PROFESSIONAL EXPERIENCE:

Oriented individual with over 12+ years of diversified experience in Healthcare and Finance IT industry.

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

Extensive experience as Business Analyst in the Healthcare Industry with expertise in Affordable Care Act (ACA), HL-7, EDI Transactions (834, 835, 837), HIPAA, MMIS, Confidential and Medicaid.

Experienced in business process flows, business process modeling, case tools, business analysis, gap analysis and organizational change management.

Experienced in conducting sessions and worked with executives, developers, and end-users to define the exact requirements.

Solid understanding of Membership, Claims Processing, Billing, Benefit/ Eligibility, Authorization/ Referrals, COB, and have experience in HIPAA standards and corresponding EDI transactions (837, 834 and 820).

Knowledge of health care services regulatory environment in compliance with HIPAA, ICD, MITA, MMIS.

Knowledge on Confidential, Medicaid, MMIS, HIPAA EDI transactions 278, 820, 834, 835, 837, ICD-9, ICD-10, HL7, HMO, PPO, ANSI X12 Procedural and Diagnosis codes.

Used Microsoft SharePoint as a Web-based Content Management System as well as a Document/ Project Management tool.

Excellent knowledge of HIPAA (Health Insurance Portability and Accountability Act) 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 enrolment).

Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/ Drafts, Claims pricing and testing, HIPAA, enrolment, EDI, HER, HIX, Confidential, Medicaid, CDHP (consumer driven health plans).

Ability to develop business rules, context data flow diagram, entity relationship diagram, workflow diagramming, prototyping and document current state, gaps and future state processes.

Experience in multi-tasking such as managing numerous simultaneous projects with great attention to detail.

Experience in solution assessment, validation and applying critical thinking for problem solving approach.

Experience in Requirements elicitation techniques like conducting user interviews, document analysis, JAD sessions and managing the requirements.

Comprehensive knowledge of Software Development methodologies (SDLC) such as Waterfall, Agile, Spiral and Scrum.

Create various documents like the Software Requirement Specifications (SRS), Business requirements document (BRD), Use Case Specifications, Functional Specifications (FSD), and Systems Design Specification (SDS).

Good Knowledge of software and applications designing tools for the preview of the project at the very beginning.

Analyzed different types of Risks such as Credit Risk, Market Risk etc. and developed the test scripts with all these parameters to analyze the securities.

Worked closely with project Stakeholders, SMEs, PM, to understand, analyze, document, validate, and review the requirements and specifications for new applications along with enhancements to the existing applications.

Efficient in writing Business Requirement Document (BRD), Functional Specification Document (FSD), Use Cases, User Interface Specifications (UIS), System Requirement Specification (SRS) and Report Specifications Documents.

Skilled in translating business requirements and user expectations into detailed specifications and building business process flow charts using MS Visio and Enterprise Architect to communicate project functionality to the development team employing designing techniques like OOAD and Unified Modeling Language (UML).

Sound proficiency in analyzing and creating, Use Case Diagrams, Sequence Diagram, Activity Diagram, Data Flow Diagrams, Business Flow Diagrams, Wire Frames and Mock-ups using MS Visio and Rational Rose to communicate business and functional requirements to clients and developers.

Performed AS-IS and TO-BE business process flow for clear translation of Functional to system requirement specification.

Support the Test Team and the rest of the Development Team in compliance related issues while working with them in the development phases of the projects.

Business Analyst with solid understanding of Business Requirements Gathering, Business Process Flow and Business Process Modelling and Data Mapping.

Extensive working experience on Medicaid, Confidential and MMIS projects.

Capable of managing multiple projects simultaneously

Technical Skills:

Modeling Tools

Unified Modelling Language, MS Visio, Balsamiq

SDLC Methodologies

Waterfall, Waterfall Scrum Hybrid, Agile-Scrum, Kanban

Business Skills

Process Modeling, GAP Analysis, Impact Analysis, SWOT Analysis, JAD Sessions, Project Scheduling

Requirement Management

JIRA, MS Office, Confluence

Document Processes

UML Diagrams, Use Cases, BRD, FRD,

Testing Tools

Postman, Swagger

ETL Tools

Informatica PowerCenter

Web Services

AWS Lambda, API

Databases

SQL Server

Domain Knowledge

HIPAA, Medicaid, Medicare, Claims Management, EDI Transactions, HL7, HIX, EMR/EHR, PPO, HMO, POS

Operating Systems

Windows XP/7/10

PROFESSIONAL EXPERIENCE:

Carecentrix, Tampa, FL Mar 2021 to till date

Lead Healthcare Business Analyst/ Scrum Master

Scope: The main purpose of this project is to convert a SCM Desktop application to a web based application.SCM Desktop Application has major performance issues due to the current system architecture. These areas include maintaining Provider PINs, TINs and Net IDs on the Provider Tab, generating the Compensation Schedule documents, and saving Rate Wizards with a large volume of service codes. All the existing SCM functionality should exist in the new Web based version of SCM with enhanced performance and response times.

Responsibilities:

Gathered Business Requirements from all the stakeholders and interacting with the providers, managers, developers to develop the business Processes and created User Stories & Product backlog.

Used Microsoft Office suit to develop the documents such as Visio for creating wireframes, Word, Excel and PowerPoint for creation of Business Requirement documents.

Supported PMO by mentoring specific projects in application of the new SDLC, especially from the project management, requirements and architecture perspectives.

Create data source to target mapping document with complex data transformational rules which includes the encryption of PII/PHI data using IBM Infosphere FastTrack tool.

Develop business terms & definitions, identifying critical data elements, using IBM Infosphere Information Governance Catalog tool.

Develop data integration & data quality rules, data profiling, defining thresholds & frequencies using IBM Infosphere Information Analyzer tool.

Assist Solution Architects by contributing towards the High-Level Solution Design and Detailed Design documents.

Documenting the types and structure of the business data (logical modeling).

Performing deep analysis on reporting packages (Business Objects etc.), databases (SQL etc.), programming (XML, JavaScript, or ETL frameworks).

Working with statistical packages for analyzing datasets (Excel, SPSS, and SAS etc.).

Working with IA/SA hand in hand in analyzing API’s that are required for the project.

Mapping and tracing data from system to system in order to solve a given business or system problem. Design and create data reports and reporting tools to help business executives in their decision making.

Prepared Test plans, Functional Test cases and executed the test cases in Quality Center.

Involved in the black box testing of the Healthcare application and identified the different test cases for regression testing.

Involved in Regression testing of each build during the various phases of the application using QTP.

Tested and delivered Inbound/Outbound Facets interfaces.

Used to execute test cases for several transactions such as 837, 835, 820, 834, 277, 278, 270/271.

Created EDI Export and Import processes and work with EDI Trading Partners, Payers or Vendors.

Reported defects and maintained Test Cases in HP Quality Center.

Used HIPAA 5010 transactions to support the analysis of current business processes and work with management to improve and implement enterprise solutions to ensure compliance and got involved in designing future state processes for HIPAA 5010 transaction processing EDIs 837, 835, and and ICD-10 code sets.

Recommend on implementation of HIPAA 5010 (EDI X12 837,834, 820, 278,270,999) in the new System.

Performed GAP analysis for EDI transactions such as 837, 834 to support state specified X12 5010 file formats.

Gathered requirement on FACETS EDI 834 Benefit Enrollment and Maintenance subsystems.

Worked With HIPAA compliant ANSI X12 837 formats for both professional claims and institutional claims.

Executed Test cases manually by composing 270, 276, 837 EDI files and dropped inbound and check response 271, 277, 835 using interleaves and outbound.

Ensured that relevant UML diagrams and tools were used in all requirement documents and prepared Use Case Models, Flow Diagrams, Sequential Diagrams in MS Visio.

Conducted Requirements & Impact analysis for doing ad-hoc mass changes to reference data as requested by business.

Held regular JAD meetings with the system architects, developers, database developers, quality testers during the entire project to assure that the critical as well as the minute details of the project were discussed and issues were resolved beforehand.

Environment: Agile, MS Project, MS Excel, MS Office, MS Visio, FACETS, EDI, HIPAA, Black Box, Regression, UML, SQL.

Harris Health System Houston, TX Jun 2019 to Feb 2021

Business Analyst/ Data Analyst

Scope: The Harris Health System, to create audit/testing and monitoring dashboards. Implement a data mining and analytics tool and associated processes to extract Accounts Payable (AP) and Travel and Expense data directly from source systems and utilize risk-weighted rule sets and key word searches to enable data analytics via a front-end visualization tool. This project will allow statistical sampling methodology for FCPA testing that is harmonized across regions and sectors, reduction in the time and effort currently required to extract data, analyze, and select samples for transaction testing, Minimize the need for Op Co resources to support the process, Improve integrity of data extractions, 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 EMR devices and converted the requirements into User stories and created Product backlog 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.

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

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

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

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 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

Have proven business insight and the technical know-how to implement large-scale EMR and EHR engagements

Used the ETL Tool; Informatica Power Center for Data Mapping and performing transformations.

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

Tested & Documented REST Web Services in JSON for the EHR systems & EHR Connect in Postman and assisted the QA lead in automating the Web Service Testing using UFT

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.

Environment: Hybrid Agile, SNOMED, FHIR HL7 DaVinci, Postman JSON, MS Visio, UML Use Cases, SQL Server.

Mediant Health Resources, Phoenix, AZ Feb 2017 to May 2019

Sr. Healthcare Business Analyst

Scope: As a part of the project, I worked on Claims processing module. The claims processing module involved Receipt and Verification of Claim Forms (837) and Claims Attachments (275), Claims Enquiry and Response (276/277), Adjudication, Healthcare Claim Payment (835) as per HIPAA guidelines.

Responsibilities:

Applied RUP methodology with its various workflows, artifacts and activities to manage life cycle from Inception to Transition phase.

Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of payer contacts.

Experience on all phases of Software Development Life Cycle (SDLC) from project initiation to deployment. Experience in Agile and Scrum methodology.

Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems in SOA are impacted by the EDI X12 Transaction, XML, XSLT, Code set and Identifier aspects of HIPAA.

Involved in GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.

Good Understanding of the EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.

Integrated SailPoint IIQ with their existing provisioning system in order to cater existing requirements.

Involved in the User Acceptance testing UAT to check the reliability for end users.

Designed Test Plans and Test Cases for User Acceptance testing (UAT) with the help of QA teams.

Create Mapping documents, ETL technical specifications and various documents related to data migration.

Participating in HEDIS performance reporting and intervention analysis.

Implemented & supported Identity Management, LDAP Directories, Provisioning/Identity Workflows.

Worked on the EDI 834-file load to Facets through MMS (Membership maintenance sub-system)

Worked with FACETS edits and EDI HIPAA Claims (837/835/834) processing.

ICD 9 - ICD 10 Conversion Project - Worked in the analysis of the ICD 9 - 10 codes conversion Project.

Documented the Requirement Traceability Matrix (RTM) for tracing the Test Cases and requirements in Blueprint.

Responsible for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.

Modified and created vendor specific maps for the 850, 820, 834, 855 and 856 transactions (EDI to XML, XML to EDI and delimited to XML). Worked on XSLT, XML schemas and xpath.

Developed and prepared EDI documentation for 837 outbound EDS claim processing.

Worked on HIPAA Transactions and Code Sets Standards according to the test scenarios such as 270/271, 276/277,837/835 transactions.

Coordinated with the EDI team in developing and documenting the detailed testing work plans and created the various testing documents for the assigned EDI transactions.

Responsible for attaining HIPAA EDI validation from Medicare, Medicaid and other payers of government carriers.

Created Requirement Traceability Matrix (RTM), Defect Report and Weekly Status Report.

Tested the HIPPA EDI, 834, 270/271, 276/277, 820, 837/835 transactions according to test scenarios and verify the data with Facets on different modules.

Environment: MS SQL Server, Payer, SDLC, UAT, Rational Unified Process (RUP), EDI, Rational Rose Requisite Pro, TIBCO, ETL, SSIS, SSRS, Informatica, Sailpoint, Tableau, Safe Agile, Quality Center Test Director, Clear Quest, and MS Office Tools.

Molina Healthcare, CA Sep 2015 to Jan 2017

Healthcare Business Analyst

Scope: Provided support for conversion of complicated legacy Provider network information system to better one. Worked on Business Reports and guiding in implementation and configuration. Providing expert level knowledge in creating Project Plans, Data Mapping documents, Data Load Plan, Mock Load Plans and Business Rules plan. Responsible for configuration of data mapping document. The objective of the system was to secure the health information, and to also ensure the authenticity and privacy of the member information.

Responsibilities:

Identified and validated business rules and data elements, created Business requirement document (BRD) and Functional Requirement Document (FRD).

Gathered requirements from the Client to fulfill the Application need for FACET Implementation.

Created 837 (P, I, D) claims and maintained data mapping documents in reference to HIPAA transactions primarily 837 (P, I, D), 834, 835, 270, and 271.

Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.

Worked with TriZetto based software called QNXT to obtain members information.

Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare.

Utilized SQL server to run basic queries and obtained necessary data for Medicaid and Medicare Encounters.

Worked closely with the ETL data warehouse and BI teams while developing data mapping documents & validation and wrote SQL queries

Worked with Facets software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPPA transactions and facilitate the administration of HIPAA privacy rights.

Used SQL query to produce data for 270 EDI X12 file and created 270 files.

Reviewed vendor files for any errors, missing segments, and for missing data on X12 file. Ensured file had complete data before encounter can be submitted to Medicare and Medicaid.

Facilitated meetings with the technical team and client team to analyze the current process and gathered requirements for the proposed process.

Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999, 270 & 271HIPAA EDI Transactions using MS Word and MS Excel.

Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifices.

Extensively uploaded test cases from MS Excel, MS Word to Test Director & Quality Center.

Environment: MS SQL Server, Payer, SDLC, UAT, Rational Unified Process (RUP), EDI, Rational Rose Requisite Pro, ETL, SSIS, SSRS, Informatica, Sailpoint, Tableau, Safe Agile, Quality Center Test Director, Clear Quest, and MS Office Tools.

Excellus, Rochester, NY Mar 2012 to Aug 2015

Business Analyst

Scope: The project was to improve the member portal user interface by enhancing the existing claim search engine and creating new functionality where one can check the healthcare plan eligibility and estimate the costs

Responsibilities:

Gathered Requirements from all the stakeholders and created Use case document, Vision document and prototype as per the business Requirement.

Conducted Risk Analysis and Impact analysis whenever there is any change in the business requirement and proposed solutions while continually updating the business requirement document.

Conducted JAD sessions and ultimately reducing the time spent in moving all the information from stakeholders and other team members.

Created and updated data mapping document(s) with reference to the source for 270/271 (Eligibility & Benefit Inquiry & Response), 276/277 (Claim Status Inquiry & Response) and 837 (Health Care Claim).

Conducted Gap Analysis to analyze the client’s applications programs to determine the impact of HIPAA final on EDI transaction set and defined the changes to bring the affected systems into HIPAA compliance.

Worked with FACETS Team for HIPAA Claims Validation and Verification Process (Pre-Adjudication).

Utilize Rational Unified Process (RUP) and build different phases of software developmental cycle.

Actively involved in designing EDI transactions using the new HIPAA 5010 version and ICD -10 codes and analyzing HIPAA compliance and EDI transaction.

Knowledge of the software system and the programs.

Developed and executed UAT test cases, UAT test Scenarios using HP ALM/Quality Center and followed-up defects using JIRA.

Created architectural styles such as application architecture, enterprise architecture, and service-oriented architecture with the help of Service -Oriented modeling (SOA).

Performed Requirement Tractability Matrix (RTM) to track and maintain stakeholders requested requirements and changes.

Environment: MS Project, Requirement Traceability Matrix (RTM), Rational Rose Test, JAD, RUP, MS Visio, Windows OS, MS Office, SharePoint, Server, Quality Center, ETL, SQL Server.

EDUCATION:

BE (Electronics & Communication Engineering) - 2005

CERTIFICATIONS:

Safe Certified Agilist

AHM250 certified.

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