SUMMARY:

* ***** ** ********** ** Business Analyst, UAT tester with emphasis on domain logic, identifying implementation requirements and resolving solutions to business processes based on complex software projects, that includes system development module, business process improvement, tactical planning and policy improvement.

Expertise in Software Development Life Cycle (SDLC) including Waterfall, Agile - Scrum and RUP methodology.

Proficient in creating and renovating Business Requirement Documents (BRD), Functional Specification Documents (FSD), and converting business requirement into Software Requirement Specifications (SRS) using MS Word/Templates and Rational Tools.

Excellent analytical and problem-solving skills in designing, developing, and implementing business innovative business processes using new approaches and technology.

Experienced in GAP Analysis, Cost Benefit Analysis, organizing, facilitating and coordinating many Joint Application developments (JAD), Joint Requirement Planning sessions (JRP), and Rapid Application Development (RAD) sessions, weekly, meetings, conference calls, and other regular project meetings.

Validated data prior to importing into databases, created and maintained record of company vendors and products, created and maintained various data tables for project access included maintaining daily, weekly, monthly, and annual requirement status reports.

Work as a SME on ANSI X12 EDI transactions formats and structures, creating and understanding Data Schema, using SQL queries to extract necessary 837, 835, 999, 277 data from the Database.

Worked closely with stakeholders and SMEs to fulfill the project goals and objectives as well as able to manage multiple initiatives, projects and deadlines on time.

Goal-oriented professional with excellent interpersonal skills with verbal and written communication, presentation skills and flexibility in adapting wide range of work environments by inculcating new relevant skills with ease in a time sensitive frame.

Experienced in creating Data Flow Diagrams (DFD), Use Cases, Class Diagram, Activity Diagrams, Sequence Diagram, and UML Modeling methodology using tools such as Rational Rose and MS Visio.

Familiarity with White-Box and Black-Box testing techniques such as Performance Testing - Load Testing, Regression Testing, Unit Testing, System Testing.

Developed test scenarios and implemented test plans for system testing and user acceptance testing (UAT).

Involved closely with the Developer and Testing team during defect resolution phase.

Excellent understanding of HIPAA standards (4010 and 5010), HIPAA code sets ICD-9, ICD 10 and HL7.

Experience in Process Documentation, Analysis and Implementation in 835, 837IPD, 834, 270/271, 276/277, 999/TA1(X12 Standards) processes of Medical Claims Industry from the Provider/ Payer side.

Captured all HIPAA-related EDI data in the repository using FACETS and supported integrated EDI batch processing and real-time EDI using FACETS.

Proficient understanding of Medicare Part A, Part B, Part C and Part D products and procedures managed care concepts (Medicaid and Medicare) and experienced in determining the membership eligibility, billing experience within life and disability in health plans.

Extensive knowledge of Medicaid Management Information Systems (MMIS) Medical Information Technology Architecture (MITA).

Familiar with RDBMS tools like oracle (TOAD), IBM Mainframe and MS SQL Server with very Strong SQL skills (writing queries and verifying data). Solid understanding of databases, data ware house, Data Modeling, Business Intelligent tools like Business Objects.

Research complex functional issues logged by business teams

Gather and prepare analysis based on information from internal and external sources to evaluate and demonstrate program effectiveness and efficiency

Act as Liaison between business and technical teams and able to guide technical teams

Review test cases created by QA team and help them to provide full coverage to the test scenarios

Create a detailed impact analysis document and explain technical teams about the scope of work

Working with various internal teams and clients in tracking project progress and maintaining Change Request, Requirements log and defect tracking.

Experienced in using different methods including conducting meetings, passing questionnaires and interviewing stakeholders to gather requirements.

Experienced in working with Project Management teams in various stages of the project to identify high level requirements, and resource needs for the project.

Experienced working with remotely located teams, off shore development model.

TECHNICAL SKILLS

Business Skills

Business Process Analysis and Design, Requirement Gathering Use Case Modeling JAD/JRP Sessions Gap Analysis, Impact Analysis.

Methodology

RUP, Agile, Scrum and Waterfall, SDLC, UML, JAD, GUI, UAT, RTM.

Business Modeling and Change Management Tools

UML, MS Visio, Rational Rose, SharePoint, Documentum, Requisite Pro, Clear Quest

Language/Standards

JAVA, SQL, PL/ SQL, HTML and XML, HTTP, HIPAA 4010/5010, ICD9/10, ANSIX12, CPT, CMS forms.

Applications

MS office suite, Adobe suite, Lotus Symphony, IBM Same time, communicator, Kick start, Network installation manager, IBM smart cloud meetings.

Testing Tools

HP Quality Center, Win Runner, Load Runner, JIRA, Quick Test Pro

Health Care

ANSI X12, HIPAA, EDI, Enrollment/Claims/Benefits/Remittance, FACETS.

BI Tools

Cognos 8.4/8.3/8.2/ 8.1 and Microstrategy, OBIE, Business Objects (Designer, Dashboard), Informatica, Crystal Report.

Database/RDBMS

Oracle 10g/9i/8i/DB2, TOAD, MS SQL Server, Teradata, Sybase.

Operating System

UNIX, Windows XP/ NT/2000/ 95, MS-DOS.

Microsoft Office tools

MS Office (Package), MS Project, MS Front Page, Visio, Excel, Word, Outlook, PowerPoint.

EDUCATION:

City University of New York (CUNY), New York, NY

Bachelor’s in Business Administration

WORK EXPERIENCE:

TriZetto - Cognizant Company, Pune Maharashtra, India Feb 2016 – Jan 2018

Business Analyst

Project involved resolving complex issues, defining and developing the custom interfaces, extensions and reporting during an implementation from client applications to TriZetto products. Serving as a product expert to new clients during installations, providing advice and expertise in system configuration as it applies to the client's business, application system technology and business experience as the context for delivery. The Project concentrated on the EDM Application to establish the stability of all the inbound and outbound 837 I, 837 P, 835, 999, 277, 277CA files for the Medicare, Medicaid and other Healthcare Organizations

RESPONSIBILITIES:

Gather functional, business and technical requirements using individual group meetings and document system functional requirements.

Gather and document client processes and data using Microsoft Excel in order to perform gap analysis between client’s systems.

Maintaining overall account responsibility for maintaining and growing bookings and revenue for assigned client (Aetna)

- Strong EDI Database Experience

- Healthcare Claims Knowledge (Encounters)

- EDI knowledge (837 I/P, 835, 999, 277, 277CA)

Work task implied processing, validating, adjudicating claims and generating Remit transactions for claim payments from provider as well as payer side.

Expertise in handling HIPAA ANSI X12 - 277CA, 999, 835, 837 ICD9/10 following HIPAA compliance and Healthcare systems.

Analyzing customers' business and technical requirements and software and product objectives, developing an application design to meet client needs.

Estimating time frames, quality and quantity of resources required to successfully complete activities; developing project plan incorporating all project variables.

Suggesting improvements in service delivery processes and techniques in preparing weekly status reports on all project activities and providing project oversight.

Identify and document total data needs for strategic enterprise programs where worked closely with business stakeholders, portfolio project teams, and application SMEs to identify and document the total data needs of strategic programs for Enterprise Data Management for Encounter Data.

Develop business use cases, business and data requirements, and related documentation in support of Enterprise Data Management using Rational tools.

Good understanding of source data as well as transformation, cleansing, or aggregation rules that impact Master Data Management (MDM) while scrubbing 837 X12 Data’s.

Facilitate the scrum meeting following to timeline for the purpose of project updates and datelines by creating the Project tracker.

Experience with health care Systems: FACETS, QNXT, Medicare and Medicaid systems.

Environment: Agile/Scrum, Share Point, MS Visio, Use Case Analysis, MS-SQL Server, Facets, Microsoft Office Suite, test Director, Zephyr, Access, PowerPoint, MS Project, MS Word, MS Excel, Jira, Clear Quest, Migration Tool, Rational Robot tools, Facets, QNXT.

Optum Global Solutions, Noida, Uttar Pradesh, India April 2014- Feb 2016

Business Analyst

Ensure that an electronic data interchange system operates properly and adequately meets users' needs. Translating business requirements to technical specifications. Create test cases, performing data performance testing, and supporting the day-to-day operations of EDI, including identifying any technical problems with sending/receiving transactions.

RESPONSIBILITIES:

Ability to translate the requirements of the customers to the appropriate technical or business team(s) throughout the life of each project ensuring system performance and data integrity.

Gathered Business Requirements from the Subject Matter Experts (SMEs) and documented the requirements in the BRD.

Created and maintained the Requirement Traceability Matrix (RTM) and map the developed Test plans and Test cases to the requirements to ensure that the requirements were fully tested and implemented according to the specifications.

Identified and implemented process improvement efforts within the EDI structure including system interface, policy and procedure changes.

Performed detailed analysis of project requirements and assisted in the development of functional specifications.

Performed detailed design and mapping specification creation for translation between Legacy and EDI formats.

Led customer-based projects digitizing current process and fully utilizing EDI capabilities such as Autoload.

Acted effectively as point-of-contact on status of EDI transactions from internal and external customers.

Developed and prepared EDI documentation, as well as provided content and format testing for internal and external use.

Established and supported communications to proactively share information via incoming help desk calls.

Developed and maintained intake process to register, track and test with external trade partners prior to production data exchanges.

Identified and analyzed necessary process modifications to meet the requirements of the Healthcare.

Configured and tested all modifications in Epic Systems.

Coordinated with business owners to insure business needs and EDI transaction format requirements were met and troubleshoot issues that arose.

Identified and recognized opportunities to resolve problems related to EDI transactions.

Prioritized customer requirements and maintained continuous improvement through customer feedback and interactions.

Worked on HIPAA ANSI X12 - 277CA, 999, 835, 837 ICD9/10 following HIPAA while in claim processing and remit transaction.

Experience providing primary analysis for business processes running on the EDI (Electronic Data Interchange) standard.

Conducted JAD/JARP sessions for user interviews to gather requirements.

Evaluated and tested the new and modified software application to verify that the program functions according to both technical and business requirements.

Develop, execute and validate user acceptance test plans (UAT) and implementation support.

Hands on experience in manual testing of the application for claims processing.

Performed Analysis of ICD 9 Procedure and Diagnosis Codes in accordance with ICD 10 CM and ICD 10 PCS Conversion Compliances.

Conducted gap analysis for HIPAA 4010 837P, 837I transactions and HIPAA 5010 837P, 837I. Transactions.

Comparison of CMS 1500 and UB 04 forms with the production files.

Responsible for testing complete claims processing and Remit processing as per business requirements

Developing test strategies, test scenarios and test cases.

Expertise using SQL queries, joins for Database Data filter and update for transactions 835, 837, 999, 277, 277CA.

Expertise in identifying and troubleshooting remit transactions.

Create User stories, epics, and task using rational tool for documentation and task updates

Analyzed EDI ANSI X12 file mapping and reported in analysis spreadsheet and performed validation of 837 and 835 format files

Environment: Clear Quest, SQL Server, Quality Center, MS Visio, Rational Rose, Requisite Pro, SQL, Gentran, Vista, HL7, EDI, UE, Windows, Agile/Scrum, Share Point, Use Case Analysis, Facets, Microsoft Office Suite, Zephyr, Jira, Clear Quest, Migration Tool, Rational tools, Facets, QNXT.

Omega Healthcare Management Services Pvt. Ltd., Trichy Tamilnadu, India Jan 2013- March 2014

Business Analyst

Project Description: The project involves Medicare line of business for Health Plan Services (HPS) and Provider Data Exchange (PDX). Reviewing design and configuring the Provider Data Exchange in accordance with the recommendations in the Business Requirement Documents, Functional Requirement Documents. The enhanced documents were used to create Provider Directory File(PDF), Provider Network File(PNF), and Provider Delegated Risk File(PDRF) to support multiple markets and make system flexible, easier to use, more tightly controlled system to achieve the corporate goals of improved speed to market.

RESPONSIBILITIES:

Worked on Business Requirement and functional requirement that were implemented and analysis through JAD session.

Worked with Developer teams to verify the Business requirement document and Vendor logic.

Worked on detailed plans involving the update and conversion to various internal tables, extensions, back end technical considerations and internal and external interfaces.

Worked on HIPAA ANSI X12 - 277CA, 999, 835, 837 ICD9/10 following HIPAA compliance and Healthcare systems.

Submitted, modified, and track changed requests using Rational tool

Used Migration tools as well as UI bypass in Toad and MS-SQL to perform the migration of the Fee Schedules.

Checked the documentation in Gatekeeper and approve it for the migration in the system.

Validated the Puma load performance in FSS table created.

Used Pivot tables, formulas and relational tools to show the relation between the tables in Excel for the upload purposes.

Served as to do the IT BA testing for various types of Provider Data via MS SQL server.

Involved in verifying Inclusion Report, Exclusion Report, and Health Plan files using advance MS SQL joins in Facets Tables and Data Mart.

Performed Defect Tracking and Project Tracking using Zephyr and Jira - Change Notification Request (CNR).

Involved in the peek review of Test Plans, Test Cases with the BA/QA team to verify implementation of new features and enhancements on Dev, QA, and Prod.

Experience in SQL Server Integration Services (SSIS), SQL Server Analysis Services (SSAS) and SQL Server Reporting Services (SSRS).

Worked closely with development team to work through issues/defects and resolution with the development.

Worked closely with development team to ensure business requirements are accurate and clearly understood.

Worked on utilizing SQL and SSRS (SQL Server Reporting Services) for the products.

Participated in requirements reviews, designing reviews, and changing control activities.

Created test plans, test requirements, test scenarios, and test data for use during the testing phases of the software development lifecycle, for existing software systems/products (HMO/PPO/SNP/SEL) with various markets.

Produced and presented formal test plans and leading the testing effort for assigned projects.

Documented and reported issues discovered during testing, with follow ups for resolution with the Developers.

Worked as part of Agile Scrum Development Team, conducting and effectively participating in sprint planning, task estimates, task sequencing, task assignments, sprint reviews and retrospectives.

Experience in databases; include Access/Excel/MS SQL, responsible for monitoring data with reports made via SSRS and SQL Server 2008/2012 data warehouse and Facets Application.

Other duties, as assigned.

Environment: Agile/Scrum, Share Point, MS Visio, Use Case Analysis, MS-SQL Server, Facets, Microsoft Office Suite, Zephyr, Access, PowerPoint, MS Project, MS Word, MS Excel, Jira, Toad, Clear Quest, Migration Tool, Gatekeeper, PUMA, Rational Robot tools.

Emblem Health, New York, NY Dec 2009 - Nov 2012

Reimbursement Analyst

Responsible for business process review to ensure accurate payment and operational efficiencies. Created and maintained provider payment fee schedules; utilizing all current reimbursement methodologies and researching new reimbursement methodologies. Worked on project goals by developing project plans, establishing deadlines, monitoring milestone completion, and providing timely reporting of issues that impact progress and the resolution of conflicts. This included documenting and prioritizing assignments. Worked cross-functionally and interacted with all levels of Management. Worked on multiple projects representing the department regarding reimbursement methodology and assisted Management by analyzing data, identifying root causes, and making recommendations.

RESPONSIBILITIES:

Analyzed contract terms, prepare fee schedules and accurately document file changes into the claims processing system.

Identified defects and improved accurate provider payment by performing root cause analysis on specific examples through each step of the Claims Process.

Performed data analysis on large claim data samples.

Provided recommendations on short and long-term solutions for claims and remit related issues.

Researched and identified published updates to fee schedules from Medicare, Medicaid, and third-party sources.

Conducted testing, maintained accurate documentation and met timelines for assigned projects.

Responsible for the overall success of applicable testing, including results verification before sign-off and Production.

Assisted on internal and external audits of payment accuracy

Understood project concepts, objectives and approach.

Assessed the current/future state of reimbursement projects and address operational impacts, workflow, and training issues of all assigned project(s).

Used rational tool for documentation and task updates for the purpose of creating User stories, epics, and task.

Completed assigned tasks and/or oversee the completion of those tasks within project timelines.

Demonstrated expertise in assigned reimbursement content areas.

Monitored for Medicare and Medicaid changes and ensure they were reflected in project works.

Prepared Executive Summaries for management consideration.

Understood Center for Medicare/Medicare Services (CMS) 837 claims editing policies and 835 payment methodologies.

Utilized knowledge of areas related to Claims, e.g. Network, Benefits, Authorizations, Provider Operations, Finance, and Enrollment.

Completed other projects and duties as assigned.

Environment: Agile/Scrum, Share Point, MS Visio, Use Case Analysis, MS-SQL Server, Access, PowerPoint, MS Project, MS Word, MS Excel, Migration Tool, Rational tools.

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