the problems with claims management
• Performed Data Mapping to map the EDI 834 data to XML.
• Worked on pharmacy benefit management (PBM) systems to make use of our existing web applications that provide pharmacy/Rx related member functionality
• Wrote and executed complex SQL queries to validate successful data migration and transformation.
• Performed Gap Analysis for 5010 enhancement using the TR3 implementation guides, Washington Publications and side-by-side HIPAA 4010 to 5010 guides provided by CMS (Center for Medicare & Medicaid Services).
• Define and develop process flow charts for all EDI applications
• Analyze EDI -X12 data elements captured by the existing system to validate it against the data elements required for new system.
• Worked on the PBM’s Medical Claim Data feed, Data Dictionary layout and definition, Eligibility files and various File Transfer
• Assisting the project manager in creating detailed project plans and scheduling and tracking project timelines.
• Tested the HIPPA EDI 834, 837/835 transactions according to test scenarios and verify the data on different modules.
• Work closely with Health Insurance Trading Partners and with other contractor companies to ensure the quality of the cases.
• Drafted the Physical Data Mapping document for the data flow from Facets to the data warehouse.
• Responsible for Business Process Management (BPM) for development of various projects.
• Incorporated FDA guidelines (21CFR) and HIPAA (Health Insurance Portability and Accountability Act).
• 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.
• Drafted the Physical Data Mapping document for the data flow from Facets to the data warehouse.
• Tested the ANSI X12 Version 5010 / EDI transactions (HIPAA) like 837P, 837I, and 837D.

Environment: - ANSI X12 834,837,270,271 EDI transactions, Oracle, HTML, XML, SOAP UI, TOAD, WSDL,MS Office, MS Project, MS Visio, Quality Center

Business System Analyst

Responsibilities:

• Prepared the Business requirement Document (BRD) and Functional requirement document (FRD) for the enhancement of the existing services.
• Developed Data Mapping Document (DMD) using Informatica 9.0.1, Oracle 11g for developers and testers.
• Analyzed and resolved the ongoing issues with the Data Warehouse and the upstream and downstream applications.
• Worked on developing the business requirement and use cases for QNXT batch process, automating the billing entities and commission process.
• Wrote complex SQL queries during DB Validations.
• Supported testing efforts and production implementation for State of Ohio System Redesign, related to ACA (Affordable Care Act) (Obama Care) mandates.
• Tested the ANSI X12 Version 5010 / EDI transactions (HIPAA) mainly on 837 Professional and Institutional Claims
• Conducted Backend testing, writing extensive SQL queries.
• Worked on Pharmacy Benefit Management (PBM) System and Health Insurance in the United States, in depth knowledge of Health Care Laws and ICD Standards.
• 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.
• Involved in writing complex SQL queries to extract the data from Oracle database
• Coordinated the upgrade of EDI Transaction Sets 837P, 835 and 834 to HIPAA compliance.
• Involved in claim adjudication process of facets application.
• Create, analyze and test Summary of Benefits and Coverage (SBCs) for all market segments, Consumer, Small group, Midsize, Public Sector and National, under the Affordable Care Act (Obama Care) to help employers and individuals better understand their coverage options.
• Wrote SQL queries to test data
• Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system).
• Experience working with 2 of the Major Application that includes QNXT (For Claim Processing) and e-CW (EMR, Patient Portal, Accounts, Providers.)
• Worked on the PBM’s Medical Claim Data feed, Data Dictionary layout and definition, Eligibility files and various File Transfer Specifications.
• Used Facets for various health insurance areas such as enrollment, member, Products and other Facets related modules
• Executed SQL queries to retrieve data from data bases to validate data mapping.
• Work with solutions/delivery teams to implement data quality processes during acquisition, ETL, and delivery stages for Business Intelligence solutions and changes to Data Warehouses.
• Worked with EDI and verify if received, translated, and posted Institutional/Professional ERA output to Stratus.
• Experiences working in ANSI X12 837-835 EDI Transaction.
• Involved in Validation of HIPAA/EDI for 270/271, 276/277, 837, 837i and 835 claims used for professional, Institutional and Dental billings by Writing Test cases, Test Plans
• Successfully worked on Pharmacy Claims processing chiefly: Direct Claims, Retail Claims and Card/Mail Order Claims developing a complete understanding of Pharmacy Claims Gateway.
• Did gap analysis for HIPAA 4010 837P and 835 transactions and HIPAA 5010 837P and 835 transactions.
• In depth knowledge of Health Insurance process, Claims, HIPAA & its approved transaction codes.
• Analyze EDI -X12 data elements captured by the existing system to validate it against the data elements required for new system
• Utilized Agile Methodology to configure and develop process, standards and procedures.
• Did GAP analysis and Impact analysis for the facets up gradation system 4.71 to 5.01.
• Attended daily SCRUM and guided QA and Developer regarding the defects, Technical Specification Documents and Mapping Documents.

Environment: Agile, SharePoint, MS Visio, MS project, XML, UML, Oracle, SQL, MS SQL Server, MS Office

EDI Business Analyst

Responsibilities:

• Under general direction, gathered, defined and documented highly complex business requirements for NPI crosswalk.
• Review and understand the claims process and complex requirements for the enhancement of the current system created under the Requirement Specification Documents after conducting interviews with End Users, JAD Sessions and analyzed their current systems.
• Writing the General System Design Documents that demonstrate current and proposed/solution business design and changes to the current Legacy System.
• Analysis and Design of existing transaction sets, and modification of these transaction sets to ensure HIPAA compliance.
• Tested HIPAA EDI Transactions such as 837, 997, 277, in various claims validation processes.
• Involved in validation of HIPAA for EDI 837/I/P.
• Designed and developed Use Cases using UML and Business Process Modeling. Consulted with healthcare insurance company to develop conversion specifications for other insurance Coordination of Benefits (including Medicare).
• Worked extensively on Business Requirements, Functional Specification, Data-Integration, Data Mapping, and Data Warehouse access using SQL and Crystal Reports, ETL process, use cases modeling (UML) using MS Office (Word, Excel, Access, Visio) and dashboards
• Did gap analysis between ICD 9 and ICD 10.
• Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.
• Involved in HIPAA assessments and HIPAA X12 EDI transactions mapping and identified the requirements and involved in finalizing the system requirements.
• Develop business requirements for new projects involving federal and state government initiatives regarding Health Insurance Exchanges (HIX).
• Documented complex Business requirements and made process flow diagram for the 837, 270/271, 276/277 & 835 Remittance transactions as per the 4010 to 5010 implementation for the Medicaid claim processing system enhancement.
• Worked on solving the errors of EDI 834 load to Facets through MMS.
• Worked on Data Mapping documents explaining flow of data from one-to-another table for the system enhancement purpose required by HIPAA 5010 implementation.
• Serve as liaison between State-Based Exchanges (SBEs) contacts and health insurance issuers regarding state policy and development.
• Validate EDI Claim Process according to HIPAA compliance
• Facilitated various brainstorming, requirement gathering sessions, and provided training on HIPAA Compliance, HIPAA Standard transactions and current version of X12 HIPAA 4010A1.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets, ICD-9, ICD-10 coding and HL7.
• Verify health insurance benefits, collect co-pays, and assist with patient inquiries.
• Work with technical staff and business users to problem-solve and identify workable solutions.
• Maintained Requirements Traceability Matrix (RTM) throughout the project.
• Conducted meeting and facilitate Joint Application Development (JAD) sessions with different users and internal stakeholders for defining business requirements and User Acceptance Testing (UAT) standards.
• Developed Companion Guides for the business users and managed User Acceptance Test (UAT) for business users to explain Mainframe CICS screens for claim processing.
• Answer questions and inquiries about system functionality and provide user support, including training, help and instructions for the Trading Partner Application used by Nebraska Medicaid.
• Worked on As-Is To-Be analysis of ICD 9 for the new qualifiers used in the 837 claims for the diagnosis and procedure/HCPCS codes.

Environment: - Clear Quest, JIRA, Microsoft Office, MS Project, SQL and Microsoft Visio

Business System Analyst

Responsibilities:

• Worked with the project manager for planning and organizing the project activities, and in communicating with other business center mangers and stakeholders of the project.
• Followed Agile/Scrum Methodology for Software Development Life cycle.
• Gap Analysis of client requirements, generated workflow process, flow charts and relevant artifacts.
• Ensure quality of claims, and provider data acquired from health insurance plans.
• Acted as liaison to the physicians, nurses, and professional staff incorporating business and clinical requirements into PQRS and other applications.
• Gathered requirements for Claim Based Reporting, Registry Based Reporting, and EHR based Reporting, Lab Data Reporting and Group Practice based Reporting for PQRS system.
• Submitted claims to insurances and Processed payment from insurance companies.,
• Worked with EDI team to assure the collection and transfer of accurate data in order to report PQRS data.
• Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.
• Followed the complete 1095-A cycle, from assigning a case to closing the case in Health Insurance Caseworks
• Designed Use Cases using UML and managed the entire functional requirements life cycle using Agile/Scrum.
• Involved in writing and implementation of the test plan, and various test cases for UAT.
• Provided overall project management to multiple projects successfully completing them on-schedule and on-budget.
• Prepared the Business Workflow using MS-Visio with input, output, and Pre and Post conditions.
• Used SharePoint for tacking Change Process Requests, adding/updating/modifying Requirement Documents.
• Used Rally for creating user stories, tracking status of project for faster and improved quality.

Environment: - Clear Quest, MS Office, Oracle Identity and Access management, SQL, TOAD, MS Share Point