Anthony Merza

Senior Business Analyst

434-***-****

ad0v8w@r.postjobfree.com

SUMMARY:

Qualified professional with over 8+ years of extensive experience in the field of Sr. Business Analyst working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.

Adequate knowledge in Business Analysis and Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, enrollment, Medicare, MMIS, Medicaid, CDHP (consumer driven health plans),Healthcare Billing, Enrollment, Claims, Business Analysis, Requirement Gathering, Use Cases, Design, Change Control Process, Test Plans, Test Cases, User Acceptance Testing, User Manual and User Training.

Experience in source-to-target mapping, data analysis, and process improvement.

Implemented and performed all business analysis and testing activities in all phases of Software Development Life Cycle (SDLC).

Gathered business requirements through JAD sessions and one-on-one interviews with the Business Stakeholders and tracked the requirements.

Extensive knowledge of MMIS claims processing for Managed Care Organization (MCO) and Fee For Service (FFS)

Experience in utilizing IBM Sterling solutions to optimize healthcare processes and data exchange.

Extensive knowledge of Eligibility and Enrollment process, 834 EDI.

Proficient in SQL queries and SAS. Worked on MA SQL server, XML and Web services.

Experience with HIPAA Compliance requirements and HL7 standards and possess strong knowledge of healthcare X12 EDI (270/271, 276/277, 834,835, 837) transaction, ICD-9 and ICD 10.

Demonstrated expertise in data mapping and data analysis, contributing to the seamless integration of FACETS.

Experience with insurance administration systems included Policy Application, EDI Transactions, Eligibility, and Enrollment, Claim processing, Encounter Processing, Billing and Payments.

Ability to define timelines for prioritizing work requests using tools such as MS Project.

Ability to model business processes (BPM) in enterprise level projects using industry standard case tools.

Sound knowledge of concepts like Gap Analysis, Risk Analysis, Impact Analysis, Data analysis, etc...

Excellent writing skills in writing Business requirements document, Technical requirement documents, Design documents, USE Case Specifications, Functional Specifications, Systems Design Specification (SDS), Systems Requirements Specification (SRS)

Expertise in Agile, RUP, SCRUM, Waterfall SDLC (Software Development Methodologies).

Prepared Test Plans, High level Scenarios, and Test Cases from Requirement and Design documents.

Prepared comprehensive and detailed Status, Defect and Test Summary reports.

Escalation of problems & issues related to test environment with support team.

Experience in Quality Center, TFS, JIRA (Bug Tracking Tool) for bug Project management and bug tracking application.

TECHNICAL SKILLS:

Methodologies

Agile, Waterfall, Rational Unified Process(RUP), UML

Business Modeling Tools

MS Visio, Rational Rose, Axure, Adobe Photoshop

IDE Tools

Rational Rose, Rational Clear Quest, Rational Clear Case, MS Visio, UML.

Requirement Management Tools

TFS, Rational RequisitePro, Doors, MS Share point, HP ALM, HP QC

Project Management

MS Project, JIRA

Business Applications

MS Office Suite –MS Word, Excel, PowerPoint, MS Outlook

Testing Tools

Software Application Testing Life Cycle,QTP,QC

Reporting Tools

Business Objects

Databases

MY SQL, SQL Server, Oracle, MS Access

Operating Systems

Windows, LINUX/ UNIX

Domain Knowledge

HIPAA, Claims Processing, EDI, HL7, HIX, EMR/EHR, PPACA, FACETS, Medicaid, Medicare (Part A, B, C and D), PPO, HMO, Dental claim and POS.

PROFESSIONAL EXPERINCE:

Sentara Medical Group - Norfolk, VA

July 2021- Present

Sr.Business Analyst

The objective of the project was to improve healthcare quality, coordination, and access by extensively customizing and configuring EHR and EDR to fit the provider's needs. The customization was incorporated into the systems which resulted in increased communication, increased opportunity for further collaboration, and gave directions for the future projects.

Responsibilities:

Organized and facilitated JAD sessions to elicit the requirements and document the client requirements for the customization of the EHR and EDR devices and converted the requirements into Business Requirements Document (BRD) and Functional Requirements Documents (FRD) as per the client's requirements.

Interviewed the stakeholders from different departments to identify their current needs and understand their Current Workflows and Ideal Workflows, to created process diagrams documented As-Is and To-Be business processes.

Customized SharePoint forms, lists, and workflows to accommodate the specific needs of the incident reporting process.

Developed test plans and test cases to validate the functionality of the incident reporting system and its compliance with business requirements.

Orchestrated the gathering of precise requirements and meticulously crafted detailed functional documentation for FACETS versions 4.71/5.0.

Collaborated closely with cross-functional business units to define, document, and analyze both functional and technical requirements within the FACETS framework.

Actively contributed to an array of FACETS projects, spanning output generation, interface development, and seamless migration initiatives.

Executed thorough testing procedures on FACETS front-end screens, scrutinizing modules that encompassed membership, billing, and provider-related processes.

Conducted comprehensive data analysis to detect underlying trends, patterns, and opportunities for process enhancement.

Conducted data profiling, cleansing, and transformation to improve data quality and reliability.

Assisted in the integration of Big Data solutions into existing systems and processes.

Developed data models and skillfully translated business requirements into precise technical specifications for data warehousing solutions.

Took charge of designing and executing ETL (Extract, Transform, Load) processes, ensuring seamless data integration.

Ensured that the incident reporting system on SharePoint had appropriate security measures and access controls in place.

Worked closely with the PMO to develop the Project Plan and helped the SME's in analyzing the reports for Project Execution. Was involved in requirements gathering with the clinicians and other healthcare practitioners.

Successfully led the optimization of ticketing systems, resulting in a 30% reduction in response times for resolving patient inquiries and issues.

Assisted in the automation of sales and marketing processes within Salesforce, helping to streamline lead management, campaign tracking, and lead nurturing.

Offered ongoing support to address user inquiries, troubleshoot issues, and ensure Salesforce adoption.

Analyzed business operations to develop business requirements which lead to 45% revenue increase

Expertise in gathering and documenting user requirements for ticketing systems, ensuring alignment with healthcare organization needs and compliance with HIPAA regulations using ServiceNow.

Implemented process improvements within ticketing systems, leading to a 20% reduction in duplicate requests and a more efficient allocation of resources.

Ensured that ticketing systems and processes adhered to healthcare regulations, maintaining patient data confidentiality and security.

Collaborated with cross-functional teams to conduct source-to-target mapping of healthcare data, ensuring accurate data transfer and integration between systems.

Led data quality assessments and identified discrepancies, resulting in a 30% improvement in data accuracy.

Designed and implemented data governance processes to maintain data integrity and compliance with industry regulations.

Developed and maintained dashboards and reports using tools such as Tableau, Power BI, and Excel to provide actionable insights to clinical and administrative stakeholders.

Played a key role in the successful implementation of Sentara Medical Group, resulting in streamlined workflows and improved patient care coordination.

Conducted root cause analysis and recommended process improvements, leading to a 25% reduction in billing errors.

Collaborated with IT teams to identify system integration opportunities, facilitating interoperability between electronic health record (EHR) systems and other healthcare applications.

Provided training and support to end-users on data analysis tools and best practices, increasing data literacy across the organization.

HIPAA 5010 and ICD 10 compliance check were carried out by developing a checklist of compliances.

Worked with the system architects in understanding and designing the User Interface as per the stakeholders needs by preparing a systems design document. Helped in Developing Functional and Technical Design Specifications

Assisted the Project Manager and the development team in understanding the requirements for developing generic (History of Previous Illness) HPI templates used to document each of the Chief Complaints

Documented complex Business requirements and made process flow diagram for the EDI transactions EDI 837/835 as per the 4010 to 5010 implementations for the Medicaid claim processing system enhancement.

Actively documented the HPI templates which were used by the patients with the diagnoses of bronchitis, otitis media, sinusitis, pharyngitis, and upper respiratory tract infection

EDI file testing for checking the HIPAA 4010 compliance of the inbound 837 claims.

Assisted the team in conducting Technology Acceptance Model Questionnaire (TAMQ) which was used to assess participants' perceptions towards ease-of-use, usefulness, and intent to use before and after the template changes.

Used IBM SPSS Statistics to analyze Pre and Post-Test Data. Participant's responses were evaluated using descriptive statistics to obtain means of percentage.

Used JIRA for Issue Tracking, user story management and Requirements Traceability weekly progress reports relating to the progress of the process were submitted to the Project Manager

Used the ETL Tool; Informatica Power Center for Data Mapping and performing transformations. Well versed with various Data Warehousing Concepts, Schemas, Data Marts, Data Structures, and ER Diagrams.

Used SQL Server for writing SQL Queries to perform Data Retrieval, Manipulation, Analysis and Validation.

Formulated and executed Test Scenarios and Test Cases based on functional requirements documents (FRD) and helped to develop the Test Plan; performed Sanity Testing to validate reports and dashboards

Worked with Application Development Team on Test issues and conducted daily status meetings with Development and User Team during UAT, Coordinated with Project Management in Planning and Implementing Test Schedule for UAT testing.

Environment: Hybrid Agile, MS Visio, MS Excel, JIRA, Tableau, Postman, JSON, REST Web Services, EDI 835/837, XML, UFT, HTML, IBM SPSS Statistics, SQL, JIRA

Cigna,Remote

Healthcare Business Analyst

Jan 2020 to June 2021

Prepared Business Requirements Documents, Functional Requirement Documents.

Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential.

Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.

Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.

Experience providing training to development teams on how to track, plan and analyze using JIRA.

Conducted JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.

Successfully led the implementation of Salesforce Health Cloud, resulting in a 20% increase in patient engagement through the secure patient portal.

Proficient in gathering and documenting user requirements for Salesforce customizations, ensuring alignment with healthcare organization needs and compliance with healthcare regulations, including HIPAA.

Implemented seamless data integration between Salesforce and Electronic Health Records (EHR) systems, streamlining patient data access and reducing data entry errors by 15%.

Designed and configured Salesforce workflows and automation rules to enhance appointment scheduling and patient follow-up processes, resulting in a 25% reduction in no-show rates.

Created custom reports and dashboards in Salesforce to provide healthcare teams with real-time insights into patient outcomes, enabling proactive care management.

Conducted training sessions for healthcare staff to ensure effective use of Salesforce, reducing user errors and improving system adoption.

Facilitated all Aspects of scrum framework, including product backlog, release backlog, sprint planning session, daily scrum meeting, sprint reviews and sprint retrospectives.

Communicated dependencies and potential risk to the completion of the sprints including resources, costs, and systems.

Created data mappings to transform the data according to business rules.

Developed Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.

Prepared various diagrams by using MS Visio.

Prepared documents for the wireframe and prepared a data dictionary for the same

Managed testing for various functionalities using Quality Center tools.

Worked closely with QA and Developers to clarify/understand functionality, resolve issues and provided feedback to nail down the bugs.

Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.

Conducted project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.

Anthem,Norfolk, VA

Business Analyst/Scrum Master

Jan 2017-Dec 2019

Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.

Gathered high-level requirements for all the external projects in a release.

Performed the requirement analysis, impact analysis and documented the requirements.

Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.

Developing a single application to process data from multiple integration points, convert the data for reporting purposes and feed data into mainframe system to be compliant to reporting requirements.

Performed Analysis on Data mapping between different data models.

Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.

Helping Scrum master across the company to customize JIRA for their requirements.

Used different ad-hoc analysis, the Reports assist in defining strategy for each customer category. Informatics was used for ETL process and Business Objects.

Created ICD-9-CM/ICD-10-PCS comparison document and dealt with DRG shift through CMS files.

Documented ICD9 to ICD 10 mappings one to one/one to Many according to the GEM files from CMS with the functional and structural changes related to the conversion.

Involved in order to understand and implement Processing ICD-9 ICD-10

Worked on EDI transactions: X12,835, and 837 P.I to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes.

Executed the test cases and test scenarios using Confidential Quality center QC.

As Scrum Master maintained the capacity plan, iteration board, sprint backlog, velocity charts and burn down charts.

As Scrum Master facilitated all aspects of the scrum framework, including sprint-planning sessions, backlog-grooming session, daily scrums product demos, sprint reviews and sprint retrospectives.

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.

Facilitated and led JAD sessions aimed at functional requirement walkthroughs for all the impacting projects and updated the documents based on recommendations if any.

Created various reports such as billing payment reports, Billing Grouping Payment, and discount reports.

Use Confidential Quality Center to house all test documentation and report/track all issues and defects Defect Management

NYC Health.NY, NY

Business Analyst

Feb 2015-Sept 2016

Spearheaded the implementation and customization of IBM Sterling B2B Integrator to enhance data exchange and interoperability between healthcare systems.

Collaborated with internal and external stakeholders to define requirements and workflows, ensuring seamless integration of healthcare data.

Led a team responsible for source-to-target mapping, data transformation, and mapping rules within the IBM Sterling platform.

Developed and maintained healthcare data maps, ensuring compliance with industry standards like HL7 and regulatory requirements like HIPAA.

Implemented data quality monitoring and governance processes using IBM Sterling Control Center, resulting in a 25% improvement in data accuracy. - Designed and delivered training programs for end-users and IT staff on the use of IBM Sterling solutions and best practices.

Created custom reports and dashboards within IBM Sterling to provide real-time visibility into data exchange processes and identify bottlenecks.

Collaborated with cross-functional teams to troubleshoot issues, optimize workflows, and ensure the secure transmission of sensitive healthcare information.

Conducted regular assessments of IBM Sterling configurations and made recommendations for enhancements to align with evolving business needs.

Interacted with Business Users and stakeholders to gather the requirements and Creating application Prototypes and screen mock-ups and experience in using VISIO, MS office.

Gap analysis of all dimensions required to build the new Data Warehouse and worked extensively in Fixed Income, Securities, Derivatives, Equities etc.

Involved in developing mapping documents indicating the source tables, transformation required, business rules, and target table's columns and data types for Data models dealing with Swift.

Involved in documenting the business requirements and data specifications for Business Objects Universes and Reports and documented functional and non-functional requirements.

Conducted JAD sessions involving the user community to identify, analyze and formalize requirements and establish working relationships with business functions and solution delivery teams to meet the individual needs of the business functions.

Managed all the requirements in Requisite Pro, making them available to the whole project team and also developed requirements traceability matrices.

Developed the workflows using Workflow Manager to run the sessions and monitor them using Workflow monitor and also used MS Project and Clarity and also experience with 21 CFR Part 11 Compliance and documented functional and non-functional requirements.

Developed the reports using features like drill capabilities, Functions, slice and dice, and cross tab tables with multiple breaks.

Created Test Scenarios and developed strategies with QA team to track and resolve defects.

Used SQL tools like TOAD to run SQL queries and validate the data in warehouse.

Keep track of scheduled environment refreshes and coordinate/communicate with Dev Ops, and Analysts and Creating graphical representations of complex business processes.

EDUCATION DETAILS:

Bachelors of Science in Computer Science

The American University of Beirut

Passing year is 2014

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