Business analysis

PROFESSIONAL SUMMARY

*+ years of experience facilitating business solutions for leading corporate organizations

Highly motivated, passionate, persuasive and articulate; excellent collaboration, communication and negotiating skills

Expert in application/system development life cycles (SDLC); concurrent development strategies, process streamlining, iteration modeling, rapid application development (RAD), and waterfall, Agile and RUP methodologies

Excellent understanding of insurance policies like HMO and PPO and proven experience with HL7, HIPPA 4010 EDI transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (claim status), 834 (benefit enrollment), 835 (payment/remittance advice), 837 (health care claim)

Ability to multitask and work independently as well as in teams

Experienced in customer/client interaction, deep understanding of business systems functionality and technicality

Partnered with subject matter experts to gather and develop detailed business requirements for system implementations and service requests

Strong knowledge and experience in healthcare industry with functional knowledge of Medicaid Management Information System (MMIS)

Experienced in using ICD 9/ICD 10 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for inpatients, outpatients, reimbursement methodology

Educated in Medicaid operations experience

Strong knowledge of skills in development of use case diagrams, collaboration diagrams, sequence diagrams, activity diagrams, state chart diagrams, and class diagrams

Proficient in gathering business and technical requirements from both formal and informal sessions through interviews, NetMeeting, questionnaire, video conferencing, JAD sessions and conference calls

Good knowledge of Medicaid Management Information System (MMIS)

Extensive knowledge of the Order Management (OM) and Supply Chain Management (SCM) starting from the Point of Sale (POS) to SCM which include Warehouse Control System (WCS), Retail Control System (RCS), Transport Control System (TRCS)

Medical claims experience in process documentation, analysis, and implementation in 835/837/834/270/271/277/997 (X12 Standards) processes of medical claims industry from the provider/payer side

Worked on healthcare standards such as HIPPA 4010, 5010, Section 508 Compliance, ICD-9, ICD-10 and SOAP

Good knowledge of facets like claims, membership, billing, and experience in end-to-end testing of these modules

Created Requirements Traceability Matrix to keep the stakeholders informed of the progress of the project

Managed test plans; thorough hands-on experience with designing test cases covering all test conditions and eliminating redundancy and duplications

Extensive experience in functional, integration, regression, User Acceptance Testing (UAT), System Load and Black Box Testing

TECHNICAL SKILLS

Modeling Methodologies Agile and Waterfall

Process/Modeling Tools MS Visio, BPMN

Databases MS Access, SQL Server

Quality Management HIPAA, CMMI, CMM

Languages SQL, HTML, JAVA, C++

Operating System WINDOWS 98/2000/NT/XP, UNIX, LINUX

Office Tools MS Word, MS Excel, MS PowerPoint, MS Access, MS Project, MS Outlook, SharePoint, MS Visio, Trello, Lucid Chart

Project Management MS Project

Testing/Tracking Tools HP/ALM Quality Center, ALM, SOAPUI, QTP

PROFESSIONAL EXPERIENCE

Business Analyst, TMHP. Austin, TX (Accenture) Aug 2022 - Nov 2022

The Texas Medicaid & Healthcare Partnership (TMHP) is committed to helping clients to join the thousands of Texas providers who are helping low-income Texans stay healthy. TMHP Provider Relations Representatives are available to assist both new and existing providers in understanding program policies and procedures, provide technical support for TMHP secure portals, TexMedConnect, and help with claims filing and payment issues. The goal of Texas Medicaid is to provide health care to over 4.2 million Texas residents who might otherwise go without medical care for themselves and their children. To achieve this, Texas Medicaid and a variety of health-care programs rely on a network of dedicated professionals to meet the growing healthcare needs of our clients. Enrolling in Texas Medicaid is a prerequisite for enrolling in other state healthcare programs. By becoming a provider for Texas Medicaid and other state healthcare programs, each provider can improve the health and well-being of Texans in their community.

Responsibilities

Worked with PM to ensure a full understanding of new requirements

Documented user stories in JIRA working with team members to ensure completeness and appropriate level of granularity

Attended daily stand ups, providing updates on current/upcoming work and any blockers and assisting in clearing blockers as requested

Explained the functional requirements to the Development and Testing teams

Performed preliminary analysis of new requirements

Assisted in grooming the backlog – review and refine requirements as needed

Updated Business Requirements Documents (BRDs) as needed

Provided testing assistance as requested in Model Office

Performed extensive requirement analysis including gap analysis

Managed preliminary analysis of issues with tools like FILE TRACKER; ensure understanding of issue and communication to developers on what files to be fixed

Reported status to project management and project owners on a weekly and monthly basis.

Assigned tasks to the team members keeping in mind the complexity and priority of the tasks

Performed manual testing for few Test Cases and verified their working by using positive and negative data

Skilled in project coordination and infrastructure management in fast paced dynamic environments.

Experienced in areas of online transactions applications and agile methodology process model.

Documented the objectives, constraints and scope of the system keeping in mind the changing business requirements.

Performed Manual Testing and Automated Testing. Experienced in Analyzing, designing, executing, and reviewing new and old Test plans, Test cases, developing and maintaining Test scripts, analyzing bugs etc.

Analyzed the EDI X12 data elements in the existing system to validate it against the data elements required in new system

Environment: Windows, MySQL, FACETS, SQL Server, Tidal, MS Office, Ms Visio. Ms Project, Agile, Azure DevOps, Microsoft Teams, SharePoint, TFS software, Jira

Business Analyst, Covenant Health. Knoxville, TN Dec 2020 - Apr 2022

Covenant Health is a comprehensive health system established by the consolidation of Fort Sanders Health System, Knoxville, Tennessee and MMC HealthCare System, parent company of Methodist Medical Center of OAK Ridge, Tennessee. At Covenant Health, I worked for a clinical value integration program/initiative aimed at understanding functional status, risk status, well-being, cost, healthcare satisfaction ratings, perceived benefits and clinical outcomes. This project aimed at measuring the value of care for similar patient population and analyzes the above-mentioned factors to improve the value of healthcare services. Managed MMIS module of Medicare/Medicaid claims and worked extensively on MMIS module as well as back-end database system. Responsible for documenting requirements and provided guidelines for development. Also worked on Facets Claims Processing System (configured facets modules such as benefit plans and contracts as well as related modules such as enrollment, billing, claims, finance, and configuration).

Responsibilities

Involved in gathering requirements from stakeholders

Prioritized stakeholders by developing a stakeholder list and stakeholder assessment matrix

Identified and validated business rules and data elements

Developed and maintained Requirement Work Plan and assessed the Performance metrics of the team members

Gained extensive knowledge in insurance products like HMO, PPO, Managed Care, and HIPAA Regulations

Conducted Risk Analysis and developed mitigation plans

Developed, coordinated, and supported Information Technology division on all operational requirements of Facets claims processing system and production management

Assisted the Project Manager in the development of SDLC methodology and documentation strategy

Executed testing the professional, institutional claims processing and adjudication and validate data with facets.

Managed Medicaid Claims Resolution/Reimbursement for state health plans using MMIS

Gathered requirements for new MMIS, conducted JAD Sessions

Documented the Physical Data mapping and new claim processing flow of Facets and compared with the new application

Documented complex business requirements and made process flow diagram for the 837, 820, 834, 278 transactions as per the 5010 implementations for the Medicaid claim processing system enhancement

Translated the requirements prepared for SDLC methodology to User Stories and implementing Agile methodology as a standard for the ongoing project

Updated System Requirements Document (SRD) and Business Requirements Documents (BRD)

Designed Functional Specification Documents

Involved in the testing of web portal of New MMIS system

Developed User Interface prototypes to capture and validate requirements

Conducted business and requirement analysis activities to incorporate HIPAA and Medicaid provisions for design, development, and implementation project

Proposed strategies to implement HIPAA 5010 in the new MMIS system

Gathered requirements for new MMIS as well as conducted JAD Sessions

Adjudicated medical benefits claims

Experienced in using Microsoft SharePoint for managing requirements documents

Developed test plans, test scenarios and test scripts and participated in System Testing

Advised in integration testing on Facets system to verify HIPAA compliance from 4010 to 5010

Environment: Windows, MySQL, FACETS, SQL Server, BizTalk server, Tidal, Instream server, MS Office, SharePoint, Ms Visio. Ms Project, Agile, Azure DevOps

Business Analyst, State of Rhode Island. Providence, RI Dec 2018 – Jun 2020

State of Rhode Island Health and Social Services Health Plan and Medical Services segment provides health plan commercial risk, Medicare advantage, and Medicaid for Resident. State of Rhode Island Health and Social Services’ Medicaid expertise helps communities around the nation support their Medicaid recipients gain control over their health challenges. The Centers for Medicare and Medicaid Services (CMS) had implemented a timeline that requires adoption of the HIPAA 5010 ASC X12 standards. The project was to upgrade the system that currently uses HIPAA 4010 to comply with HIPAA 5010. Gap Analysis was performed and changes were identified in HIPAA 5010 so as to upgrade the Medicaid Management information System (MMIS) to comply with the new standards mandated by HIPAA.

Responsibilities

Served as SME for the application team and the infrastructure team

Gathered specific business requirements from several different managed care programs

Specialized in RequisitePro for writing/analyzing project vision, goals, specifications, and requirements

Performed the testing of web portal of new MMIS system

Managed Medicare bills and commercial HMO/PPO claims daily

Created and documented BRD and FRD for Medicaid managed care requirements

Developed Agile SDLC methodology such as Scrum Work Pro and Microsoft Office software to perform required job functions

Executed requirement-gathering phase and project plan

Formulated the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for processing of Medicaid claim

Responsible for analysis, design and developing technical requirements

Extensively used Agile Methodology in the process of the project management based on SDLC

Conducted gap analysis in changing old MMIS and Involved in testing new MMIS

Collaborated with other Subject Matter Experts (SME) during creation of test plans and updating of business requirements

Liaised between end user and Facets for user problems, outstanding issues, training needs and new software releases

Designed different diagrams using MS Visio

Customized an Implementation document of the transition process from ICD9 to ICD10

Supported the evaluation of progress and readiness towards performing certain key business functions using the HHS - CMS blueprint test scenarios

Developed Business Process for ‘AS-IS’ and ‘To-BE’ Business Functionality

Accomplished data mapping, logical data modeling and used SQL queries to filter data within the Oracle database tables

Profound understanding of insurance policies like HMO and PPO and proven experience with HIPPA 4010 EDI transaction codes such as 270/271 (inquire/response health care benefits), 276/277 (Claim status), 834(Benefit enrollment), 835(Payment/remittance advice), 837(Health care claim)

Environment: Windows, MS Share Point, SIT/ UAT, Quality Center, MySQL, Facets, SQL Server, MS Office, NASCO, Agile

Business Analyst, Caresource. Dayton, OH Jan 2016 to Sept 2018

As EDI Business Analyst, I was responsible for validating data per Medicaid and HIPAA regulations, and error processing for the transactions that could not be processed through system. During the implementation/claims resubmission process, I was acting as the liaison and interface regularly with external and internal customers, trading partners, software vendors, business analysts, software developers, and project managers. I worked on Facets Claims Processing System (Configured Facets Modules such as Benefit Plans and Contracts as well as related modules such as Enrolment, Billing, Claims, Finance, and Configuration). I also worked on Medicaid claims processing, which includes prioritization of claims, creating Medicaid reports and checking the status of the claims. Research and submit backlog, rejected claims which are historically rejected.

Responsibilities

Collaborated with client groups to determine requirements and goals. Utilized Rational Unified Process (RUP) to configure and develop process, standards, and procedures and create a Business Requirement Document

Responsible for preparing Software Requirement Specification (SRS) and documenting them

Created process workflows, functional specifications documents and documented system requirements

Worked in FACETS for claims processing

Participated in full software development life cycle implementations (SDLC) from project initiation to final deployment

Experienced in different modules of Facets such as members/subscriber, commissions, provider, billing

Managed membership/enrollment and billing-entered information on Facets to ensure correct eligibility

Worked alongside UI designers to have screen layouts, UI designs and mockup screens for new features based on the requirements

Validated claims against the HIPAA Standard and processed through the Gateway

Worked extensively on the EDI Transactions like; EDI 270, EDI 271, EDI 276 EDI 834, EDI 835, EDI 837

Collaborated with clients to better understand their needs and present solutions using structured SDLC approach

Interacted with the developers to report and correct bugs

Used Facets to provide seamless transactions between the provider, members, and the plan

Teamed up with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within Facets

Developed use case documentation for system requirements, business process flows, and UI mockups using MS Visio

Tested the billing and rendering provider, member subscriber, and payment modules of Facets in the UI as well as in terms of database validation through SQL Queries

Experienced in Macess for business process management and customer relationship managements and updated technical documentation from functional documentation

Co-led with management in standardizing web applications by preparing GUI standards and recommending alternatives for incorporation in a phased, iterative manner

Identified and clearly defined functional issues and support IT development staff throughout the design, development, unit testing, and implementation phases of the software development life cycle

Analyzed and translated business requirements into system specifications

Environment: Rational Unified Process, Rational Rose, Visio, MS Project, MS FrontPage, Windows, Medicare, Medicaid, Facets, HIPAA, Agile

EDUCATION

Bachelor of Information System Programming, Strayer University, Ashburn, Virginia (2013)

OTHER

Citizenship: U.S. Citizen

Languages: Fluent in English, Farsi, Arabic

Government Access: Public Trust

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