Business Analyst Quality Manager

Business Analyst

Niyati Singh Thakur

SUMMARY:

Over 9+ years of experience as a Business Analyst with an adept understanding of Business Requirement gathering, Business Process flow, and Business Process Modeling and Analysis in Healthcare.

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

Well-versed with Systems Development Life Cycle (SDLC), Waterfall, and Agile models.

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

Have experience working on HIPAA X12 EDI transaction codes such as 270/271 (inquiry/response health care benefits), 276/277 (Claim status), 834 (Benefit enrollment), 835 (Payment/remittance advice/ Explanation of benefits), 837 (Health care claim).

Gathered requirements to check HIPAA- eligibility & participation check for individual coverage.

Conducted several Joint Application Development (JAD) sessions for requirements gathering, analysis, and design to meet the business requirements and resolve issues.

Devised and implemented various business initiatives to ensure functionality, efficiency, and quality outcomes.

Have experience with Salesforce project implementations, analyzing business needs and roadmaps to configure and customize solutions

Assist with project management tasks for cross-functional projects to ensure alignment including but not limited to process mapping, and testing both functional/UAT design & execution.

Experience in the development of Process Flow Diagram, Use Case Diagram, Activity Diagram, and Sequence Diagram by using UML methodology using tools such as Rational Rose and MS Visio.

Proficient in using Microsoft Office suite (word, excel, Access, Visio), PowerPoint and Outlook) for documentation, analysis, and presentation purposes.

Skilled in performing Gap Analysis to check if the existing system infrastructure is compatible with the new business requirements.

Possess excellent organizational, interpersonal, communication, and documentation skills with good process management skills along with a remarkable ability to gather requirements to deliver a quality product.

Worked on multiple projects as a project team member and led the team projects on several occasions.

Substantial QNXT experience that includes participation in all phases of EMR implementation; including project planning, workflow analysis, design, build, validate (DBV), “Go-Live” training delivery, on-site support, and post-go-live optimization.

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

Possess strong analytical and problem-solving skills with the ability to adapt to dynamic workflow changes and to meet stringent deadlines.

Adept in writing SQL queries for data extraction, manipulation, analysis, and validation, generating user reports.

Used SQL queries for the arrangement of customer data.

Designed and maintained end-to-end data mapping and data conversion spreadsheets.

TOOLS & SKILLS SETS

Testing Tools: Quality Center /HP ALM, JIRA, Rational Clear Quest, FACETs

MS Office Suite: MS-Word, MS-Excel, MS-PowerPoint, MS-Project, Visio, Access

Operating Systems: Windows, Linux, Unix, Mainframe

Methodologies: SDLC–Waterfall Model, Agile/Scrum

UML Diagram: Use Case, Activity

Database: MS-Access, Oracle, SQL Server, DB2

Web Technologies: HTML, XML, VB, SQL, JCL

ETL Tools: SQL Server Integration Services (SSIS), Informatica Power Center, Data Stage

BI Tools: Crystal Reports, Business Object, Crystal Enterprise, SSRS

EXPERIENCE

Business Analyst

Emblem Healthcare, NY March 2022 – Present

Emblem healthcare, NY is a health insurance company which helps in enrolling in various insurance plans such as Medicare, Individual & family, Medicaid, Medicare Supplement and Group Plans. The organization uses Salesforce to provide CRM solutions to the Sales and Service teams working across Member, provider, broker, and Consumer portals.

Gather business requirements to deliver salesforce application enhancements

Develop and carry out concise user stories on JIRA

Primary contact for all phases of SDLC, including QA testing, performance, and user acceptance testing

Customized various salesforce.com objects lead, accounts, contacts, opportunity, activities and custom objects

Involved with design reviews to ensure that all deliverables meet business needs, including device or platform specific requirements

Analyze user requirements and data mapping documents by interacting with system architects, developers, and business users

Facilitate and maintain positive relationships with sales cloud and service cloud teams, clients, and partners

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

Developed clear and easy to follow test cases using JIRA for the purpose of measuring software quality and compliance to business requirements and application design

Analyzed data and created reports using SQL queries for all issued Action Items

Created Reports, Dashboards, and scheduled dashboards to the leadership

Utilized standard Salesforce Out of the box functionalities viz. Creating Objects,

Record Types, Page Layouts, Approval Process, Workflows, Process Builders etc.

Defined lookup and master-detail relationships on the objects and created junction

objects to establish connectivity among objects

Performed Administration tasks like User Management, Data Management, Creating

and Managing roles and profiles

Developed and configured various reports and report folders for different user profiles

based on the needs of the organization

Created case assignment rules and workflow rules

Work alongside sales and service delivery teams to build quality solutions

Develop solutions to automate or improve the current system

Optimize systems, design modifications and enhancements by understanding the current functionality and the expected future application

Create workflows and technical development documents for developers for guidance

Implement data migration and mapping in compliance with HIPAA

Interface with IT and sales team to fix technical issues

Work on creating proof of concepts (POC) in test environments, test and validate the code in various environments

Environment: UML, MS Excel, MS Word, MS PowerPoint, MS Project, MS Visio, Test Plans, Use Cases, Agile, SQL, and Oracle.

Business Analyst

PLEXIS Systems, Orlando, FL Dec 2019 – March 2022

PLEXIS benefits administration software automates medical, dental and vision claims to process for healthcare organizations across the United States. PLEXIS has been developed to integrate, enable EDI, for HIPAA compliance, claims re-pricing, and adjudication solutions for healthcare payers. Its claims software also supports Medicaid, Medicare, and Medicare Advantage claims processing. It is a rule-based, intelligent, claims automation solution that enables employers, and other managed care organizations to improve operating efficiencies and business outcomes.

Responsibilities:

Responsible for business analysis, requirement specifications, project planning, and identifying the resources and implementation of the project

Led the team on several projects and prepared project charters to conduct professional meetings for the client and team members

Implemented JIRA to manage and track projects. Provided administrative support for JIRA products such as confluence

Created the Computer Validation Report, which involved extensive research and interaction with SME’s and our clients

Monitoring SQL server and providing database backups as and when required

Created business workflows on the claims module for the client along with a detailed BRD to help the client gain a better understanding of the software and all functional and non-functional requirements

Used UML extensively for specifying, constructing, and documenting the software system

Worked closely on 834 transaction code for Benefits Enrollment and performed testing using Quality Center

Involved in Validation of HIPAA for 837, 270/271, 276/277,835, 834 EDI transactions

Performed the Gap analysis of the previous systems, generated a detailed requirements document describing new system architecture with the help of Use Cases and Activity diagrams.

Created functional flow diagrams, context diagrams, and other high-level diagrams for documenting the functionality of separate modules using MS-Visio and UML

Developed Class Diagrams, State Diagrams, and physical Component diagrams/ DFD’s to capture the entire system functionality and thereafter built a framework for the software development phase

Works on user story development and prioritization

Recognize trends and issues and troubleshoot errors in UNIX; monitoring requests and faults on ORACLE database

Utilized business and technical tools to develop business and system requirement analysis with supporting variance reports, business process flows (both current and target), and traceability matrices

Designed message formats, queues, legacy systems interfaces, and worked with the SMEs and stakeholders through interviews and JAD sessions. Created front-end prototypes as deliverables and projected the end-delivery modules

Prepared requirement specification, functionality trace matrix, quality assurance plan, and designed test cases. Communicated with business and technology leadership for gaining an understanding of project/program office milestones

Environment: UML, MS Excel, MS Word, MS PowerPoint, MS Project, MS Visio, Test Plans, Use Cases, Agile, HP Quality Center, Requisite Pro, RUP, SQL, and Oracle

Business System Analyst

Affinity Health Plan - Bronx, NY Sep 2017 – Nov 2019

As a Business Analyst, I was accountable for the health Quotes Module. Based on the search criteria given by the consumer this module suggests the coverage and/or type of coverage for individuals, families, and businesses. The objective of the project was to circumvent any losses, improve billing efficiency and claims, and oversee monetary expenditure within eligible Medicaid receivers. The system effectively processes the patients' medical insurance details and transmits the insurance claims, eligibility inquiries, responses, and benefits using HIPAA codes set.

Responsibilities:

Eliciting and preparing detailed system requirements by conducting JAD sessions, interpreting business requirements, and working with stakeholders and development teams

Gathered and documented high-level detailed business requirements for different business units such as BRD, FRD. This includes the EDI Claims Intake, Claims Adjudication, Medical Management-Utilization Management, Case Management, and Provider Reimbursement-Provider Payment

Providing consultative services through all phases of the System Development Life Cycle

Providing operational support of SQL database and running queries of the product database

Reviewing Test Scripts, Technical Specification Documents, and working on the application's input/output data definitions

Ensuring coding and configuration, complying with the current business policies and practices, and supporting the efforts of compliance review and audit of employer group benefits

Documentation of the audit results and making recommendations as required.

Conducting a quick Gap Analysis; current / future business process analysis, generating documents of future business processes and validating the same from the company

Preparing the requirement specifications such as Use cases, System requirement specifications, and supplementary specifications and managing them

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

Manage the HIPAA compliance lifecycle from GAP Analysis, data mapping, and implementation

Experience in implementation of ICD-10-CM codes changes in the current claim processing modules in MMIS

Prioritize user stories, create acceptance criteria, work on testing and development support.

Oversee the project templates, requirement types, and traceability relationships in Requisite Pro

Maintain JIRA projects, workflows, and permissions

Map, categorize, integrate and define data needs and evaluate using SQL

Conducted requirements walkthrough sessions with Stakeholders and Business Team to gauge if all their needs were met. Ensured that the requirements were not violating the SOX and HIPAA compliances and managed to get the business signoff on requirements

Monitor UNIX server alerts and maintenance of LINUX operating systems.

Provide support for UAT

Helped QA team to create Test Plans and Test Scripts and performed knowledge transfer to the technical/development and QA team

Experience with ORACLE database management and troubleshooting

Provided support for Salesforce maintenance and administration

Creating Business Analyst Governance for Dashboards, Project Tracking, and Traceability Matrixes

Designing and reviewing various documents including USE Cases, Business requirements document (BRD), Use Case Specification’s, Requirement Traceability Matrix (RTM), and testing documents

Environment: Microsoft Office, SharePoint, Agile, Rational Requisite Pro, MS Office, SQL Server, MS Project, Rational Quality Manager, Mainframes and Rational ClearQuest, ClearCase

Business Analyst

Cooks Children Health Plan, Fort Worth, TX Feb 2015 – Aug 2017

The health plan provides health care for CHIP and STAR (Medicaid) members in the Tarrant service area. The counties served are Tarrant, Johnson, Denton, Parker, Hood, and Wise. The Plan offers not only quality health care plans but affordable health care plans for the whole family. The CHIP and STAR programs allow you to choose from many doctors, clinics, hospitals, and specialty services.

Responsibilities:

Gather requirements, create user stories, work on backlog items

Submit and gain approval of EDI encounter transactions with the State of Texas

Worked on QNXT including Claim processing (online and batch adjudication), Case management, Customer service, Member/subscriber administration, Provider network management, and reporting

Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.

Optimizing database performance and deployment on ORACLE

Responsible for system integration testing of 837 claim files, 834 eligibility files, and 270/271 interface files to ensure that the required interactions are met during the SDLC process

Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting of any errors with the process of EDI inbound and outbound files

Validated outbound 835 transactions including but not limited to the vendor on QNXT mapping and system configuration

Maintaining SQL sever database to support the data warehouses

Worked on data migration and mapping from source to target system for specific fields

Business Process Analysis/End User Education/Business Requirements Documentation

Validated System configuration, including enrollment, provider, and benefits modules

Worked on Agile and Scrum for Salesforce implementation.

Worked with JIRA filters, dashboards, and fields

Creation of queries and reports to assist Health Plan Operations with the analysis of data pertaining to claims, members, and providers

Execution of daily, weekly, and monthly reports and processes and the creation of ad-hoc reports.

Broad knowledge of CCHP departmental processes, procedures, and data

Environment: QNXT, RUP, Rational Rose, Requisite Pro, MS Visio, RUP, MS Project, SQL, Oracle, MS Access, MS Excel, and MS Word.

Business Analyst

Rx-CROSSROADS, Louisville, KY Sept 2014 - Feb 2015

The objective is to provide a brand support solution by customizing access services and connecting patients to therapy. The projects are based on the requirements from various healthcare and pharmaceutical clients and revolve around Brand Support Services and Third-Party Logistics Solutions.

Responsibilities:

Worked as a liaison between business users, all internal IT staff, program managers, and stakeholders to elicit and document functional and non-functional business requirements using agile methodology.

Accomplished several projects at a time while successfully handling the deployment dates.

Interacted with Pharmaceutical and Healthcare clients and worked on the enhancement of the healthcare projects.

Involved in HIPAA/EDI Medical Claims Analysis, Design, Implementation, and Documentation.

Involved in preparing the Test Scenarios for Health Care Claim Payment/Advice.

Devising specifications, diagrams, and flowcharts to aid in the process.

Use JIRA to create user stories.

Assisting with the documentation and reporting of defects, errors, and issues.

Assisting and providing support during the User Acceptance Test and Deployment phase.

Assisting in controlling and coordinating release scope, coordinating change requests, and change tracking.

Enabled the development and maintenance of the team processes, procedures, and templates to continuously improve release quality and deployment schedule.

Formulated test plans and test cases for the projects.

Environment: UML, MS Excel, PowerPoint, MS Project, MS Visio, Test Plans, Use Cases, Agile, SQL.

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