PROFESSIONAL SUMMARY:

• Over 9 years of comprehensive experience in IT industry working as a Facets and EDI Systems Analyst in HealthCare Industry. Extensive noledge of ICD - 10, HIPAA and other Healthcare related business experience. Extended expertise in requirement gathering, documentation, UML diagrams, Business Intelligence, Documentation UAT. Having deep understanding of testing technology with focus on delivering business solutions;
• Good noledge of business analysis methodologies and iterative software development lifecycle using Rational unified process. Thorough noledge of implementing RUP in all four phases of a project.
• Experience in working in domain like Healthcare and IT.
• Strong work experience in tools like TOAD SQL Developer, SQL Navigator SQLPLUS.
• Involved in claims adjudication process of FACETS application.
• Expertise in designing and developing test plans.
• Assisted QA’s and end user to understand functionality and technical requirements.
• Strong noledge on HIPAA standards, ICD9/ICD10, EDI transactions and Medicare and Medicaid Services.
• Experience in working with GAP analysis between HIPPA Gateway 4010A1 and HIPPA Gateway 5010 for Medical Medicare members (MMIS).
• Ability to organize document and track changes and defects using teh rational clear quest and archive change request in clear case.
• Good communication skills with strong analytical, qualitative, quantitative and problem-solving skills.
• Expert in current industry standards such as Medicaid, Medicare, FACETS, HIPAA, EDI & other supporting applications for insurance providers and service providers.
• Excellent understanding of software development life cycle.
• Implemented EDI transaction 834 for medical members
• Expertise in interacting with teh client and teh IT department and thus acted a s a facilitator between both clients and IT department to resolve conflicts through co-ordination, negotiation and interpersonal skills.
• Worked on operators in PL/SQL like union, union all intersect and minus
• Experience with Medicare and Medicaid (MMIS) claims processing, Medicaid billing, Medicare and eligibility verification and care management.
• Knowledge on Relational database management system (RDBMS).
• FACETS support systems were used to enable inbound/outbound HIPAA EDI transaction in support of HIPAA 834 transactions.
• Experience with enrollment transactions.
• Expertise to design Business Requirement Specification (BRD), System Requirement Specification (SRS), User Requirement Specification (URS), Use Cases Document, Work Breakdown Document (WBD), and Requirement Traceability Matrix (RTM)
• Assisted in performing various types of testing like Functional Testing, Unit testing, Integration Testing, System Testing, Performance Testing, Regression Testing, User Experience with premium payment transactions
• Knowledge of X12 standards development processes
• Excellent communication and writing skills and adept at facilitating walkthrough and sessions.
• Externally certified AHM250(PAHM)
• CSTE, CSQA & ISTQB certified
• Extensive noledge on Healthcare domain
• Expertise in Agile, V&V and Waterfall Test Methodologies.
• Expertise in creating and developing Test Strategy, TestPlan, Test Cases,Test Scripts, Test Summary Reports and Defect Reports
• Expertise in conducting Functional Testing, System Integration Testing, Database Testing, Regression Testing, End-To-End Testing of SAP, Mainframe and WEB Applications (Includes Java and .Net).
• Strong experience on SOAP UI
• Experienced inTracking DefectsandCreating reportsusingJIRA, Quality Center and ALM (Application Lifecycle Management)
• Experience in developing UATs, Test Summary Report and Traceability Matrix
• Good noledge in Software Development Life Cycle (SDLC), Software Testing Life Cycle (STLC) and Test Methodologies

TECHNICAL SKILLS:

Technology: Facets, Informatica, Teradata, Angular JS, JavaScript

Domain / Skills: Health Care - Facets (Various Modules), EDI (83x / 27x transactions)Edifecs, ClarEDI, ICD-10, HIPAA

Tools: ALM, Quality Center, Clear Quest, QTP, JIRA

Scripting Languages: HTML5, CSS3, JavaScript, VB Script

Operating System: Windows XP/Vista/7

Database: Oracle 11i, SQL Server, MS Access, mongo DB

Microsoft Office: Excel, Word, Power point

PROFESSIONAL EXPERIENCE:

Confidential

Responsibilities:

• Responsible for collecting and analyzing Business Requirements, Process Modeling and preparation of Functional Design Specifications by employing use case scenarios, sequence diagrams.
• Created use cases, activity diagrams and process diagrams using Microsoft Visio.
• Gatheird requirements for HIPAA 5010 migration.
• Followed teh Business Rules, and ensured dat HIPAA compliant Rules are followed to display minimum benefit information dat teh Provider is required to pass on teh EDI transactions.
• Managed teh privacy and security environments of healthcare data dat was governed by HIPAA and other government mandates.
• Validated teh EDI 834-enrollment transactions.
• Prepared high level and detailed system requirements documents for teh application
• Analyzed ICD-10 standards for 834 transactions, related to providers, payers, subscribers and other related entities.
• Identified teh requirements for accommodating ICD-10 standards for 834 transactions and captured these requirements to create BRD.
• Participated in teh walkthroughs and meetings specifically for modules.
• Validated teh process flow for “AS IS” system and understand where exactly ICD-9 Procedural and Diagnosis Codes are used.
• Translated teh requirements gatheird during interview with SME’s and created process flow diagram based on teh requirement captured.
• Identified various points of integration among teh new and existing applications and required integration with other IT components.
• Good experience with FACETS Claims Adjudication.
• Develop ad-hoc reports on data from teh other applications on claims, benefit plan, provider and financials using Business Objects Enterprise XI, Desk Intelligence, SQL Developer, MS Access and Excel, SQL, and Oracle.
• Extract claims detail including ICD-10, procedure codes, diagnosis codes; member eligibility data for analysis, claim overpayment projects.
• Validate data analysis and extractions against FACETS front-end system.
• Manage analysis; FACETS claims analysis and ad-hoc reports.
• CompileSQLQueries to validate teh data integration between teh various Database tables.
• Involved in mapping data from different EDI files onto database using different routing transformations.
• Performed gap analysis for migration of HIPAA transactions from 4010 standard versions to 5010 standard versions.
• Work together with teh architects and team responsible for supporting rules processing tools during teh project to assist with teh required support.
• Work closely with teh business team, development team and teh Quality Assurance team to ensure dat desired functionalities have been achieved by teh application
• Assisted teh project with Change requests and held responsible for weekly changes to teh applications. Maintained and recorded teh ticket numbers for request changes on CR manager tool.
• Involved in testing Facets Member/Subscriber, Billing, Medical Plan, Dental Plan modules.
• Provide business and technical suggestions and recommendations during teh project life cycle.

Confidential

Responsibilities:

• Worked in Enrollment, renewals and Claims module for HMO project. This includes - Configuration testing, ITS claims, and External systems such as DST, Argus, UM etc…
• Worked with a cross functional and diverse team of business users and developers to enable accurate communication of requirements and ensure consensus for BRD and FRD and business docs.
• Analyzed data and created reports using SQL queries for all issued Action Items. Performed teh Gap Analysis to find teh existing gap between teh HIPAA 4010 and HIPAA 5010 EDI transactions.
• Involved in teh testing of web portal of New MMIS system
• Acted as a liaison and conducted meetings, JAD sessions and presentations with teh teams
• Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio.
• Worked on teh existing mainframe system, documented teh system requirements and came up with Use Cases from teh analysis.
• Performed Migration and Validation per SDLC standards. Interacted with teh Test Team and reviewed Test Plans and Cases.
• Assisted in Regression Test, System Test, and UAT.
• Worked with teh business/functional unit to assist in teh development, documentation, and analysis of functional and technical requirements within FACETS

Confidential

Responsibilities:

• Collected weekly status reports to ensure dat all deliverables are met on time and on schedule.
• ConductedJAD sessionwith management, senior management executives, and other stakeholders for open and pending issues on teh development of teh project.
• CreatedUse Casesfrom teh list of requirements and prepared use case diagrams using Rational Rose.
• Conducted Web Meetings with Off-Shore team members to ensure dat everybody is on teh same page.
• Managed and developed EDI specifications, for data feeds and mappings for integration between various systems, to followANSI X12 4010formats including270 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 andexceed HIPAA requirements set forth by teh federal government.
• Performed EDI activities dat comply with government reporting requirements and standards.
• Overseeing and maintaining teh EDI inquiry problem database including teh evaluation of problems or issues through resolution.
• Perform analysis on EDI 270/271,837, ANSI-12XN etc. HIPPA code sets for Medicaid health plan members.
• Assisted in tailoring teh views and applets for opportunities, accounts and contacts etc., as per teh client requirements.
• Worked on FACETS up-gradation project (from version )
• Validated teh member information of different groups against FACETS during teh batch enrollment.
• Set up teh subscriber/member Group, Sub Group, Plan, Product etc. using GUI application and halp of batch process.
• Entering Claims and Customer Service Tasks into teh FACETS.
• Further analysis of teh requirements was performed using rational rose through teh use of sequence, entity relationship diagram and class diagram.
• Conducting regular audits of EDI transaction of Medicaid members to determine accuracy and areas for improvement and maintaining EDI maps and business rules for HIPPA validation software.
• Responsible for creating and reviewing business requirements, functional specification project schedules, documentation and test plans.
• Coordinated with project managers to resolve risk issues and ensure compliance of security system -related to teh HIPPA.
• Assisted testing teams in creating test scripts and UAT to check teh security of teh CRM system to improve stability and halp better customer satisfaction.
• Closely interacted with designers and software developers to understand application functionality, navigational flow and updated them about end user sentiments.
• Assisted in teh improvement of teh CRM system of teh organization by carrying out JAD Sessions to enhance usability and functionality of teh system.
• Extracted theBusinessRequirementsfrom teh Business Users and documented it for teh developers following theHIPAA guidelines by conductingJADsessions and Interviews.
• Worked Extensively with Inbound837I and837 P and835(Out bounds) claims processing systems.
• Used Query Analyzer, Execution Plan to optimize SQL Queries.
• Interacted with client and teh Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.

Confidential

Responsibilities:

• Maintained clear understanding of project goals among stakeholders by conducting walkthroughs and meetings involving various leads from BA, Development, QA and Technical Support teams.
• Facilitated Joint Application Development (JAD) Sessions for communication and managed Net Meetings.
• Conducted meeting with teh EDI team and other stakeholders team members to discuss teh requirements.
• Prepared gap analysis document for each transaction.
• Analyzed “AS IS” and “TO BE” scenarios, designed new process flows and documented teh business process and various business scenarios.
• Wrote use cases and relevant UML diagrams such as Use Cases, Activity and Sequence diagrams.
• Wrote high level and low level business requirements for teh project.
• Developed and conducted statewideHIPAA 5010 and ICD-10 awareness program for all AMFC staff in teh Philadelphia Campus.
• Worked on analysis of FACETS claims processing system and gatheird requirements to comply with HIPAA 5010 requirements.
• Presented teh process improvement solutions to teh client, performed Project Management Office (PMO) activities.
• Worked closely with teh business team, development team and teh quality assurance team to ensure dat requirements are understood as intended in order to achieve teh desired output.
• Participating in all facets of teh standard project life cycle and ensured smooth transition of projects to production support

Confidential

Responsibilities:

• Leads joint application design requirements and solution sessions across IT teams
• Maintain and develops documentation as part of defect resolution and change management.
• Perform peer review of design documentation
• Provides subject matter expertise to halp identify impacts of system design
• Demonstrates s high level understanding of how health insurance business works
• Perform source to target mapping efforts for multiple health care records to ensure source system data is properly matched/identified for further processing.
• Work with data architects, data modelers and developers to ensure accuracy with data mapping. Source to target mapping(STTM) expertise.
• Assure teh integrity of project data, including data extraction, storage, manipulation, processing and analysis.
• Perform data profiling and detailed data analysis of source systems and target solutions.
• Perform peer review of design documentation.
• Possesses and applies a broad range of expertise of principals, practices and procedures of particular business function to teh completion of complex assignments.

Confidential

Responsibilities:

• Understanding teh Business requirements and case study.
• Preparing Test design and creating test data.
• Executing test cases.
• Performed System Integration Testing for IFP SIT Project.
• Schedule teh Batch jobs/Interface jobs in Tidal application
• Preparation of teh KT document for teh new requirements
• Regular interactions and reporting teh defects in QC.
• Updating teh Status to Senior Management.