Chicago, IL Nov' 15 - Present
Project Description: CareFirst BCBS is the leading insurance company in Washington D.C area. As a Sr. Business System Analyst I was involve in gathering requirements and preparing artifacts for FEPThin, a real-time claims and processing system for complete, on-line mediation of medical claims as per HIPAA guidelines. I was also involved in enhancement project which is use for operation and service people all over the company. The high level objective of the Claims Enhancement Project is to re-architect the CareFirst FEP Claims processing system from Mainframe Application to a hosted environment and enable the retirement of the existing legacy system (FLEXX). After successful completion of HIPAA 5010 project I am also involved in ICD-10 project to complete the analysis, design, and development phases to implement the ICD-10 changes across all the sub-systems.
Role: Sr. Business System Analyst
• Led the initiative to improve system performance that increased the adoption rate among customer service representatives from 80% to 98% and average application processing time to less than a minute from a day or two.
• Extensively involved in implementation of effective requirements practices, including gathering User Requirements, and analyzing Project Requirement Document (PRD), and Functional Specification Document (FSD), use and continuous improvement of a requirement gathering processes.
• Interacted with Business and End users to gather information on changes initiated by HIPAA and government regulations.
• Created Adhoc reports by writing SQL queries in TOAD
• Created Project Requirement Document and Change summary for ICD-10.
• Managed all the projects artifacts and reports in SharePoint.
• Worked on ICD-9 to ICD-10 mapping tools like HLI Leapi10 and knowledge on GEMS mapping.
• Conducted JAD sessions to resolve conflict arising from ambiguous requirements.
• Worked on defining the project schedule and creating the project plan during the initial stages of the project.
• Created Functional and Non Functional Requirements by Analyzing Legacy Code and holding meetings with various SME's and Technical Architects.
• Involved in analyzing and researching Technical & Business Process Analysis with SMEs & business users to identify the business rules needed for Business Rule Engine (BRE).
• Gathered requirements for HIPAA 4010 to 5010 compliance.
• Worked on day-to-day claim processing and wrote the change summary for claim processing error.
• Applied agile methodology with its various workflows, artifacts, and activities to manage life cycle from Inception to Transition phase.
• Involved in participating in daily Scrum meeting with technical design team and architects, which required all team-members to give a quick 5-minute update on daily activities.
• Acted as liaison between development team, business and testing team and standardize product requirements specification documents such as PRD, FSD, Wireframe, and Mapping document.
• Created flow diagram for existing use case and presented to the management with a proposed changed summary.
• Assisted JAD sessions to identify the business flows and determine whether the EDI X12 Transaction, Code set, and Identifier aspects of HIPAA impact any current or proposed systems.
• Involved in GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims. /worked on EDI transactions: 270, 271, 835, and 837 (P, I, D) to identify key data set elements for designated record set.
• Involved in conducting Functionality testing, Integration testing, Regression testing and User Acceptance testing (UAT). Provided analysis and insight to QA Team in defects and bugs tracking. Technologies: Windows 7, Agile, Serena, HP Quality Center, Toad, EDIFECS Specbuilder, SharePoint 2010, UML, HTML, MS Word, MS Excel, MS Visio, MS PowerPoint.
- Sr. Business System Analyst I at CareFirst BCBS
- Sr. Business System Analyst at HUMANA INC
- Business Analyst at Highmark Life Insurance
- Business Analyst Healthcare at Regence Blue Cross Blue Shield
3 years, 2 months at this Job
- Master's - Software Engineering
Worked has healthcare business analyst for various hospitals and clinics across the nation. Assisted in the development of metrics and performance tracking systems Coached and mentored "High potential" HBAs to know how to create excellent documentation artifacts Conducted analysis of alternatives, recommendations, and data mapping. Created plans and led the technical team-members, supporting Project Managers, to ensure that the solution architectural vision gets realized Created end user training material and operational documentation Designed and developed creative alternative architectural approaches wherever conventional ones are not possible Developed detailed IT specifications of user requests for Information Technology Developed project work plans and documented work flow processes Participated in the QA effort for configuration work performed by other analysts Presented weekly status on technical approach, and roadblocks for new EMR connections Proficient in performing data analysis, querying data bases, and utilizing SQL query tools. Review work performed by others and provide recommendations for improvement Work with new EMRs to sandbox test work flow processes Worked with users to define existing or new processes and recommend solutions and improvements
- Healthcare Business Analyst/ Independent Consultant at TORCHTEL RESOURCES
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- at PRESBYTERIAN HOSPITAL
6 years, 8 months at this Job
- Masters - Healthcare Leadership &Management
- Certification - Project Management
- Bachelors of Science - Economics
Blue Cross Blue Shield of Tennessee is an independent licensee of Blue Cross Blue Shield Association. It's a part of 41 independent locally operated companies called plans. Each Plan is community based, working closely with local hospitals and physicians to assure its customers receive excellent and affordable care tailored to their needs. I worked as a Business Analyst on the Health care application Dashboard. The project was to upgrade the existing Dashboard phase from phase 1 to 2 for claims and benefits. I was responsible for Requirement gathering and design, including process mapping and gap analysis and writing use case on the extended application which supports Dashboard and involved in writing Business rules based on 270/271 transactions and HIPAA Standards.
• Identified and validated business rules and data elements.
• Gathered Requirement from the Client to fulfill the Application need for FACET Implementation
• Created 837(P, I, D) claims, and maintained data mapping documents in reference to HIPAA transactions primarily 837(P, I, D), 834, 835, 270, and 271.
• Worked within project team to identify and interpret state Medicaid and Medicare policies as applicable to customer defined algorithm research as well as assist with internal development of new healthcare analytics.
• Worked with Trizetto based software called QNXT to obtain members information.
• Worked with Medicare and Medicaid Encounter Pro to obtain Encounter from the main server to be submitted to Medicare and Florida Medicaid.
• Utilize SQL server to run basic queries and obtain necessary data for Medicaid and Medicare Encounters.
• Worked with Facets software for maintaining data about the enrollment, billing and health care claims management and to store, send, receive HIPPA transactions and facilitate the administration of HIPAA privacy rights.
• Using SQL query to produce data for 270 EDI X12 file, and create 270 files and submit to MEVSNET to check dual snip member for Medicaid benefits eligibility.
• Review vendor files for any errors, missing segments, and for missing data on X12 file. Ensure file has complete data before encounter can be submitted to Medicare and Florida Medicaid.
• Analyzed Impact analysis when there is any change in the requirements and updated the Business Requirements Document (BRD) and Systems Requirements Specification (SRS).
• Facilitated meetings with the technical team and client team to analyze the current process and gather requirements for the proposed process.
• Analyzed Audit and Change Files of 834, 835, 820, 837 PDI, 997, 999, 270 & 271HIPAA EDI Transactions using MS Word, MS Excel.
• Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifecs.
• Tracked the change requests.
• Utilized Ramp Manager Application from Florida Medicaid to check X12 files for any error before submitting to Florida Medicaid.
• Daily and weekly status reporting to senior management.
- Healthcare Business Analyst at Blue Cross Blue Shield
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- Healthcare Business System Analyst at Florida Blue
- Business/System Analyst at Dr. Reddy's Laboratory
1 year, 11 months at this Job
HMS is a healthcare cost containment company for government and commercial healthcare programs. As a Business Analysis the primary role is to implement contracts into the HMS Zone (SQL Based) for each different line of business requested by the implementation team, the process to implement a contract consists of the completion of spec documentation based off of the Implementation Manager's business requirements.
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets. Performed the requirement analysis, impact analysis and documented the requirements using Rational Requisite Pro.
• Utilized knowledge of SQL Programming to author over 20 Queries in the HPQC Dashboard.
• Gather information from different data warehouse systems and loaded into warehouse using Fast Load, Fast Export, Xml import, Multi Load, BTEQ, Teradata parallel transporter (TPT) and UNIX shell scripts.
• Created approach to standardize Excel Reporting using SQL in the HPQC Dashboard.
• Wrote transformations for data conversions into required form based on the client requirement using Teradata ETL processes.
• Incorporated HIPAA standards, EDI (Electronic data interchange), Implementation and Knowledge of HIPAA code sets.
• Manage and analyze data communication channel to ensure compliance security requirements in accordance to ISO, HIPAA and PCI guidelines. Coordinated with Project Managers to resolve risk issues and ensure compliance of Security System related to the HIPAA.
• Worked with PPI Teradata tables and was involved in Teradata specific SQL fine-tuning to increase performance of the overall ETL process
• Involved in requirement gathering phase (Provider, Claim components and HIPAA) . Utilized Rational Unified Process (RUP) to configure and develop process, standards and procedures.
• Manage and lead day-to-day operations of system upgrade to comply with new federal reporting requirements and security protocols including HIPAA.
• Skilled in gathering business and application requirements, Business Processes, identifying risks, impact analysis, UML modeling, and Sequence and Activity Diagrams using Rational Rose and Microsoft Visio in Clinical and Health Information Management (HIM) processes.
• Used BTEQ and SQL Assistant (Query man) front-end tools to issue SQL commands matching the business requirements to Teradata RDBMS.
• Sound knowledge of Patient Protection and Affordable Care Act (PPACA), HIX (Health Insurance Exchange), Sarbanes-Oxley Act (SOX), ACORD, SOPs (Standard operating Procedures) and forms, GMP's terms and Practices. Involved profoundly in the GAP Analysis of the transition from HIPAA 4010 to 5010 (EDI 835 and 837) focusing on how current transactions and system will be effected by the new 5010 compliance.
• Interacted with client and the Technical Team for requirement gathering and translation of Business Requirement to Technical specifications.
• Conducted interviews, meetings and JAD sessions during the process of Requirement Gathering.
• Planned and documented procedures for data processing and prepared data flow diagrams for the application.
• Analyzed and translated business requirements into system specifications utilizing UML and RUP methodology.Performed Gap Analysis to check the compatibility of the existing system infrastructure with the new business requirements.
- Healthcare Business Analyst at Healthcare Management Services (HMS)
- Business Analyst at STACK IT Solutions
2 years, 4 months at this Job
CIGNA Healthcare is the for-profit health insurance company, which operates under the CIGNA corporation umbrella. CHC operates health plans throughout much of the United States and in a growing list of countries around the world.
Cigna Navigator Web Application provides quality level of Health services for customers. The web site and the supporting system are developed to provide online insurance services to their customers and Agents. The insurance Application involves quotation tool and also enables the customer to complete the transaction after selecting the insurance plan, pricing, location details etc. Also, agents are allowed to quote or complete the application online on behalf of the customer. This includes Health insurance, Policy and Claim Service modules. I focused more on Health insurance claims automation module. The motivation behind that was to provide effortless and accurate form filing for agents and customers with minimal human errors during filing forms. Also, the existing mainframe-based batch processes were gradually replaced with distributed processes to provide faster and robust computing for multiple processes.
• Conducted the role of Senior Business Analyst for the Cigna Health Insurance Marketplace Eligibility & Enrolment project.
• Gathered Business Requirements, interacted with the Users, Designers and Developers, Project Manager and SMEs to get a better understanding of the Business Processes.
• Gathered and analyzed the User Requirements from walkthroughs and interviews with the business groups and in-house stakeholders, and many other departments like accounting, fund management, human resource and thus converted User Requirements into Business Requirement Documents (BRD).
• Manage company's EDI catalog for prospective EDI customers.
• Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
• Implement new services and programs via MMIS for the Medicaid program by directly interfacing with the customer and the system engineers on a regular basis.
• Developed a work plan that ensured RFP would meet federal prior approval requirements including use of modular project development, compliance with MECT, MITA, HIPAA and other federal guidelines
• Used Electronic Medical Record (EMR) to extract useful information regarding patients for claim submission to the insurance company.
• Involved in various Facets Data models like Gateway, Claims, Membership, Provider, Billing, Capitation, Invoice, Benefits, Product and Plan.
• Created and maintained requirement documents for Facets for the different modules like Billing, Member enrollment and Claim adjudication.
• Facilitated Scrum meeting with technical/non-technical team, Accounts updating, data analysis and sharing with XML patterns, SME's to clarify business rules & solve impediments, rectifying the regulatory issues with SME's and translated Functional requirements into User stories using JIRA.
• Prepared test data from user stories, write and execute test cases in JIRA
• Created UML Diagrams including Use Cases Diagrams, Activity Diagrams/State Chart Diagrams, Sequence Diagrams, Collaboration Diagrams and Deployment Diagrams, using Rational Rose and MS Visio and thus defining the Business Process Model and Data Process Models.
• Coordinate with Health Insurance Exchange (HIX) program staff and other stakeholders to define and develop requirements for correspondence generation across various business lines.
• Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped. Used SQL for data mapping and querying.
• Worked in Agile Methodology, worked on all phases of software development life cycle to build the different phases of Software development life cycle.
• Performed Gap Analysis to check the compatibility of the existing system infrastructure, features and functionality with the new business design using the "As Is" and "To Be" methodology.
• Developed business case which included results of the business-impact assessment, gaps identified, alternative solutions, risk assessment, preliminary work plans, resource requirements, and a budget for completing the initiative.
- Healthcare Business Analyst at Cigna Health Care
- Healthcare Business Analyst at Aetna Healthcare Inc
- Business Analyst at LA CARE
2 years, 5 months at this Job
• Use facilitation and modeling techniques to document the current environment in terms of business processes, data, systems, services and technology infrastructure.
• Analyze business processes to help understand and manage the current environment, identify gaps, duplications and redundancies and identify opportunities for improvement.
• Identify impacts and/or dependencies across the current and future environments.
• Work with CMS business owners to define their target goals and propose alternative business solutions.
• Develop work plans to reach the target goals.
- Healthcare Business Analyst at ASRC Federal
- Operations Analyst at Signify Health
- Lead Provider Onboarder at Signify Health
- HIM Specialist at StoneSprings Hospital
4 months at this Job
- M.S - Healthcare Management
- B.S - Health Administration
● Scope of the project was to implement centralized billing system that maximizes automation.
● The system performs all the functions of medical billing cycle such updating new and existing patient records, auto posting of the charges and payments to the patient records and submission of claims to the medical insurance Carrier.
● Provided business requirements with in an Agile Software development SCRUM Framework
● Documented and delivered Business Requirement Document and Functional Specification Document to the project team.
● Determined business requirements and business work flows from legacy system to the Detailed financial transaction interface.
- Healthcare Business Analyst at Billing Concepts Inc
- Technical Support Representative at School District U-46
3 years, 4 months at this Job
➢ Interact with business heads to finalize the Business Requirements.
➢ Derive Functional Requirement Specifications based on User Requirements.
➢ Understand and articulate business requirements from user interviews and then convert requirements into technical specifications.
➢ Prioritize business requirements and segregate them into high, Medium, Low level.
➢ Coordinated between business head, supervisor and the technical team throughout the project.
➢ Experience in creating user stories, sprints in agile environment using JIRA.
➢ Experience in creating data flow diagrams using MS visio
➢ Create, analyze and amend automated / Ad hoc reports in a timely and accurate fashion using SSRS, Visual Studio and Power BI.
➢ Support analytics team with optimizing existing queries, views, and stored procedures using SQL.
➢ Perform analysis and provide user-friendly reports, analysis, presentations, dashboards related to business information.
➢ Create and maintain necessary documents for the projects.
➢ Knowledge and Experience of working on several different Texas programs.
➢ Analyze report and fix bugs in stored procedure.
➢ Experience in creating stored procedures, views, function and tables using T-SQL
➢ Experience in building enterprise level data transformations (ETL) solutions using SSIS and IpSwitch.
➢ Create schedule run for different stored procedure.
➢ Experience in creating Dashboards for leaders using Power BI and SQL.
➢ Experience in creating provider Network Maps using GeoNetwork Environment: MS Office, MS Visio 2010, MS SQL Server-2013, SharePoint, Power BI, SSRS, SSIS, GeoNetwork
- Healthcare Business Analyst at Community Health Choice
- Business Analyst at HVHC Inc
- Data/SQL Analyst at Azket E-Intelligence LLC
- Data Analyst at Priyadarshani Group
2 years, 11 months at this Job
- - Mater of Business Administration
- - Mater of Business Administration
- Bachelors in Computer Science - Computer Science
The project was to improve the claims reimbursement user interface of Coventry One for a better user experience and incorporate changes as per HIPAA guidelines. The main objective of the system was to secure the health information entered by the user at the time of submitting the claim, and to also ensure the veracity and privacy of the user information.
• Prepared the Functional Specification Document FSD and Software Requirement Specifications SRS as per SEI-CMM standards.
• Conducted the JAD Sessions with stakeholders and developers to have a clear picture of a project.
• Experience in adding Member ID demographic information in and adding Service Type Codes in MMIS.
• Managed and built relationships with clients to build the EDI benefit enrolment file feed.
• Help answer member questions about missing information for Part C, D and Medicare supplements plans
• Conducted interviews with key stakeholders to analyse existing data and gather requirements.
• Extensive knowledge of Medical Management Information Systems (MMIS) and HL7.
• Used UML to create use case diagrams, sequence diagrams and activity diagrams
• Worked on improvement of Claims Reimbursement User Interface for a better experience and incorporate changes as per HIPAA 4010 /5010 guidelines using the gap analysis.
• Developed flowchart and process diagram using MS Visio.
• Wrote SQL scripts for creating performance evaluation reports
• Clarified QA team issues and reviewed test plans and test scripts developed by development team and QA team to make sure all requirements have been covered in scripts and tested properly.
• Performed Backend testing by using PL/SQL queries to test the integrity of the application was in regular contact with Business partners on the status of issues, action plans and timeframe for resolution throughout the development cycle.
• Involved in Data mapping to define how the Source data is modified before it reaches the Destination or the Target object. Also to validate and customize Claims daily load into FACETS for processing the transactions and in Facets Configuration to make sure all information will be sent without any error.
• Analyzed and documented HL7 Interfaces according to the client requirement.
• Identified bugs during the test phase and reported them using HP Quality Center
• Maintained Traceability Matrix throughout the project.
• Created Operational Dashboards to monitor frequently changing business processes, Strategic Dashboards to track the KPIs across organization and Analytical Dashboards to analyze large volumes of data using Informatica and Tableau.
• Conduct Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.
• Extensively used Soap UI to validate SOAP/WSDL and web services for Request and Response data validation.
• Conducted UAT, documented and reported user feedbacks to management team, and developed training materials for different end users and assisted in users training for the new system. Environment: MS Office, PL/SQL, SQL, HIPAA, Web Services, HL7, MS Visio, SOAP UI, Informatica, Tableau, UML, EDI, MMIS.
- Healthcare Business Analyst at McKesson
- Business Analyst at Coventry Health Care Inc
- Business Analyst at Sentara Medical Group
2 years, 5 months at this Job
Blue Cross Blue Shield of Tennessee is an independent licensee of Blue Cross Blue Shield Association. It's a part of 41 independent locally operated companies called plans. Each Plan is community based, working closely with local hospitals and physicians to assure its customers receive excellent and affordable care tailored to their needs. The project was to upgrade the existing Dashboard phase from phase 1 to 2 for claims and benefits.
• Involved with the phases of Software Development Life Cycle (SDLC) methodologies like Waterfall, Agile, Hybrid throughout the project life cycle which involved gathering, analysis and documenting business and technical requirements
• Created Use Cases and Business Requirement Document after accessing the status and scope of the project and understanding the business processes
• Performed Feasibility Study and Risk Analysis to identify the critical requirements from the user's perspective.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicare Claims.
• Authored business system analysis reports based on state regulations, HIPAA compliance and product business rules
• Gathered requirements for Medicare Systems as part of Patient Protection Affordable Care Act (PPACA)
• Validated 837 (Health Care Claims or Encounters), 835 (Health Care Claims payment/ Remittance), 270/271 (Eligibility request/Response) and 834 (Enrolment/Dis-enrolment to a health plan
• Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI X12 Transaction, Code set and Identifier aspects of HIPAA.
• Experience in working with Medicare and Medicaid insurance data, Medicare parts A, B, C & D, Claims Processing, Insurance Pricing and Claim Adjudication.
• Mentored business analysts in methodology for defining ICD-10 mapping processes and documenting business requirements
• Interacted with Claims, Payments and Enrollment , analyzing and documenting related business processes
• Worked with the SMEs (Subject Matter Experts), IT managers, software architects to identify the key changes pertaining to HIPAA, and participated in Health Management to communicate effectively with them
• Develop test data and execute test plans while defining and/or modifying testing procedures.
• Performed data analysis by using SQL queries and used Query Analyzer optimize SQL Queries
• Performed Unit Testing and User Acceptance testing (UAT) assisted in developing Test Plan and Test Cases to be used in testing based on Use Cases and Functional Specifications
• Used MS Access, MS Excel (Pivot tables), and SQL for data analysis and data validation. Environment: QTP, MS Visio, Word, Excel, PowerPoint, CMMI, SQL, EDI, Tableau
- Healthcare Business Analyst at BCBS of TN
- Business Analyst/ UAT at Depository Trust & Clearing Corporation
- Business Analyst/UAT at Deloitte Consulting LLP
- Business Analyst (Waterfall Methodology) at Bank of America
1 year, 10 months at this Job
- MBA - HealthCare Management