Business Analyst Healthcare

RIYA PATEL

Healthcare Business Analyst

*********@*****.*** 732-***-****

Over 6 years of progressive experience in Agile and Waterfall environments, leading critical healthcare initiatives across payer systems, Medicaid platforms, and EDI transformation programs. Highly skilled in bridging business and technology through detailed analysis, cross-functional coordination, and healthcare domain expertise.

PROFESSIONAL SUMMARY

Expert in healthcare payer solutions, claims processing, and benefit administration with comprehensive understanding of EDI transactions (837, 835, 834, 270, 271, 276, 277).

Strong background in SDLC with experience in business requirements gathering, documentation (BRD/FRD), gap analysis, and solution assessments.

Adept at eliciting business needs and converting them into actionable specifications and functional models.

Deep understanding of HIPAA compliance, ICD-9/ICD-10 standards, Medicaid Management Information Systems (MMIS), and revenue cycle operations.

Skilled in conducting JAD sessions, preparing Use Cases, and developing UML diagrams including Activity, Sequence, and Workflow Diagrams using MS Visio and Gliffy.

Proficient in SQL and PL/SQL for back-end validation and analytics to support testing and reporting activities.

Capable of managing testing life cycle from test plan creation to UAT, with a strong emphasis on RTM maintenance and test coverage.

Experienced in Agile tools such as JIRA, Confluence and DevOps for backlog grooming, sprint tracking, and documentation.

Effective communicator capable of aligning technical solutions with business objectives across diverse healthcare stakeholders.

Delivered enterprise healthcare portals, eligibility systems, provider registries, and EHR interfaces for multi-state operations.

TECHNICAL SKILLS

Tools & Technologies

Core Skills

Healthcare Domain Knowledge

JIRA, Confluence, MS Visio

Requirement Elicitation, User Stories

Claims Processing, RCM, EDI Standards

SQL, PL/SQL, Oracle, SSMS

Backend Validation, Data Mapping

ICD-9, ICD-10, HIPAA, MMIS

HP ALM, TestRail, TestLink

UAT, Test Plan Creation, RTM

Provider, Member, Employer, Agent Portals

UML, BPMN, Lucidchart

Use Cases, Diagrams, Prototypes

Medicaid/Medicare, Payer Systems

MS Office Suite, SharePoint

Traceability, Documentation, Reporting

Eligibility Systems, Benefit Administration

PROFESSIONAL EXPERIENCE

Healthcare Business Analyst

CureWise Health Systems – Edison NJ May 2023 – Present

Overhauled the claims reimbursement platform to align with HIPAA regulations and increase automation for EDI claims submission and adjudication.

Led the implementation of 837P/I and 835 EDI transactions to streamline the adjudication lifecycle.

Facilitated requirements workshops with claims processors and compliance officers to gather HIPAA-mandated criteria.

Developed flow diagrams for adjudication pathways and provider payment logic using Visio.

Authored comprehensive BRDs, FRDs, and data mapping documents aligned with system functionality.

Supported QA team by reviewing test cases and validating backend claim settlement logic with SQL.

Maintained traceability using RTM throughout SDLC and ensured all test scenarios were mapped.

Liaised with external clearinghouses to support real-time eligibility (270/271) and claim status (276/277) flows.

Conducted UAT sessions and captured user feedback to refine UI elements and backend triggers.

Ensured compliance with state-specific billing codes and Medicaid expansion policies.

Participated in sprint retrospectives and maintained backlog in JIRA across three agile teams.

Environment: JIRA, SQL, Visio, HP ALM, Oracle, 837P/I, 835, 270/271, Agile Scrum

Business Systems Analyst

WellPath Analytics – Edison NJ Sep 2021 – Apr 2023

Focused on redesigning the GAP (Group Approval Process) engine within claims intake and adjustment, with HL7 integration for pharmacy systems.

Managed end-to-end requirement lifecycle for claim submission (837), eligibility (270/271), and remittance (835) modules.

Performed in-depth gap analysis and documented transition requirements for HIPAA 5010 compliance.

Led analysis and transformation of inbound HL7 messages for real-time prescription adjudication reporting.

Created decision matrices for pharmacy business rules and drug classification logic.

Partnered with the offshore QA team to prioritize test stories and ensure alignment with technical specs.

Authored XML-based HL7 message templates and verified outputs using online schema validators.

Integrated scenarios and acceptance criteria directly into JIRA user stories and Confluence wiki pages.

Drafted weekly executive status reports and facilitated sprint demos with internal stakeholders.

Participated in the design of provider search, coverage estimation, and formulary view modules.

Leveraged SharePoint for project document versioning and stakeholder communication.

Environment: HL7, 837P/I, 270/271, 835, JIRA, SQL, SharePoint, XML, Agile, Pharmacy Systems

Business Analyst

Genovate Life Sciences – Waltham, MA Feb 2019 – Aug 2021

Delivered a customized EHR interface and patient portal integration for diagnostics and medical report exchange in compliance with MU2 standards.

Collected, analyzed, and documented client-specific requirements for electronic medical records (EMRs).

Developed comprehensive use case specifications and designed mock-ups for clinical workflows.

Facilitated JAD sessions with lab technicians, sales teams, and developers to validate business process re-engineering.

Created SRS documents outlining system logic, access control, and patient data formats.

Oversaw sprint planning and ensured scope alignment during backlog refinement.

Defined activity and sequence diagrams illustrating lab-to-provider data flows using UML.

Worked closely with developers and product managers to trace scope creep and its implications.

Participated in sprint review meetings, captured feedback, and updated the RTM accordingly.

Managed data flow from lab systems to provider EMRs ensuring HL7 compliance for lab result formatting.

Acted as the SME liaison for defining and refining use cases involving diagnostic workflows and result sharing.

Environment: MS Visio, UML, JIRA, HL7, SQL, EMR/EHR Systems, Agile

EDUCATION

Bachelor of Science in Chemistry

HNGU, Gujarat, India

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