business analyst

Ettireddy Padmanabha: US Citizen

Columbus, IN

******************@*****.***; 469-***-****

SUMMARY OF PROFESSIONAL SKILLS:

Overall 13+ plus years of experience as Business Analyst and 7+ years of exp. In Healthcare Industry.

Strong work experience with industry standards such as HIPAA (Health Insurance Portability and Accountability Act) and Six Sigma.

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

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

Well versed with Agile and SAFe agile /Scrum work environment and familiarity with writing user stories and following the development process through user story acceptance.

Highly efficient in Business Analysis, documentation gathering and knowledge of version changes (5010) and how it impacts backend systems and Front-end systems and applications.

Knowledge of ICD-9 and ICD-10 Diagnosis, Surgical and Procedural Codes.

Experienced working in various domains and systems such as eCommerce, Retail and Customer merchandising, Media, Manufacturing, CRM, CMS and Mobile Apps Android and IOS and understanding of BI Business Intelligence System.

Exceptional skills in healthcare business process review and design use cases, documentation, gap/fit analysis, impact assessment, testing, and training.

Experienced in Medicare and Medicaid domains of the healthcare systems and Claim Process and Payer Domain business process

Knowledge of MMIS (Medicaid Management Information System), EMR (Electronic Medical Record), EHR (Electronic Health Record), HIE (Health Information Exchange) and healthcare reforms like the Patient Protection and Affordable Care Act (PPACA).

Strong expertise in Health Insurance Claim process, CMS1500, UB04 billing for Medicaid, Medicare

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).

Experience in provider’s domain, provider data management and FIHR

Experience in Utilization Management, Case Management, Disease Management, Maternity, Healthy Lifestyle

Extensive knowledge on performing Process reengineering by documenting and evaluating existing business processes.

Highly familiar with understanding all phases of project development life cycle using standard methodologies including analysis, design, and development of software applications.

Sound knowledge & experience using Unified Modeling Language (UML), Rational Unified Process (RUP), Rational Suite including Rational Rose and Requisite Pro.

Experience in laboratory Information and management Systems (LIMS)

Experience in Data Model analysis of large databases, working with large datasets/databases. Strong SQL knowledge

Familiar with various elements throughout the development lifecycle, including test data requests, creating User Acceptance Test (UAT) scripts, conducting UAT.

Experience as the Product Owner and Agile Scrum Master.

Experience in project management, risk control matrix, process mapping, wealth management and risk mitigation plan as a part of process documentation.

An energetic, self-motivated team member, effective communicator with excellent relationship building and interpersonal skills.

Experience in writing research project proposal, Engineering Standard Work (ESW), Specification standards, Technical Reports, Standard Operating Procedures (SOP) and Quality Assurance Project Plan (QAPP) for any aimed projects.

Six Sigma Green Belt: Experience in using six sigma tools for cost reduction as well as process improvement, example: design of experiments (DOE), measurement system analysis (MSA), capability analysis (CpK and PpK), process mapping; cause & effect (C&E) matrix, failure modes and effects analysis (DFMEA and PFMEA); design verification plan & report (DVP&R), fault tree analysis (FTA) or root cause analysis, RASI matrix.

Proven problem-solving approach; ability to work under pressure; outstanding communication, presentation, and interpersonal skills; time-honored record of planning & organizing, initiative skills; ability to work independently as well as with cross-functional teams.

Wide experience in process development, project management functions, program resourcing estimates, operational budget setting, technical cost reduction and coordinate working situation of diversified groups (customers, stakeholders, and cross-function teams).

Strong analytical, problem solving and organizational abilities.

KEY TECHNOLOGIES & TOOL EXPERIENCE:

UML Tools

Rational Rose / Microsoft Visio / Enterprise Architect /Provision

Rational Tools

Clear Case/ Clear Quest, Requisite Pro, SharePoint

Databases

Mainframe, Oracle, DB2, MS Access, SQL Server,

Methodology

Waterfall, RUP, SDLC, UML, Agile, JAD

Web Design

HTML, DHTML, XML

Front end tools

Microsoft Project, MS Visio

MS Office Tools

MS Outlook, MS Word, MS Excel, MS Access, MS PowerPoint

Operating Systems

Windows, Mac OSX

PROFESSIONAL EXPERIENCE:

Sr. Business Analyst/Product Owner/ Scrum Master Jun 17- Till Date

Massachusetts Dept. of Health & Human Services, Boston, MA

Description: The project was to gather requirements, write and prioritize user stories, daily scrums, scrum review and retrospective meetings. Involved in provider’s data management and calculate the rate and set the premium based on the input data from the Data file. Activating healthcare exchange members (HIX) data directory was extensively used to secure the information.

Responsibilities:

Used Agile and involved in SAFE Agile SDLC methodology, gathered requirements from customers, stakeholders, then wrote and prioritized user stories, managed product backlog.

Prioritized the sprint and product backlogs directly working with the product owner and scrum master.

Gathered high-level requirements from the product owner and coordinated with the scrum master to conduct sprint meetings.

Worked with the EDI team to validate the input and the translated files based on the mapping guide.

Worked with medical coding and transition of ICD 10 and developed Schemas of EDI X12 Claims (837) and Eligibility forms in XML and also used SQL Server to write stored procedures, SQL statements.

Analyzed inbound x12 HIPAA files and execute Trading partner testing and integration and facilitated UAT for successful end user sign off.

Helped design the mobile app with similar styles and functions.

Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.

Created lists of ICD10 CM/PCS codes, with reference to the usage percentile and provided to Stakeholders to determine if codes were best fit or all possibilities.

Used the Descriptive Analytics experience to gather the data from different zip code, agent code and the rate information.

Used knowledge of Health Care Information Systems EMR model to develop proposed workflow in MS Visio.

Experience with developing HIPAA Companion Guides for 834 Enrollments, 270/271 Eligibility Inquiry/Response & 820 - Health Plan premium payments for MMIS.

Created, socialized, and obtained approvals for three decision documents: ICD 10 Procedure Codes, Medicare, and Backward Mapping.

Experienced on providers domains, providers process, provider data management, HL7, FIHR, and claims process from provider side.

Handled project management, risk control matrix, process mapping, and wealth management risk mitigation plan as a part of Healthcare Exchange HIX process documentation.

Developed HL7 messaging for bi-directional case and disease report exchange, in text and XML formats, in accordance with HL7 specifications.

Validated and documented data masking requirement to support process ad workflows, developed data mappings to existing data sources.

Business analyst for collaborating requirements from CA, MT and NY state Medicaid system used JIRA as a tool to manage the requirements.

Actively involved in Healthcare Exchange HIX process flow analysis for a content management system.

Coordinated and monitored Affordable Care Act (ACA) Mandates within Health Care Reform Program; mapped the business and functional requirements to those with 100% accuracy.

Facilitated UAT with IT and Business Stakeholders.

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

Involved with the management to improve and to enhance the future processes for HIPAA5010 transaction sets of EDI including 837, 835, 834 and 820.

Imported data from various patient accounting systems via delimited text files, XML, HL7, FHIR.

Tested ICD-10 codes for EDI files within HIPAA specific guidelines creating SQL queries for manual testing.

Tested various transactions Enrollment EDI 834, Payment EDI 835 and claims 837 for their compliance with the HIPAA regulations.

Experience in the use analysis of HL7, LOINC, SNOMED codes and other coding schemas for making EHR more effectively.

Tested healthcare benefits and enrollment X12 EDI 834 initial enrollments, change transactions, terminations\Cancellations, membership renewals.

Developed test scripts, Business Deployments Strategy documents, RTM, facilitated UAT testing.

Wrote UAT Test Plan, organized and conducted User Acceptance Testing with clients and worked as a part of support team.

Providing reporting guidance to ensure compliance with CMS, DHCS & DMHC reporting requirements

Developed and configured all the XML & T-SQL code that was used in the project workflow so that end to end processing was automated. This consisted of configuring various XML files for each step.

Performed Defect Analysis in EDI 834 and EDI 820 transactions using Quality center and proposed the resolution and fix for the defect by using Mapping document and implementation guide and deployed to appropriate developer to fix the defect.

Executed data validation testing for systems implementation projects to confirm the quality of project deliverables.

Developed Use cases and activity diagrams and analyzed business requirements.

Performed UAT testing, End-to-End Testing, Functional, and Regression Testing and Business Scenario Testing.

Experience on working on several different databases like Oracle, SQL Server, MySQL, and Access.

Environment: MMIS, UAT, MS office, MS Visio, C, C++, Java, Quality Center, SDLC, Facets, Use Cases.

Scrum Master/ Sr. Business Systems Analyst Dec 2015-Mar 2017

Well Care, Tampa, FL

Description: The goal of the project involved HIX member’s enrolment, billing claims and customer services process that are required to participate in the federal health insurance exchange (HIX). This exchange was according to the compliance with Patient Protection and Affordable Care Act (PPACA). The project employed RUP methodology.

Responsibilities:

Gathered business and user requirements through open-ended discussions, brainstorming and prototyping to achieve the following goals.

Involved in configuration of FACETS Subscriber/Member application

Worked on FACETS Data tables and created audit reports using queries. Manually loaded data in FACETS and have good knowledge on b business rules.

Implemented new services and programs via MMIS for the Medicaid program by directly interfacing with the customer and the system engineers regularly.

Compiled validated and report system-wide metrics to attest meaningful use of EMR, EHR and HIE using FHIR to the Centers for Medicare and Medicaid Services.

Prototyped the automation and enhancement of the manual processes in member enrollment, terminations, and reconciliation

Design process flows of EDI Transactions (Portal --> (HIX) --> Carriers) using MS Visio.

Facilitated JAD sessions for Updating Member Billing capabilities / processes and reporting, Updates to Delegate/Vendors Interfaces, Develop / Enhance Call Center and Customer Service Processes

Ensured billing and premium collection are modified to support 820 HIPAA transactions set.

Involved profoundly in the GAP Analysis organizations’ current systems’ capabilities and future system requirements for facilitating connectivity with the Exchange.

Understanding the user requirements through conducting interviews, ethnographic research, creating audio/video recordings to capture consumer insights and convert them into innovation mobile applications.

Worked on providers domains, providers process, provider data management, FIHR, and claims process from provider side.

Enhanced 834/999 EDI file transfers to enable transfer of member data with Exchange platforms.

Worked with Health Care Reform / Customer Service team to establish a dedicated Customer Service Model to address member needs at each point in the customer experience (pre-enrollment, during enrollment, post-enrollment etc.).

Worked on different EDI scenarios for batch processing and ensured day-to-day EDI transmission reject tracking and Reconciliation.

Working on SOA Web Service testing, using SOAPUI to test web service request and response between two ends, and

Tested the ability to store Identification number received from the Exchange and create a unique identifier for members received through the Exchange.

Worked with IT in developing a new capability that will allow tracking new HIX membership’s alignment across their consumption and utilization within organization’s plans/products.

Used Rational Clear Case to keep different versions of the documents and Rational Clear Quest to report bugs or defect.

Maintained a Requirements Traceability Matrix (RTM) in order to keep the clients and all the teams up to date with the current progress of the project.

Designed the test plan and test cases, involved with reviewing defects reported from UAT efforts and analyzed for root cause and took actions based on the findings.

Environment: Rational Rose, Rational Requisite Pro, MMIS, UML, SQL Server, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), Visual Basic, Windows, Java, Oracle, VB.Net, RUP.

Business Analyst/Scrum Master Nov 2013 to Nov 2015

Harris Health System Huston, TX

Description: The Harris Health System, previously the Harris County Hospital District, is a governmental entity with taxing authority that owns and operates three hospitals and numerous clinics throughout Harris County, Texas, United States, including the city of Houston. 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:

Requirements gathering from Subject Matter Experts, project stakeholders and Business users to obtain maximum details of requirements and involved in documenting Business Requirement Documents (BRD).

Liaison between the Business needs (business users and sponsor) and the Technical team (development and testing staff), ensuring technical solutions satisfied business requirements.

Conducted JAD sessions involving the management, development, and user teams for clarifying requirements and facilitating better communication.

Careful documentation of business requirements ensured that they are aligned with UI from the initial stage itself.

Worked in Healthcare Claims Administration – Healthcare Claims.

Processing (837/835) includes facility claims and professional claims.

Did data analysis, created data mapping documents and kept the documents updated with changes in requirements and functional specifications.

Worked with EDI Team for Data Mapping and Building 837 Maps.

Participated in entering, tracking system defects in Rational Clear quest.

Apply UML notations and methodology in developing models that accurately represent the business process and workflows and clearly communicate them to the stakeholders.

Analyze EDI data elements captured by the existing system to validate it against the data elements required for new system.

Was also involved in the configuration set up of provider reimbursement, benefit package, membership, and pricing in FACETS.

Used Microsoft SharePoint as the version tracking tool for managing the requirements documentation.

Ensured that the claims processing is strictly under the HIPAA compliance regulatory document to safeguard patient information.

Environment: Claims, Rational Clear Quest, HIPAA, MS Visio, MS SharePoint, UML Use Cases, SQL Server, Use Case Documentation.

EDUCATION:

B.Sc. (Maths, Phys, Chem), Osmania University, 1997

M.Sc. (Chem), Osmania University, 1999

PROFESSIONAL CERTIFICATIONS:

Six Sigma Green Belt

Project Management

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