PINKI SHETH

Chicago IL 903-***-**** Legal Status: US Citizen

SUMMARY

* ****'s industry experience as Business Analyst with excellent understanding of Business Requirement Gathering, Business Analysis, Business Process Modeling.

Excellent communication, writing and presentation skills. Experience working with business users and senior management.

Solid understanding of all phases of Software Development Life Cycle (SDLC) methodology (requirement, analysis, design, data modelling, business process modelling, implementation, and deployment).

Broad knowledge of test plans, test cases and test scripts from the Requirements Document.

In-depth knowledge of Rational Unified Process (RUP); risk engineering, data modeling and mapping, and design using UML (Unified Modeling Language), Rational Rose and Visio.

Experience in interacting with stakeholders like business clients, end users, vendors, SDLC team, configuration manager and production team to identify information needs and initiate process change.

Expertise in creating various artifacts like BRDs, Functional Specs, Used Cases, UML Diagrams, Data Mapping Documents, Test Plans and Test Strategies, pre and post RTMs and Status Weekly Reports, etc.

Expertise in using various tools like Requisite Pro and Microsoft Office for requirement gathering, Quality Center and ClearQuest for Defect Management/Defect Tracking, MS Visio for UML Diagrams, Outlook, and SharePoint for information sharing.

Conducted successful projects with the help of teams to achieve deadlines timely and proficiently.

Experience working in Medicare and Medicaid projects.

Knowledge and experience in implementation of HIPAA, HL7, FHIR and other transactional standards

Created Requirements Traceability Matrix to keep the stakeholders informed of the progress of the project.

Strong expertise in Health Insurance Claim process, social services, and Medicaid.

Belief in team work, dedication, and professional ethics within the working environment.

Extensive experience in conducting Joint Application Development (JAD) sessions for project definition involving analyzing requirements, creating prototypes, user interface, database schema and system design.

Well versed with HIPAA, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing corresponding solutions.

Extensive experience in gathering Business/Functional user requirements, creating Use Cases as per user requirements, developing/designing diagrams such as Activity, Class, and/or Sequence Diagrams, and in addition to creating Business Requirements Document (BRD).

Organized, goal-oriented, self-starter, and ability to master new technologies, manage multiple tasks while following through from start to completion.

Flexibility in adaption to a wide range of work environments.

Good in requirement gathering including JAD and requirement analysis.

Extensive experience in working in a customer - oriented environment.

Ability to inculcate new relevant skills with ease in a time sensitive frame.

Analysis done to determine if the system abides by the HIPAA regulations.

Experience in writing Use cases and Functional Requirement Document (FRD).

Excellent knowledge of HIPAA transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 470 (benefit codes), 835 (payment or remittance advice), 837 (health care claim) and 834 (benefit enrollment).

TECHNICAL SKILLS

Methodology Agile, SCRUM, RUP, UML, Waterfall, RAD Defect Tracking tools HP ALM, Rational ClearQuest

Project Management Microsoft Office (MS Project)

Tools and Applications Microsoft Office, MS Project, Visio, Excel Requirement Mgmt Tools Rally, JIRA

EXPERIENCE

Business Analyst Abbvie, Remote November 2020 to Present As a business analyst i worked on the project of Data integration for different brands

Created a project charter for various projects.

Also was being a part of project management for brand Launch project.

I worked on building a dashboard for leadership team.

Worked on ebv project.

Involved in gathering requirements, identifying and preparing Use Case specification documents, creating Traceability matrix.

Heavily involved in process flow creation and evaluation of all usage scenarios derived from the process map.

Responsible for performing detailed GAP analysis.

Responsible for reviewing test cases and automation scripts provided by the vendor company.

Involved in reviewing and approving release notes provided by vendor company.

Experience with test case and test plan creation(manual).

Participated in defect review meetings focusing on reproducing critical defects and responsible for upgrading test cases for any upcoming change results.

Developed and reviewed the test cases to cover the complete functionality of the application.

Executed test cases manually to verify the complete functionality of the application as per the requirements.

Performed System Testing to ensure that the compiled software components of the applications adhere to project standards, performance criteria and functional specifications.

Responsible for entering and updating Jira tickets as needed.

Maintained various versions of the documents generated during the project. Business Analyst CVS Health, Hartford, CT Dec 2018 to October 2020 The Project was for creating and maintaining applications that would provide information in a consolidated manner to its managed care and strategic pricing business partners, in a timely manner, necessary for making key business decisions.

Gathered detailed business & technical requirement and participated in the definitions of business rules and data standards.

Identified/documented data sources and transformation rules required to populate and maintain data warehouse content.

Responsible for understanding Pharmacy Benefit Management (PBM) and pharmacy claims data Delivered advanced health insurance analytics and development of statistical, predictive models.

Created specifications for EDI HL7 (A28, A31, ADT) and X12 (837/835) transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers.

Worked with data migration and file mapping for various EDI transactions. Enhanced the Provider/Patient verification criteria using additional parameters based on the information retrieved from the EDI 837 I/P transaction files.

Translated the EDI X12 data into XML format for initial transformation/migration.

Facilitated functional requirement gathering from system users and prepared BRD.

Created Business Process Mapping Diagrams and Documentation for the process improvement recommendations.

Used MS Visio for flowcharting, Use Case process model and architectural design of the application.

Implemented the RUP methodology guidelines with its various workflows and artifacts in Requirements Management and Development.

Gathered and documented functional requirements and use cases for automation of operational and administrative business processes.

Provided overall project management of multiple projects; successfully completed on-schedule and on- budget.

Documented the "AS-IS" Business Workflows adhering to UML standards. Conducted JAD sessions to define requirements and finalize the FRD.

Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML and Visio.

Interfaced with team leaders to identify, and analyze the given information, procedures, and decision flows, evaluated existing procedures, methods, and technical documentation. Communicate with executives, managers and other stakeholders regarding project scope.

Responsible for business process analysis that includes requirements facilitation, definition & analysis, alternatives, software selection, prototyping, business process design and mapping.

Maintained a Traceability Matrix to ensure that all functional requirements are addressed at the use case level as well as the test case level.

Involved in identifying use cases, actors and writing use case narratives. Created use case diagrams and activity diagrams using MS Visio.

Conducted meetings and JAD sessions for project definition, resource identifications and deliverable prototype identification.

Interfaced with Developers, Analysts, Customers, and Project Managers to discuss requirements and recommended solutions, to help resolve issues.

Worked on EDI transactions: 270, 271, 834, 835, and 837 (PID) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.

Played a substantial role in the process definitions and business and functional requirements gathering in an effort to develop a practical technology solution for automating sales methodology.

Involved in testing the Pharmacy Claims adjudication and Billing processing is done through PBM (Health Trans) and Claims Accumulation and Adjudication is done through Diamond.

Performed gap analysis of claims and enrolment business process for changes from SSN identifier to USI

(Unique Subscriber Identifier) affecting for HIPAA EDI X12 transactions 837, 834, U277, 276/277, 270/271, 278,835 and 820.

Business Analyst III Delta Dental of California, San Francisco, CA Sept 2017 to Nov 2018

Primarily worked on Core Business Membership - Enterprise Streamlining Projects (ESP) for Electronic Eligibility Process (EEP) and Eligibility Management Application (EMA).

Performed business research designed to improve business processes and contribute to cost savings and increase efficiency.

Conducted requirement elaboration sessions and documenting business requirements and business solutions.

Developed use cases, workflows, screen mock-ups and conversion requirements.

Facilitates communications between customers, SMEs, and Technical staff. Participate in various testing functions (i.e. string and acceptance tests) to verify that results are correct.

Analyzed the data and created class diagrams and ER diagrams for designing databases.

Planned and defined Use Cases created Use Case diagrams, Scenarios and Use Case Narratives using the UML methodologies.

Analyzed applications including - EEP, EMA, Enrollee Portal.

Utilized RUP to configure and develop process, standards, and procedures.

Documented various workflow diagrams like As-Is and To-Be processes.

Used Rational ClearQuest for handling change requests.

Involved in Inception Phase and prepared vision statement and initial data models that contain Business Requirement Documents and supporting documents that contain the essential business elements and detailed definitions.

Executed SQL queries and managed databases.

Performed data mapping and data migration.

Interacted with other team members and participated in daily scrum meeting to ensure all team members were on the same page.

Prepared test cases based on business requirements and business rules for HIPAA EDI Transaction 834, 837, 835.

Worked on 834 Re-enrollments/Renewals and Reconciliation of patient encounter data

Involved in processing 834 Files upstream and downstream, identifying Enrollment Scenarios and deriving test scripts from the scenarios and adjudicating Claims effectively.

Defined a repeatable process that is followed in the early stages of the Concept phase which defines risks and impact of product development.

Hands on experience with the 834 ANSI X12 transaction understanding loops, segments, elements, and structure

Performed Data mapping and data modelling and used Canonical data model to map data from X12 834 transactions.

Worked with cross functional teams to define KPI's for each stage of the Product Development and Release Process.

Worked with functional teams in an Agile environment, analyze factors and components of systems and processes to manage interrelationships and facilitate change. Detected inefficiencies or conflicts in systems and processes and helps to identify effective improvements. Business System Analyst Aetna Inc, Hartford, CT Oct 2015 to Aug 2017 The project implemented increased scalability, capacity, and service delivery, streamlining internal processes for real-time data integration between legacy and external vendor systems. The focus was to enhance workflow processes for the entire claims processing cycle, involving HIPAA ANSI X12 transactions. Enabling the IT teams to identify and resolve system errors in the adjudication process.

Assisted in creating implementation guides for various EDI X12 transactions.

Responsible for importing all reports from Web Report Studio, Stored Process, BI Dashboard, and Information Map to Information

Coordinated Agile based planning/review activities and meetings, followed Iterative SDLC Process, Agile using Scrum

Articulated business requirements from user interviews, weekly requirement gathering sessions and then converted requirements into technical specifications

Liferay upgrades from one version to another version. Capable to upgrade till Liferay DXP.

Worked on Adobe AEM & Liferay DXP Dev.

Prepared, scheduled and lead meetings between enterprise business and technical resources and multiple vendors in preparation for demonstrations and site visits resulting in more efficient and productive meetings with fewer follow up questions and communications.

Worked with the Data Governance Team to ensure the data quality of compliance reports for EDI transactions.

Assisted in closing gaps for associated Stories in each individual Sprint.

Assisted in entering and updating Issues (Epics, Stories, and Tasks) onto JIRA Agile application.

Delivered Enterprise Data Governance, Data Quality, Metadata, and ETL Informatica solution

Part of daily Scrum work meetings and weekly project progress meetings

Assisted the Project Manager in defining the project plan, project charter, scope, vision, and timelines. Handled Requests for Proposals (RFP), making presentations to customers, and negotiating project timelines and deliverables.

Conducted complex documentation and user needs analysis. Interface with team and staff to develop HL7 integration.

Prepared Business Process Models (BPM) and UML diagrams like workflow diagrams, activity diagrams, sequence diagrams, use case diagrams, by using MS Visio, for visual representation to explain various steps involved in business.

Involved in creating and executing test cases, test plans and test scripts for EDI 837 Claims (I & P) Transactions.

Performed data mapping to validate and customize Claims daily load into FACETS for processing the transactions.

Performed data profiling through careful range and pattern analysis and checked for data integrity by looking for various data anomalies and doing data normalization and data verification using Informatica Data Quality Center.

Built Data Dictionary for various designers, developers, users, and administration with information on contents, data-type, and data element in various tables, columns and rows, and data modeling through star and snowflake schema.

Participated in validating ETL process by creating various simple and complex SQL queries.

Responsible for the development and implementation of HIPAA EDI Data Mapping artifacts for various claims related transactions.

Validated HL7 messaging protocols for bi-directional case and disease report exchange, in HTML and XML formats, in accordance with HL7 specifications for electronic communication of patient health information.

Created test cases for the premium calculations and Claims limits and deductibles (Claims calculations).

Wrote SQL queries to match the results with the actual BI report for various analytics purposes. Associate Business Analyst Best Buy, Richfield, MN Jan 2013 to Sept 2015

Interacted with customers and internal stakeholders as part of requirements elicitation and analysed business requirements and share with development team.

Created UML, process flow diagrams and workflow process for approval mechanism and created various patient forms viz., Preauthorization Form, Claims Form, Patient admittance forms.

Performed Dev planning, analysis, design, and execution in Agile methodology by understanding the product backlog, sprint iterations, scrum session, stand up and defect triage.

Implemented Gap Analysis for finding out the required number of customizations needed to meet the client requirements.

Worked with management to develop policy, workflow, and technology best practices, identify issues and develop creative solutions.

Assisted in generating Business as Usual (BAU) reports. Supported ad-hoc presentation/analysis development and responds to information requests from management.

Assisted Senior BA in providing subject matter expertise and priorities work for the development team.

Used judgment within defined practices and procedures. Worked under minimal supervision. Follows established direction and work assignments.

Developed internal work procedures and initiate process improvements.

Developed and executed through project, change management, and test plans and aid in the closure of gaps and defects.

EDUCATION

Bachelor’s in Accounting University of Mumbai

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