Over six (6) years of solid experience in business analysis,project co-ordination & management with extensive knowledge in, Software Requirement Analysis, Designing & Visualization at different phases of Software Development Life Cycle (SDLC) in Health Care domain.
· Immaculate skills in creating Business Requirement Documents (BRD), Functional Specifications or Requirement Documents (FRD), Technical Requirement Document (TRD), System Design Documentation (SDD), UAT documents, Requirement Traceability Matrix (RTM), Issues Log, Data and Action List and training manuals.
· Proficient in developing UML artifacts such as Use Case documentation, Use Casediagrams, Class diagrams, Activity diagrams and Sequencediagrams using CASE tools like Rational Rose and MS Visio.
· Experience in conducting Jointrequirement Planning (JRP) sessions and Joint Application Development (JAD)sessions with end-users, expert team, development and QA team for project meetings, walkthroughs and customer interviews.
· Experience in conducting and documenting the As-Is/To-Be processes and Business Process Re-engineering (BPR) exercises according to the Rational Unified Process (RUP) and UML development methodology.
· Experienced in coordinating UAT user acceptance / QA testing.
· Experience in Creation and Documentation of Test Plans, Test Cases, Test Scripts based on the Design and User Requirement Documents for - Unit, Integration, Regression, Functional, Performance, and User Acceptance Testing with QA and UAT teams.
· Knowledge of health information and health care services regulatory environment including HIPAA, Medicaid/Medicare, CCHIT, EDI and XML.
· Strong HIPAA EDI 4010 and 5010 with ICD-9 and ICD-10, analysis & compliance experience from payers, providers and exchanges perspective, with primary focus on Coordination of benefits.
· Proficient in medical terminology and coding outpatient and inpatients diagnosis Experience in building applications for ICD and CPT Electronic Data Interchange.
· Experienced working with the centers for Medicare and Medicaid services (CMS), the Healthcare Common Procedure Coding System (HCPCS), Electronic Data Interchange (EDI), Medicare Part D Services, and State Pharmaceutical Assistance Program (SPAP) services.
· 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.
· Experience in FACETS with various applications involving Sales & Enrollment, Claims Processing (Dental, Medical/Hospital), Customer Service and Billing areas.
· Experience in healthcare FACETS data model and configuration.
· Highly motivated team player with excellent communication, presentation and interpersonal skills, always willing to work in challenging and cross-platform environment.
RUP, Waterfall, Agile, Scrum
Business Modeling Tools:
MS Visio, MS Project
Requirement Management Tools:
Rational Requisite Pro
Defect Tracking Tools:
Rational Clear Quest, Quality Center/Test Director
Mac, Windows NT/XP/2000, Unix
Oracle, DB2, SQL Server, MS Access
Content Management Tools
MS Word, MS Excel, MS Power point, MS Visio, MS Project, SharePoint 2007/2010
IBM Datacap, Filenet
Highmark BCBS, Harrisburg, PA June 2011- Current
Project Abstract: Highmark Blue Cross Blue Shield provides insurance for individuals and families, Medicare, companies. Optimum System for Claims Adjudication and Reporting otherwise known as OSCAR is the claims system used by Highmark for most of its health business. Supported the OSCAR claims system as a business analyst. Worked on OSCAR Legacy Modernization projects including modernization of Claims Validation and Finalization subsystems of OSCAR, integrating a Medicare Supplemental claims system into OSCAR, and integrating a new Provider/Facility data base into OSCAR. Other areas of experience includes BlueCard ITS, BlueSquared, BlueExchange, HiPAA 276/277 Transactions, HIPAA 5010 / ICD 10 Implementation.
· Worked with Business users and technical lead for gathering requirements and data transaction information.
· Evaluated/Analyzed Mainframe Claims OSCAR System Screen displays and created Mock-Up screens illustrating content and format for team, customer, and development areas.
· Worked in a team for Claims processing and was involved in prioritized claims, identified problems, prepared an action plan, implemented the solution, identified claims outside the benchmark.
· Created the business process model using MS Visio and present it to SME’s for validation and getting the sign-offs. Document testing process flows using Visio flow-charting
· Gathered requirements and analyzed requirements for documenting reports which spotlights payer’s performance.
· Identified Claims Management work flows, business rules and developed flow charts and activity diagrams
· Participated in Billing System Process Flow analysis and identified revisions to the billing system documentation.
· Performed data quality analysis on data by writing queries to ensure data integrity across tables in DB2 database environment.
· Documented System Design Documentation (SDD) describing the systemsrequirement, operating environment, files and database design, input format, output layout, detailed design.
· Analyzed customer needs and existing functions in the area of HIPPA transactions to determine feasibility, consistency with the established scope of work.
· EDI experience with X12 transaction sets 835, 837, 270/271.
· Responsible for mapping of ICD9 to ICD10 and also did testing for 270/271, 837I/P/D, 835R transactions to migrate to HIPAA 5010
· Configured FACETS to adhere to customers work flow for claims processing, claims automation and group administration.
· Used FACETS Workflow to route the claims according to the priority.
· Analyzed DB2 database table and element usage and maintained business level documentation.
· DevelopedSQL scripts for extracting data and maintaining administration tasks.Tuned the SQL queries using SQL profiler
· Designed and developed UML diagrams such as use cases, activity diagrams and sequence diagrams.
· Designed, built, tested, and assisted in Quality control testing of test cases.
· Participated in unit testing of the system that was currently being implemented. This initiative included the creation of testing scenarios, reviewing test cases and validating the various queues the claim processes to, tracking development issues and programming bugs.
· Assisted the project manager in writing business cases, to verify that this financial tool meets the needs of the business.
Environment: HIPAA, Agile, IBM Datacap 8.0.1, Filenet,ICD9/ICD10, EDI, Agile/Scrum, Rational Requisite Pro (ReqPro), Rational Clear Quest (CQ), Oracle 11g, SQL Queries, SQL profiler , DB2, IMS, UML, UNIX, MS Office, MS Visio, Adobe Acrobat, Sharepoint 2010, Quality Center, FACETS 4.51, Lotus Notes, Windows Vista/XP
Project Abstract: To comply with HIPAA requirements, HPHC prepared to transition from the electronic health care transaction standards to version 5010 standards. Worked as Business Analyst with HPHC and its external Trading Partners (TP) to develop, test, support, and implement transaction sets in accordance with ANSI X12, HIPAA 4010/5010 standards and client's standards. Experience with the Electronic Data Interchange (EDI) standards and process of ANSI transactions; including routing, transformation, messaging, audit and validation. Knowledge of the following HealthCare EDI Transactions: 834, 270/271, 837 I and P, 835, 276/277, 278, 997, 999, 277CA and TA1.
· Coordinated with Business Owner, Application Vendor, Business Project Teams, Payers and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010-compliancy requirements.
· Conducted and participated in JAD sessions with stakeholders and system users to collect the software requirement specifications (SRS) and used RequisitePro to maintain the requirements.
· Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis expected results for 5010 compliance.
· Gained an understanding of ICD-9/10-CM (Diagnosis), ICD-9/10-PCS (Procedures Codes) – The mapping process: General Equivalence Mapping(s) (GEMs), ICD Code Set Mapping, CMS Reimbursement Mapping and the ICD 9/10 Code Set Maps.
· Helped with building ICD 9 to ICD 10 crosswalk map by grouping thousands of codes and ranges in Clinical, Benefits, Financial, Medical policy waves.
· Prepared use cases and data flow diagrams to analyze the impact of ICD-10 diagnosis codes embedded in different systems and applications.
· Gathered and validated inventory of applications, interfaces, and reports that will need to be modified to comply with ICD-10 requirements.
· Conducted working sessions to gather and document high level business requirements and detailed level business requirements for different business units impacted by ICD10 such as EDI Claims Intake, Medical Management- Utilization Management, Case management and Provider Reimbursement- Provider Payment.
· Organized impacted systems into high, medium and low impact to help business analyze the level of effort for remediation activities and ease resource allocation work.
· Prepared and maintained requirements traceability matrix (RTM) throughout the project lifecycle.
· Created business workflows on the claims module for the client to get a better understanding of the software and prepared a detailed BRD including all functional and non-functional requirements.
· Worked closely on 834 transaction code for Benefit Enrollment and was involved in Validation of HIPAAfor 837, 270/271, 276/277, 835, 834 EDI transactions.
· Performed the Gap analysis of the earlier systems, generated a detailed Requirements document describing new system architecture through Use Cases and Activity diagrams.
· Wrote and tuned advance SQL queries, procedure, cursor, triggers, scripts.
· Designed robust 5010 testing and 4010 regression SIT and UAT Testing Scripts for the 5010 Project. Scripts were written on an application level and subset by payer resulting in over 600 combined scripts with a maximum of 70 testing scripts steps per script.
· Documented workflows and executed comprehensive testing and training plans to ensure the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.
· Tracked all required resolutions required that were identified as needed from Vendors or Payers based on testing results.
· Wrote SQL Queries for data extraction on the oracle database.
· Identified all risks associated with the project and gave suggestions for mitigating the impact the identified risk posed to the business.
Environment: HIPAA, ICD9/ICD10, HCPCS, EDI, Agile, Requisite Pro (ReqPro), Rational Rose, Clear Quest (CQ) , UML, SQL Queries, Oracle 9i, MS Word, MS Excel , MS Office, MS Visio, MS Project, Adobe Acrobat, SharePoint 2007, Lotus Notes, Windows XP
Tufts Health Plan (THP), Watertown, MA Nov 2009-Dec 2010
Project Abstract: Tufts Health Plan is constantly challenged to improve administrative productivity and efficiency.Employeeswere manually entering data from all paper claims, which is both time consuming and error prone. THP team collaborated with SunGaurd to configure and install the new iWorksFormWorks system which helped provide new web-based technology inside the Plan’s claims management area. FormWorks automation enabled THP to maintain operational throughput with a significantly reduced staffing complement. With FormWorks, throughput increased from 55-60 documents per hour per keyer, to over 150. Web-based keying helped THP greatly improve data security by limiting the amount of information that was stored on a keyer’s machine
· Analyzed Business requirement and developed Business Requirement Document (BRD), Technical and Functional Requirement Specification (FRS) and Software Requirement Specification (SRS).
· Create metric reports to effectively and efficiently convey project information, and work with large amounts of data for manipulation and reporting. Monitor documentation uploaded to Filenet Systems.
· Works closely with THP staff to accurately report and analyze company and industry trends through effective planning, analysis and project support.
· Conducted surveys and interviews with sales representatives to gather requirements, developed and finalized test plans and use cases.
· Consulted with Claims&Benefits Management Team, and develop project plan, time frames, communication plans, milestones and deliverables.
· Analyzed requirements for making the system compliant with HIPAA standards, Medicare eligibilities and benefits
· Planned and defined system requirements to Wire Frames with Use Case, Use Case Scenario and Use Case Narrative using the UML (Unified Modeling Language) methodologies.
· Transformed the business requirements maintained in the RequisitePro into Functional Requirements and prepared the Functional Requirement Document (FRD).
· Worked as an Interface between users and the technical teams involved in the application development for the better understanding of Business and IT processes.
· Facilitated with business and technical requirements involving multiple stakeholders’business partners, IT Organizational units and technical analysts in an environment with different applications/IT Systems based.
· Involved in testing HIPAA EDI Transactions and mainly focused on 270/271 eligibility transactions.
· Tested all HIPAA transactions for multi version support (4010) and validated the database to file elements.
· Experienced with documenting Business transformations and business logic involved in Report data analysis.
· Developed, documented, and analyzed ‘as is’ and ‘to be’ process flows for GAP analysis covering all the functionality to satisfy business requirements.
· Created SQL queries, tables, file feeds and links as needed to maintain data integrity of the Claims Database in an effort to facilitate the programming requirements for the new system
· Contributed to process re-engineering and improvement. Interviewed business users, interface development team, risk Managers, and operations staff to understand and document business requirements and functional specifications for new pricing excellence fare management projects.
· Analyzed systems and data to identify functionality gaps. Liaised with developers and users to clarify specifications as necessary.
· Analyzed test results using reports and graphs generated in Quality Center.
Environment: HIPAA, MMIS,EDI, Agile, Requisite Pro, Rational Rose, Clear Quest , UML, Oracle 9i, SQL Queries, MS Word, MS Excel , MS Office, MS Visio, SharePoint 2010, Quality Center, Windows XP, UNIX
Physicians Mutual Insurance Co. Omaha, NE July 2008 – Oct 2009
Project: Online Insurance Lead Generation/ Quoting Engine
Project Abstract: Project goal was to implement an online price-quoting system for managing, underwriting and monitoring ecommerce marketing efforts for the company, a $4.5 billion dollar insurance corporation. The objective was to re-engineer the company’s existing application to address all aspects of the E-commerce model and automate all the stages of business processes for Life and Commercial Property & Casualty Insurance, including: Ecommerce Marketing, Online Lead Generation, System Pre-Qualification, Call Center Routing, Laboratory Checkup, Underwriting Process, Policy Issues, and Operations/Executive Committee Reports. The Enterprise Application Integration System was designed to store information using a DB2 database, End User Technologies, and Remote Access Solutions.
· Carried out queries from customer data base using SQL, data mapping, field mapping, data integration and sorted extracts as per insurance application status, age, gender, time services, demographics, lead aggregator sources, agent IDs, and call-center division to help design an effective, efficient and theme oriented online quoting engine.
· Understand and articulate business requirements thru user interviews, JAD Sessions and convert them into Technical Specifications. Conducted joint requirements planning sessions as a facilitator to gather requirements from the business area.
· Implement RUP by following iterative, Use Case driven process for requirement documentation and deployment.
· Modeled use-case diagrams in Rational Rose to show end-user interaction with the personal information, loan information &property information modules
· Analyze and integrate processing and central database systems for Underwriting, Actuary, Insurance Agents and Customer Service deploying Web Services and Service Oriented Architecture
· Facilitate JAD Sessions with the system architects, developers, database developers, QA team thru SDLC for defects’ resolution
· Coordinate with the Release Manager in defining scope/ planning releases.
· Analyze Business Requirements and create Use Cases, high and low level Activity/ Sequence/ State Chart Diagrams, using Rational Rose
· Define validations for applications in line with the functional requirements.
· Participate in meetings with Developers, PMs and QAs to discuss BRs, test planning, resource utilization, and defect tracking.
· Designed and developed Use Cases, Activity Diagrams using MS Visio
· Work closely with the UI team to model the screens, as per BRD’s usability requirements.
· Interacted with the Subject Matter Experts (SME) and stakeholders to get a better understanding of client business processes and gather business requirements.
· Coordinate model office cycle runs in different test regions before implementing them into the live production environment.
· Ran SQL queries using SQL Navigator and produce reports from Oracle Database using SQL Plus.
· Provided management with metrics, reports and schedules as necessary and participated in the design walkthroughs meeting using MS Project
· Participated in entering, tracking system defects in Rational Clear Quest.
Environment: RUP, RequisitePro, Rational Rose, ClearQuest, UML , SQL Queries, SQL Navigator , Quality Center, Sharepoint 2007, Oracle 9i, MS Word, MS Excel , MS Office, MS Visio, MS Project, Windows XP
Shelter Insurance, Columbia, MO Jan 2008 –June 2008
Project Abstract: Shelter Insurance provides its insurances in more than 10 states and has more than 1000 agents. The goal of the project was to develop an Internet application that allows potential customers to file claims online for claims related to Storm Damage, Auto, Glass related, and Property Damage in addition to Emergency Road Services. This application helps the customers find local agents contact information for assistance.
· Facilitated meetings with Subject Matter Experts (SME) for Requirements Gathering and transforming them to functional specification.
· Acted as a primary liaison between business lines, operations, and technical areas throughout the project cycle.
· Conducted several Requirement Gathering Sessions for gaining detailed requirements and finalizing Business Requirement Document (BRD).
· Created User Requirement Specifications (URS) and Functional Requirement Specifications (FRS) documents.
· ConductedJAD sessions and meetings with developers, QA team, and users for communicating primary requirements, discussed different versions of requirements, queries, and clarified the issues.
· Reviewed Business Requirements Documents and the Technical Specification.
· Design UML diagrams like Use Case Diagram, Class Diagram, Sequence Diagram, and State - Diagram for project documentation using MS Visio.
· Set up definitions and process for test phases including Product test, integration test, system test and User Acceptance Test (UAT).
· Wrote SQL Queries to perform Data Validation.
· Implement business modeling using MS Visio to develop screens for the application.
· Extensively used MS-Office and SQL Queries for data handling
· Ensured that project followed Business Rules and was compliant with HIPAA rules to display minimum benefit information.
· Extensive use of MS Project to maintain record of recommendations, communications, activities, schedules and to monitor progress of project in real time.
· Used Rational Rose and UML to produce use case models, and sequence diagrams, as part of the detailed design of interfaces.
· Established strategic partnerships with the business units to develop a solid understanding of the business line; including the business plan, products, and process and revenue streams.
· Involved in defect tracking and bug management using Rational Clear Quest.
· Planned, scheduled, and controlled projects based on plans and requirements outlined by the business.
Environment: RUP, Rational Rose, ClearQuest, UML, SQL Queries, SharePoint 2007, Oracle 9i, MS Word, MS Excel , MS Office, MS Visio, MS Project, Windows XP
MDIndia Healthcare Services (TPA) Pvt. Ltd, India July 2005 – Sept 2007
Project Abstract: The project was to build a system application to enable client directory which involves client history and reports and communicated it to the claim coordinator. The company deployed IBM Content Collector for File Systems which automatically collects various forms of data from multiple systems and archives the data based on predefined rules to either Content Manager or IBM FileNet Image Services.
· Team member, FileNet Administration Support. FileNet is an Enterprise Content Management (ECM) System.
· Administer user provisioning (Security Administration) for FileNet.
· Conducted JAD Sessions with the subject matter experts, stakeholders and other management teams in the finalization of the User Requirement Documentation. During business requirementgathering, conducted personal and telephonic user interviews.
· Performed GAP analysis to meet the end state requirements.
· Responsible for the creation of reports/cubes using SQL Server 2005 Reporting Services and Analysis Services
· Created class diagrams, use case diagrams and sequence diagrams to view the system from different perspectives.
· Followed the UML based methods using MS Visio to create: Use Cases, ad-hoc reports Activity Diagrams/State Chart Diagrams, Sequence Diagrams, Collaboration Diagrams.
· Lead and actively participate in the development of written, detailed business requirements, Interviewed Clients and defined the Functional and non-Functional requirements.
· Performed Unit testing of code as required by test plan and Produce high quality documentation
· Produced aTraceability matrix by tracking, managing and tracing all the requirements types (needs, features and use cases) usingRational Requisite Pro.
· Analyzed user requirements, attended change request management (CRM)sessions to create, track and schedule change requests using Rational Clear Quest.
· Automated tasks and maintained different versions with Rational Clear Case.
· Assisted to develop the Test Plan, Test Cases and Test Scenarios to be used in testing based on Business Requirements, technical specifications and/or product knowledge.
· Designed and developed Use Cases, Activity Diagrams using MS Visio.
· Assisted with developing and maintaining quality procedures and ensuring that appropriate documentation is in place.
Environment: RUP, Rational Rose,ClearCase,ClearQuest, Rational Requisite Pro, SQL Queries, SQL Server 2005, MS Word, MS Excel , MS Office, UML, MS Visio, Windows XP
Bachelor of Computer Applications