Project Manager Data

Location:

Alexandria, OH, 43001

Posted:

June 03, 2019

Contact this candidate

Resume:

Rishi

Business Analyst

315-***-****

Over *+ years of extensive experience as a Business Systems Analyst/Business Analyst, in insurance and Healthcare, using IT business analytics and SDLC (Systems Development Life Cycle)

Provided extensive support to various CMS, NCQA and HEDIS audits - in creating universe; coordinating with business and IT team to finalize the data; performing quality assurance of the data configuration, Eligibility & Pricing configuration, medical billing, Claims processing, and Healthcare Payer Domain.

Strong experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.

Extensive knowledge of Medicaid (MMIS), Medicare, Procedural and Diagnostic codes and Claims Process.

Proficient in developing & automating reports, iteratively build & prototype BI dashboards using Tableau to provide insights at scale, solving for analytical needs of business team.

Adept in writing SQL queries for data extraction, manipulation, analysis, and validation, generating user reports and proficient knowledge of Relational Database Management Systems (RDBMS), and Data Warehousing.

Comprehensive knowledge of software development methodologies such as Waterfall, RAD, RUP and AGILE SCRUM.

Adept at preparing Business requirements documents (BRDs), Functional requirements documents(FRDs), defining project plans and delivering project reports

Expertise in Project Planning, Project Design, creating functional specifications and data flow diagrams.

Lead and worked with teams to examine and solve business problems by accurately analyzing the needs of clients and helping them achieve improved quality and value for their customers, strong leadership and mentoring skills, and highly proficient organizational and computer skills

In depth knowledge of RUP's Iterative Software Development Life Cycle (SDLC) process, Agile Software Development and Waterfall models

Experience in developing Test Plans, Test Scenarios and Test Cases based on functional requirements.

In-depth knowledge of Healthcare organization operations including outsourced operations, Health Insurance, HIPAA, and Medicaid/MMIS, including MITA.

Mentored other team members on the development & support of HL7 interfaces for clinical applications.

Knowledge of HL7 and/or X12 standards, segments and fields required

Strong background of analysis of HL7 and / or X12 workflow documentation

Significant Epic EMR work experience, tasked with building, implementing and supporting the Epic application from both the end user (clinical) and technical perspectives.

Solid Epic experience that includes participation in all phases of EMR implementation; project planning, workflow analysis, design, build, validate (DBV), "go-Live" training delivery, on-site support, and post go-live optimization.

In depth knowledge of insurance policies like HMO and PPO and proven experience with HIPAA 4010/5010 EDI transaction codes such as 277/277CA (Claim status) Analyzing the 837 (Inbound/Outbound), 835 Outbound, 997 Acknowledgement Inbound and Outbound EDI Transactions.

Extensively worked with different X12 Hierarchical Levels (HL structures) in various inbound claim/inquiry-response transactions (837 P/I/D, 270/271, 276/277).

Involved in testing HIPAA Database, which incorporates all the HIPAA (Health Insurance Portability and Accountability Act) transaction sets

Worked on development and implementation of policies, procedures and QA methodologies

Gathered requirements to check HIPPA- eligible & participation check for individual coverage.

Technical and business knowledge in multiple disciplines/processes.

Strong understanding of HIPAA Transactions & Code Sets Standards like (820- Premium Payment for enrolled health plan members, 834- Enrolment /Disenrollment to a health plan, 835, 837 etc.)

Plan, Design and implement application database code objects, such as tables, stored procedures, user defined functions, triggers, SQL, packages, cursor & schedulers etc. in windows environment.

Build SQL scripts, indexes and complex queries for analysis, extraction & creation of data on client server.

Experience in executing Test Cases to test the application functionality against the requirements manually.

Excellent skills in Business Analysis, OO Analysis, Data Analysis, Requirement Analysis, Business Modeling and Use Case Development using UML methodology, Project Management Methodologies include RUP, SDLC, and Waterfall

Excellent communication and presentation skills. Experience working with business user as well as senior management

Methodologies

RUP, UML, SDLC, AGILE, Scrum

Business Skills

Business Definition Requirements, Business Process Analysis & Research, Use Case Modeling, JAD/RAD Sessions, Requirements Gathering, Gap Analysis and Impact analysis

Project Management

Microsoft Project, Microsoft Office, Microsoft Visio Atlassian software (Confluence, JIRA, Portfolio), Agile Craft

Web Design

Microsoft FrontPage, Dream weaver

Testing Tools

Rational Robot, Test Director 7.x/8.0, QTP 9.2, Win Runner, Mercury Quality Center 9.0

Databases

SQL Server 2000/2005, Oracle 9i, DB2, MS-Access

Career Summary

CareSource - Dayton, OH Feb 2018 - Present

Business Systems Analyst

Roles & Responsibilities:

Conducted the role of Senior Business Analyst and Senior Quality Analyst for the CareSource Marketplace Eligibility & Enrolment project.

Gathered Business Requirements, interacted with the Users, Designers and Developers, Project Manager and SMEs to get a better understanding of the Business Processes.

Gathered and analyzed the User Requirements from walkthroughs and interviews with the business groups and in-house stakeholders, and many other departments like accounting, fund management, human resource and thus converted User Requirements into Business Requirement Documents (BRD).

Review and negotiated all existing Managed Care Long Term Care (LTC) contracts with various payers to endure market based reimbursement

Training Provider Advocates on systems such as MIC, MACESS, CSP/FACETS and Orbit (reporting).

Ability to solve process problems crossing multiple functional areas and business units; ability to analyze problems, draw relevant conclusions and implement an appropriate plan of action

Support onshore SAFe agile team in requirements elicitation, documenting and refining user stories.

Review payer contracts to become familiar with the established terms and provisions, maintain system tables for rates, healthcare-related codes (e.g. CPT, DRG, ICD-9, etc), and fee schedules.

Worked with the management for improving and giving new ideas for designing future processes of the HIPAA transactions dealing out with EDI 271, 276 and 270, 470, 835, 837, 834, HIPAA 4010, 5010, claim adjustments, claim processing from point of entry to finalizing, claim review, identifying claims processing problems, their source and providing alternative solutions using best practice model and principles and also well versed with ICD10, Facets.

Responsible for development, testing of Axway B2Bi map and configurations for communications

Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company

Involved in various Facets Data models like Gateway, Claims, Membership, Provider, Billing, Capitation, Invoice, Benefits, Product and Plan.

Created and maintained requirement documents for Facets for the different modules like Billing, Member enrollment and Claim adjudication.

Facilitated Scrum meeting with technical/non-technical team, Accounts updating, data analysis and sharing with XML patterns, SME's to clarify business rules & solve impediments, rectifying the regulatory issues with SME's and translated Functional requirements into User stories using JIRA.

Prepared test data from user stories, write and execute test cases in JIRA

Created UML Diagrams including Use Cases Diagrams, Activity Diagrams/State Chart Diagrams, Sequence Diagrams, Collaborationake Diagrams and Deployment Diagrams, using Rational Rose and MS Visio and thus defining the Business Process Model and Data Process Models.

Coordinate with Health Insurance Exchange (HIX) program staff and other stakeholders to define and develop requirements for correspondence generation across various business lines.

Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.

Worked in Agile Methodology, worked on all phases of software development life cycle to build the different phases of Software development life cycle.

Performed Gap Analysis to check the compatibility of the existing system infrastructure, features and functionality with the new business design using the "As Is" and "To Be" methodology.

Developed business case which included results of the business-impact assessment, gaps identified, alternative solutions, risk assessment, preliminary work plans, resource requirements, and a budget for completing the initiative.

Environment: Agile/Scrum, SAFE, MS Office Suite (Word, Excel, PowerPoint, Visio, Project), JIRA, UML, SQL, Confluence, SharePoint, Kanban, Lean, Kano, Rally.

United Health Group- SFO, CA Jun 2016-Jan 2018 Business Systems Analyst

As a Business Analyst, I was responsible for Health Quotes Module. Depends on the search criteria given by the consumer this module suggests the coverage and/or type of coverage (Individual, Family and Business This allows pursuing the policy that best meets consumer needs. The Project was related to testing NASCO-Single System Claims Processing System Application. The objective of the project was to avoid loss, improve billing efficiency, claims and to ensure how money is spent within eligible Medicaid receivers. The system effectively processes the patients' medical insurance details and transmits the insurance claims, eligibility enquiries, responses and benefits using HIPAA 837, NCPDP 270 and NCPDP 271 codes set.

Responsibilities:

Coordinate requirements elicitation to extract business needs by liaising with key stakeholders

Interacting with client's team SME's and key users to understand their business processes and solution management within timelines.

Reviewed Test Scripts, Technical Specification Documents, and worked on application's input / output data definitions.

Documents the results of the audit and make recommendations as needed

Prepare detailed system requirements, specifications and documents and provide consultative services through all phases of the System Development Life Cycle

Elicit and prepare detailed system requirements through conducting JAR/JAD sessions, interpreting business requirements and working with business partners and development teams

Ensures coding and Configuration, meets current business policies and practices, and supports the efforts of compliance review and audit of employer group benefits.

Undertaking Quick Gap Analysis; current / future business process analysis, generating documents of future business process and validating same from the company.

Prepare requirement specifications such as Use cases and System requirement specifications and Supplementary specifications

Worked on the database analysis part by helping the technical team in identifying the data sources required for the application and coordination with the IT team in migration of the data within the databases.

Conceptualizing and developing functional specifications across different business areas such as Claims, Membership, PBM etc.

Preparing business use cases; map Business Requirement / Software Requirements Specifications (SRS) document (As-Is & To-Be Analysis) and GAP Analysis and translating them into functional specifications, detailed test plans and coordinating for Go-Live.

Created and managed project templates, Use Case project templates, requirement types and trace-ability relationships in Requisite Pro.

Performing knowledge transfer to the technical/development and QA team by creating quality test cases and providing accurate test data.

Created Business Analyst Governance for Dashboards, Project Tracking, and Traceability Matrixes.

Involved in Configuration Management, Requirement management and analysis.

Design and review of various documents including the Software Requirement Specifications (SRS), including USE Cases, Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), Systems Design Specification (SDS), Requirement Traceability Matrix (RTM) and testing documents

Guardian HealthCare - Dallas, TX Feb 2014-May 2016

Business Analyst

As a Business Analyst, I was responsible and involved Detailed Gap Analysis, Update and Manage the guide lines as per HIPAA, Test and Migrate the Partners and Analyze Partner Compliance & Performance in production. Advanced guideline comparison to assess the scope of 5010 migration effort. Electronic version of HIPAA 5010 standards including code tables, ICD-10 codes and business rules. I was also involved in preparing the Guideline of migration to prepare the business rules for conversion and from scratch. In the end I was also involved in the testing from individual file testing to mass-parallel testing of multiple submitters and Unit Testing to 5010 Migration.

Responsibilities:

Coordinate requirements elicitation to extract business needs by liaising with key stakeholders

Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow ICD 10 Code set and ANSI X12 5010 formats.

Participated in project meetings to support the team as required, Organized various meeting with SME's and testing Team to ensure that we are on track with all of our deliverables, tracked all our deliverables on a daily basis by using Deliverables tracking Template. Teamed up with both internal and external software development teams to provide functional requirements specifications in the form of use cases, business process flows, and prototypes and management reporting requirements.

Designed Data Flow Diagrams (DFD's), Entity Relationship Diagrams (ERD's), and web page mock ups using modeling tools. Involved in formatting data stores and generate UML diagrams of logical and physical data. Used Query Analyzer, Execution Plan to optimize SQL Queries.

Used Facets for various health insurance areas through EDI 837, such asenrolment, member, Products and other Facets related modules.

Networked with Subject Matter Experts, Project Manager, Developers, and Process Analysts to understand the business process, gathered Business Requirements and identified enhancements.

Extensively developed project documentation, process flow documents, formal proposals, RFQ's and RFP's. Formulated methodologies and developed SDLC phases, strategies, time & cost estimates with milestones for each phase.

Responsible for demonstrating requirement traceability within developed products.

Responsible for analyzing pending claims in dispute using Facets.

Prepared Business Requirement Documents (BRD's) after the collection of Functional Requirements from System Users that provided appropriate scope of work for technical team to develop prototype and overall system.

Tested the Facets system through EDI transactions mainly on 837 Professional and Institutional Claims enrolment.

Worked with ICD-9 encoding to verify the validity of incoming claims, documented ICD-9 codes presently used by the system.

Creation of a Mapping Document for ICD9 Codes to ICD 10 Clinical Modifications and Procedural Codes.

Creation of Gap/Impact Analysis Document for the Prescription Drug Point of Sale System

Unicare Corporation - Cleveland, OH Apr 2013-Jan 2014

Business Analyst

Worked as a Business Analyst/QA Analyst at Unicare Corporation on a Behavioral HealthCare Administration Project for inpatients and outpatients, psychiatric, other specialized services, employee assistance programs and performed testing on various modules like eQuote, eEnroll, eService, e Bill to automate the process by providing Customer Management, Product Management, Provider Management, Revenue Management, Customer Service and Financial Risk Management. Performed Functionality Testing and Security testing of the various modules manually.