Business Analyst Process

HEENA PATEL

Murfreesboro TN • 615-***-**** • **************@*****.***

EDI Business Analyst

SUMMARY

•Approximately7yearsofhands-onprofessionalexperienceinBusinessRequirementGathering, BusinessProcess Flow, Business Process Modeling and Business Analysis.

•ExtensiveknowledgeofSoftwareDevelopmentLifeCycleSDLCincludingEnterpriseAnalysis, Requirements Planning, Elicitation, Analysis, Communication, Solution Assessment and Validation of Projects.

•Worked with Agile software development methodology using SCRUM

•Hands-OnexperiencewithallstagesofSDLC’srangingfromtraditional (e.g., Waterfall) toAgilePLM (Product Lifecycle Management) and Rational Unified process (RUP).

•Strong knowledge and experience of EDI transactions, HIPAA, ASCX12Transactionsets834 (Benefit Enrolment and Maintenance), 835 (Claim Payment/Advice, 837 (Claims and Encounters), 820 (Payroll Deducted and Other Group Premium Payment for Insurance Products) 270/271 (Explanation of Benefits (EOB) /Response to EOB), 276/277 (Claim Status/Claim Status Response).

•ComprehensivedocumentationskillsincreatingartifactssuchasBusinessrequirementsdocument (BRD), Use-Case Specifications, and Systems Requirements Specification (SRS).

•Strong understanding of Medicaid and Medicare rules.

•Good knowledge of Health Insurance Plans Medicare PartA,B,CandD,managed care concepts Medicaid and Medicareandexperiencedindeterminingthemembershipeligibility,billingexperiencewithinlifeanddisabilityin health plans.

•ExperienceinfullSDLCfromassociationwithend-usersforrequirementsdetermination, definingthesystemscope, system analysis, testing, maintenance and documentation.

•ExperienceincreatingUserStories (FunctionalStories, LogicUserStories, ServiceUserStories) fromProduct Backlog and facilitated Sprint Planning meetings and prepared Sprint Backlog.

•ParticipateinSprintCeremoniestosuggestimprovementsinthescrumprocess.

•Skilledinteambuilding, conflictresolution& escalationawareness.

•WorkedextensivelyonBusinessRequirementsElicitation, Gapanalysis, RiskAnalysis, andSWOTanalysis.

•ExpertincreatingUseCaseDiagrams,ActivityDiagrams,DataFlowDiagrams(DFD),SequenceDiagrams,State Diagrams based on UML Methodology and process flow diagrams using MS Visio and Rational Rose.

•ReviewTestScenarios,TestCases,TestScripts,Testexecutionstrategies

•Collect Test Data for UAT which is done in the perspective of the users

•UseMicrosoftTeamFoundationServer (TFS) forexecutingtestcases, taskassignments, projectbacklogplan, and version control.

•Experience with MS Visio ford enveloping UML Diagrams.

•Experience in Production Support and Unit Testing.

•Highlyorganizedwiththeabilitytomanagemultipleprojectsandmeetdeadlines.

EMPLOYMENT

Business Analyst

Guardian Life Insurance - Murfreesboro TN (Remote) January 2025 - Present

Designed and implemented HIPAA-compliant EDI solutions, improving claims processing and eligibility verification efficiency.

•Configured and validated EDI 270/271 (Eligibility), 276/277 (Claim Status), and 835 (Remittance Advice) transactions.

•Designed X12 mapping and transformation rules, optimizing payer-provider data exchanges.

•Performed root cause analysis on rejected claims, implementing business rule enhancements to reduce errors.

•Developed custom SQL queries for extracting and reconciling EDI data from payer systems.

•Documented technical and business process workflows, facilitating stakeholder alignment.

•Assisted in HIPAA compliance audits, ensuring adherence to data security and privacy regulations.

•Facilitated requirements gathering and documentation to bridge the gap between business needs and technical implementations.

•Supported end-to-end testing processes to ensure system reliability and compliance.

•Applied agile and waterfall methodologies to achieve efficient and structured project delivery.

•Collaborated with stakeholders to identify project requirements and translate them into actionable technical specifications.

•Conducted gap analysis to ensure alignment between business objectives and technical capabilities.

•Facilitated cross-functional communication between development, testing, and operational teams to streamline project workflows.

•Supported the implementation of testing strategies using a combination of agile and waterfall methodologies.

•Ensured adherence to quality standards and regulatory compliance established by the Application Development Organizations.

•Created and maintained project documentation, including test plans, progress reports, and technical guidelines.

•Provided ongoing technical support, troubleshooting, and resolution of testing-related issues.

•Delivered periodic updates to stakeholders on project milestones, risks, and mitigation strategies.

EDI Healthcare Business Analyst

CoreSource - Lake Forest, IL May2023–December 2024

As an EDI Healthcare Business Analyst, I led the implementation, optimization, and maintenance of HIPAA-compliant EDI transactions for CoreSource, a third-party administrator (TPA) that provides self-funded health plan administration services. The project involved enhancing claims processing efficiency, streamlining eligibility verification, and automating provider-payer communications. The primary objective was to ensure seamless integration of X12 EDI transactions (837, 835, 270/271, 276/277, 278) within CoreSource's claims adjudication systems, minimizing errors, and ensuring regulatory compliance with HIPAA, Medicare, Medicaid, and ACA guidelines.

Rolesand Responsibilities:

•Managed full lifecycle EDI implementation, including 837P/I/D (Claims), 835 (Remittance), 270/271 (Eligibility), 276/277 (Claim Status), and 278 (Prior Authorization) transactions, ensuring accurate payer-provider data exchange.

•Led EDI compliance audits, ensuring CoreSource met all HIPAA and CMS regulatory requirements, reducing compliance risks.

•Provided production support, analyzing system logs and transaction reports to proactively identify and mitigate EDI processing issues.

•Designed and implemented EDI mapping and transformation logic using Edifecs, Sterling Integrator, and WTX, ensuring seamless claims processing and adjudication.

•Worked closely with business users, claims processors, and IT teams to define business rules for claims adjudication, eligibility checks, and payment processing.

•Analyzed payer-specific rules and Medicaid state requirements, ensuring EDI transactions adhered to local and federal compliance standards.

•Performed EDI gap analysis and data validation, identifying discrepancies in claim submissions, remittance advices, and eligibility responses, and implemented solutions to enhance accuracy.

•Developed SQL queries and scripts to analyze and extract claims data, improving data reconciliation and reducing errors in Medicare, Medicaid, and commercial insurance transactions.

•Automated EDI validation and error reporting processes, reducing EDI transaction failure rates by 40% and ensuring compliance with ANSI X12, HIPAA, and CMS standards.

•Worked with clearinghouses, TPAs, and payer systems to configure EDI trading partners, improving interoperability across multiple health plans and networks.

•Created Functional Requirements Documents (FRD) and Business Requirements Documents (BRD) for EDI workflow automation, system integrations, and compliance enhancements.

•Led EDI system testing (UAT, SIT, regression, and functional testing) using HP ALM, JIRA, and Postman, ensuring system readiness before deployment.

•Integrated API and web service connections with EDI systems to support real-time eligibility verification and claim status inquiries.

•Led EDI system enhancements and migration projects, ensuring minimal disruption to ongoing operations while transitioning to new transaction processing platforms.

•Environment:HIPAA,MMIS,Oracle,SQL,UNIX,JIRA,Agile,MSSQLServer,EDI,SDLC, UAT.

Business Analyst

Liberty Health - BalaCynwyd, PA June2020–April2023

TheprojectfocusedonoptimizingoperationsandensuringcompliancewithinthehealthcaresystemofLibertyHealth.Asa Business Analyst, the responsibilities encompassed dissecting high-level information into detailed requirements, ensuring compliancewithHIPAAstandards, andfacilitatingtheimplementationofElectronicMedicalRecords (EMR) andElectronic Health Records (EHR) systems.

Rolesand Responsibilities:

•Disintegrationofhigh-levelinformationintodetailswithabstractionoflow-levelinformationaswellasFunction Point counting.

•Worked on HIPAA compliance and EDI transactions, ICD Codes as well as created data flow and sequence diagramstodescribehowEDIHealthcareTransactionsetwasusedtosubmithealthcarebillinginformation.

•Haveprovenbusinessinsightandthetechnicalknow-howtoimplementlarge-scaleEMRandEHRengagements.

•InvolvedinthefullHIPAAcompliancelifecyclefromGAPanalysis, mapping, implementationandtestingfor processing of Medicaid Claims.

•WorkedwithCMSclaimsandHIPAAtransactions.

•WorkedonEDItransactionstoidentifykeydatasetelementsfordesignatedrecordsets.

•InteractedwithClaims, PaymentsandEnrollmenthenceanalyzinganddocumentingrelatedbusinessprocesses.

•Updateddataprocesses, datareporting, datacollectiontoolsandotherprocessessuchasproblemlists, writing orders and referrals according to ICD code set.

•InvolvedworkingwiththeHIPPA-EDIANSIX12TransactionCodesets.

•WorkedonEDItocheckifreceivingclaimshasalltherequiredinformationornot.

•PreparedCrosswalkandmappingdocumentstotracethemigrationactivityfromHIPAA.

•PerformedGAPanalysisontheexistingsolutionanditstransitionintothenewHIPAA.

•CreatedScopeDocumentationBusinessRequirementsandconvertedthemintoSystemRequirement Specifications and Performed Feasibility and Adaptability Risk

•Analysis to identifycriticalandhigh-riskareasofthe application.

•PreparedBusinessObject/BusinessProcessModelsthatincludedmodelingalltheactivitiesofbusinessfrom conceptual to procedural level.

•CreatedUsecasescenariosanduserStoriesaccordingtobusinessneedsandspecificationsandImplemented UML methodologies to design Diagrams, Use Case

•Diagrams, Batchflowdiagrams, Processflowdiagrams, DataFlowDiagrams, ActivityDiagrams, Sequence Diagram and ER diagrams using MS Visio.

•Environment:Windows,MSOffice(MSWord,MSExcel,MSPowerPoint,MSVisio),Agile,Medicaid,EDI, UAT.

Business Analyst

Amerisource Bergen - Frisco,TX Feb2018–May 2020

As a Business Analyst involved in the Enhancement/Implementation of the Medical Record System.

•Gathereddetailedrequirementsthatcompletelydefinedtheproject.Documentedandupdatedrequirements; prepared and distributed RFPs and evaluated responses.

•Createdhigh-levelmodelsanduserprototypeinterfacestoidentifyandvalidatebusinessprocessesandsolutions.

•Acted as a liaison among Stakeholders, both Business and IT side, in order to elicit, analyze, communicate and validate requirements for changes to business processes.

•Facilitated Business/Functional Requirements review, approval and sign-off sessions. Facilitated all Scrum ceremonieslikeSprintPlanning, DailyScrumMeeting, SprintReviewandSprintRetrospectiveMeetingstoidentify pitfalls and overcome them in the next release cycle.

•WorkedtoeffectivelyinteractandcommunicatewithClaimsandITleadership.

•MaintainedacalendarandmonitorFTPsourcesforpayerclaimlinefilesand reports.

•Demonstratedstrongcompetencyandcomfortworkingwithandanalyzinglargesetsofdatautilizingvarioustools (SQL, Teradata, Oracle, etc.).Performdataminingwhileensuringvalidityandqualityofdatainsupportofproject.

•IdentifiedsolutionstothedevelopmentandtechnicalteamandFunctionalRequirements.Participatedintechnical requirements and design sessions.

•InvolvedincreatingreportsanddocumentslikeRequirementsDocumentandManagementPlan,Issue/Alternatives Documents, Project Summary and Plans.

•PreparedActivityDiagrams, SequenceDiagramsandUseCaseDiagramsforextensions.

•RevieweddefectsreportedfromUATeffortsandanalyzedforrootcauseandtookactionsbasedonthefindings.

•ConductedBusinessProcess (AS-IS/TO-BE) sessionswithvariousdepartmentdirectorsandstafftoensureTesting Plan and Test Approach meet the identified Business Requirements.

•WorkedintheAgilemethodologyusingScrumwithprimaryfocusonthemanagementpartofthesoftware development in small iterations of four weeks' sprint.

•UsedSQLquerytocreateTestData.

Environment:Waterfall,MicrosoftOfficeSuite,MSVisio,SQLServer.

EDUCATION

•Bachelor of Engineering in Information Technology

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