ASRC Federal - Reston, VA
Healthcare Business Analyst
● Analyze current health-related business processes and the automated systems that support them to identify opportunities for improvement
● Provide technical, business, management expertise, and support the Department of Health and Human Services and Centers for Medicare and Medicaid Services (CMS) in building and maintaining a comprehensive enterprise architecture program
● Take minutes of business meetings and prepare necessary documentation including agenda and/or attendance sheets
● 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 Advance Health - Chantilly, VA Credentialing Specialist
● Responsible for the creation credentialing processes and credentialing team adherence of company policies under NCQA or state regulations
● Management and verification of primary source verification/re-credentialing for Nurse Practitioners
● Preparation of yearly audits as needed by contracted health insurance organizations
● Coordinated all submissions of discrepancies found within primary source verifications of Nurse Practitioners to Chief Clinical Officer, Chief Medical Officer and Regional Managers for approval or denial Inova Health System - Fairfax, VA Health Informatics Intern
● Responsible for research of informatics program and data analysis under internship preceptor
● Attended meetings that discussed the improvement of workflow improvement within the health system
● Executed the patient rounding tool project and its effect on the Inova population via health outcomes Chisovereign PLLC - Fairfax, VA Office Manager
● Check in patients before appointments and check out patients after appointments, maintain patient confidentiality, call in patient medications, check and respond to voicemails and emails
● Schedule appointments for patients, take past medical History at initial appointments, prepare paperwork for the practitioner to complete, responsible for accurate maintenance of electronic health records, verifying patient insurance information, responsible for confirming patient referrals and collecting patient co-pays Inova Medical Group - Falls Church, VA Physician Recruitment Intern
● Assisting in Physician recruitment activities, researching educational institutions for career fairs, organizing and inputting documents, scheduling interview times and hiring selection
● Oversee resumes to ensure they meet job descriptions and organizing business meeting material
● Coordinated mass recruitment emails and newsletters
● Record keeping of candidates and documented paperwork
- Healthcare Business Analyst at ASRC Federal
at this Job
- Master's - Health Informatics
- Bachelor's - Healthcare Administration
The project AIM (Aetna Individual Markets) was to design an automated underwriting business function, Consumer Portal-Interface for online enrollment, eHealth, eVendors-Broker sites that route business to Aetna through their websites, Billing and enrolment-for Approval/Declines of applications. Responsibilities:
• Participated in Business Modelling by documenting the needs of the Business.
• Designed a new matrix covering all the conceptual parameters of the new system.
• Extensive knowledge on relevant cross-industry data and messaging standard organizations and HIPPA/EDI industry-specific organizations to maintain a point of view as to the current applicability and risks associated in implementing standards or new technologies to client environment.
• Developed applications to track risk exposure.
• Analyzed 4010A1 and 5010 TR3 Implementation guides to identify and document the changes for HIPAA EDI Transactions such as 837 P, 835, 276/ 277 and 270/271.
• Created class diagrams, use case diagrams and sequence diagrams to view the system from different perspectives.
• Conducted on-site/web conference presentations, data conversions, system implementations and end user training. Provided ongoing user assistance, enforcement of technical policies, software releases, system upgrades and resolved software related problems.
• Analyze HL7 transmissions and monitored Interoperability and interface connectivity
• Leverage Risk experience and business judgment to plan initiatives and accomplish enterprise- wide goals.
• Utilization of BPM, as-Is and To-Be modelling processes.
• Used Microsoft Visio to document Use Cases, ad-hoc reports Activity Diagrams/State Chart Diagrams, Sequence Diagrams, Collaboration Diagrams.
• Prepared Business Process Models that includes modelling of all the activities of the business from the conceptual to procedural level.
• Working knowledge and utilization of HL7 v2.0 standards
• Analyzed the problem domain, specified features, established baseline architecture, developed the Project plan, and risk analysis.
• Research and Implementation of Web Portal and Content Management Systems
• Consulting with other departments on the management of content and design of pages.
• Articulated UML through Use Cases, use case document by specifying actors, normal flow, sub flow, alternative flows for each and every use case.
• Complying with the consistent development and maintenance of the healthcare industry databases, health care insurance and health care industry related aspects with adherence to HIPAA compliances.
• Wrote SQL scripts for back-end testing.
• Provide reporting to management via excel reports of workload and work completion on a daily, weekly, and monthly bases
• Liaison and Coordinated in resolving HIPAA/EDI mapping issues arising from the third party systems.
• After successful development and testing of the product, participated in product release and deployment to End-User.
• Worked closely with the deployment team for roll out the project - external releases, packaging, distributing, installing, user assistance, beta testing, migration of software and data.
• Created Project management plans for managing on-time delivery using MS Project along with writing test cases, unit and systems integration test plans in Test Director.
• Conducted User Acceptance Testing (UAT)
• Documentation of Training Material for the implementation and the maintenance of the application.
- Healthcare Business Analyst at Aetna Healthcare Inc
- Healthcare Business Analyst at Aetna Healthcare Inc - Clarksboro, NJ
- Business Analyst at CMS Companies
- Business Analyst at Doctors On Call
8 months at this Job
MVP HealthCare is a leading insurance organization that caters to the health insurance needs of the residents in NY. Facets have been widely used across the network for the claim adjudication, claim processing and Provider Management. The National Provider Identifier Project's objective is to comply with the mandate that effective with the federal compliance date, all Providers who conduct electronic business via HIPAA Transactions with Mercy Health will be required to obtain and use an NPI. Responsibilities:
• Coordinated the upgrade of Transaction Sets 837P, 835 and 834 to HIPAA compliance.
• Analysis of inbound and outbound interfaces and extensions to FACETS claims processing system
• Completed Data Mapping for Group and detail Product analysis and report writing
• Supported all phases of the design, development and implementation of an Enrolment Resolution and Reconciliation process for health insurance exchanges
• Responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges and performing root cause analysis
• Analysis and Design of the Facets data model to ensure optimal system performance and tuning
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Designed and development of test cases based on functional requirements for Institutional and Professional claims for EDI and HIPAA Transactions 837/835, 834, 276/277, 270/271 testing.
• Utilized SDLC Methodology to configure and develop process, standards and procedures.
• Conducted JAD sessions with business users and Subject matter expert and stakeholders to define project scope, to identify the business workflows & task analysis and determine whether any current or proposed systems are impacted by the new development efforts.
• Managed and prioritized user stories using JIRA. Worked with the development team to identify blockers and provide resolution.
• Created a Requirements Traceability Matrix (RTM) ; kept a track of product backlog, sprint backlog, and time estimates using agile tools like Jira.
• Designed Test Plans, Scripts after analyzing various scenarios/requirements & performed defect tracking using Test Director & Clear Quest.
• Performed User Acceptance testing & End to End testing in interaction with Offshore QA/Dev teams for various system releases & pushed them to production.
• Completed Data Mapping for Group and detail Product analysis and report writing
• Configured facets modules such as Claims, Membership, Billing, Benefit and plan
• Involved in claim adjudication process of facets application
• Responsible for writing the Test Cases and Test Scenarios based on the Functional Specification and technical Specification and documented in Mercury Quality Center.
- Healthcare Business Analyst at MVP HealthCare
- Healthcare Business Analyst at Apachata Corporation
2 years, 8 months at this Job
- - Business Flow Diagrams
Project description: The project involved upgrading 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. Responsibility:
• Identified and validated business rules and data elements.
• Gathered requirements 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.
• Utilized SQL server to run basic queries and obtained 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.
• Used SQL query to produce data for 270 EDI X12 file and created 270 files.
• Reviewed vendor files for any errors, missing segments, and for missing data on X12 file. Ensured file had complete data before encounter can be submitted to Medicare and Florida Medicaid.
• Facilitated meetings with the technical team and client team to analyze the current process and gathered 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 and MS Excel.
• Streamlined Claims (837 EDI X12) Migration project by gathering functional specifications in Edifices.
- Healthcare Business Analyst at Blue Cross Blue Shield
- Healthcare Business Analyst at
- Business Systems Analyst at Acadia Healthcare
- Business Systems Analyst at Rose, Requisite Pro, Clear Quest
1 year, 8 months at this Job
• Experience in X12 EDI Transactions (834 enrollment, 820 payments, 270/271 eligibility/response, 837I and 837P institutional and professional claims , 835 Healthcare Claim Payment Advice, 277CA Claim Acknowledgement, 999 transactions)
• Experience with EDI HIPAA conversion
• Deep knowledge of healthcare business processes and EDI infrastructures
• Experience working with EDI standards (e.g., ASC X12, NSF, HL7).
• Involved several working sessions and much 'offline' research/documentation with the key stakeholders and SME's from the Pharmacy department.
• Involved in generation and execution of SQL queries to understand the processes used by the pharmacy department.
• Experienced in building and maintaining web applications using Adobes AEM CMS to include site architecture, custom components, workflow development, Digital Asset Management (DAM)
• Developed HL7 messaging for bi-directional case and disease report exchange, in HTML and XML formats, in accordance with HL7 specifications.
• Performed Gap Analysis by identifying current technology, policies, and procedures, documenting the enhancements for the requirements, and analyzing new HIPAA 5010 compliance and developed an action plan for the migration process.
• Analyze requirements to ensure testability, report gaps and discrepancies.
• Creating and executing test cases for GUI, Sanity, Smoke, Functional and Regression testing.
• Performed Peer review for testing related documents Test cases, Test Plan and Release summary document
• Executing test cases and log defects in JIRA.
• Retest the scenarios post defect fix.
• Adding scenarios, test data and screen shots used for testing to Test Ready User Stories in JIRA.
• Played active role during daily scrum meeting and task planning as part of agile methodology
• Interacted with offshore team to share & provide required information on planned work items for the sprint.
• Internal review of user stories with management for scenarios/test data/screen shots prior demo.
• Participated in Sprint Demo sessions with business.
• Performed Integration testing of ACMP application.
• Well versed with Microsoft SharePoint to manage project related documents.
• Involved in writing complex queries in SQL Server.
• Involved in Sprint retrospective meetings scheduled at the end of each sprint.
• Involved in UAT & SIT Concerns meetings.
• Involved in Planning & Product Backlog Grooming User Stories with Business Analyst and Team members.
• Participated in Defect Triage call to discuss open defects and Defect clarifications.
• Maintained Defect/Issues/Observations Tracking sheet. Environment: Windows, Oracle, MS Office (MS Word, MS Excel, MS PowerPoint, MS Visio), MS Access, Agile, SQL, ETL, UML, Quality Center, and SharePoint.
- Senior Healthcare Business Analyst at Connecticare
- Business Analyst at Fedilis Care
- Business Analyst at Asuris Northwest Health
- Junior Business Analyst at San Mateo Medical Center
2 years, 10 months at this Job
- Bachelor's - ENGINEERING
Trinity Health Of New England is an integrated health care delivery system comprised of world-class providers and facilities dedicated to the full spectrum of preventive, acute, and post-acute care, all delivered with the triple aim of better health, better care, and lower costs for our patient populations. Project overview: "Automation of receivables from collection agencies" projects aim at the automation of adjustment of claims that has outstanding payments from patient with the collection information received from agencies. In the current claim adjustment with the report from collection agencies is a manual process and this project's primary objective is to automate this process
Role: Claim analyst
● Conducts audits and provides feedback to reduce errors and improve processes and performance
● Work is frequently completed without established procedures
● Business Partner Issue Assistance this includes assisting in many tracking projects across different business segments
● Plan, prioritize, organize and complete work to meet established objectives
● Maintains current provider data to ensure the quality of the network
● Manage Advocate outreach for providers with multiple complaints to Medicare
● Prioritize and organize own work to meet deadlines
● Conducted sessions to understand the manual process to adjust the claims from collection reports
● Detail documentation of the current manual process
● Documentation of the feed files from collection agencies with file level and attribute level business description
● Documentation of standardization & transformation rules to automate claims adjustment process
● Transition of business requirements to the design & development team
● Discussion with business team to document the acceptance rules
● Assist in developing test cases and participates in the quality assurance process to ensure that requirements are properly implemented
● Prepared RTM (Requirements traceability Matrix) to ensure the coverage of test cases with respect to the requirements
● Execution and documentation of test results as part of user acceptance testing
● Root cause analysis for the exceptional items that did not pass through automation
● Defect logging & prioritization of defects
● Has conducted weekly reviews to discuss the progress and risks related to requirements gathering and analysis
● Used Agile (VersionOne) to report and track progress in work in the form of User Stories, Epics.
- Healthcare Business Analyst at Trinity Health of New England
- Business analyst at Eastern CT Physician Associates
- Business analyst at SRMC
8 months at this Job
- MBA - Hospital and health system Management
• Credentialing new applicants through two way vigorous screening process - Pre Application and Initial Application in conjunction with the standards of The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
• Maintaining the current database software for 560 Physicians and 140 Allied Health Professional on staff for the purpose re credentialing at the hospital.
• Working knowledge of the Medical Staff Bylaws, Rules and Regulations, and Hospital policies, and working to ensure the medical staff's compliance with the stated parameters.
• Creating and carrying out various credentialing processes in relation to physicians, medical assistants and various healthcare professionals ensuring all personnel and services adhere to facility and staff policies, department guidelines, regulations and government laws.
• Maintaining regular cooperation and compliance with all regulatory, accrediting and membership-based organizations.
• Flipping the credential files through various committees like Credentials, Medical Executive and Board of Directors.
• Helping the providers with their Onboarding process - Orientation, introduction and computer training.
• Attending the monthly credential committee meetings.
• Thorough knowledge of ECHO reporter functionality.
• Maintaining and updating the ER Call schedule and keeping a track on the invoices.
• Working with the Performance Analyst in conducting various FPPE and OPPE reports using Crimson Database.
• Creating OPPE reports in 6 different cycles according to specialties.
• Working with various physician offices to maintain daily ER Call schedule.
- Healthcare Business Analyst at Coventry Health Care Inc
- Healthcare Business Analyst at Palms West Hospital
- Business Analyst at United Health Group
3 years, 8 months at this Job
Responsible for leading, executing and coordinating tasks in support of the CMS certification of a Medicaid Management Information System (MMIS). ♦ Supported Program/Project Manager to integrate change management activities into the overall project plan. ♦ Established a requirements management strategy for the project such as process for elicitation, review and approval process, change process and communications processes. ♦ Consulted with healthcare insurance company to develop conversion specifications for other insurance coordination of Benefits (including Medicare). ♦ Facilitate and manage meetings, issue management, and facilitation of regular checkpoint meetings throughout the SDLC. ♦ Supported health systems functions and terminology to verify standard ICD-10 and CPT coding usage. ♦ Assisted in healthcare financial cycle, quality reporting, and analysis. ♦ Write and facilitate User Acceptance Testing (UAT) scripts. ♦ Resolved issues writers experience with clients and workload. ♦ Organized meetings and led JAD sessions to ensure legal and compliance deadlines of CMS (Centers for Medicare and Medicaid Services) are met. ♦ Coordinated and conducted meetings with State Medicaid staff, programmers, and project managers to discuss and develop technical and business solutions for all tasks where problems and disagreements arise. ♦ Collaborate with project stakeholders throughout all SDLC phases to ensure timely delivery of specified business solutions. ♦ Created and updated Business Requirement Documents (BRD). ♦ In-depth analysis of system functions and operational procedures for compliance with CMS certification requirements. ♦ Gathered business requirements from the client and translate them into use cases and functional specifications. ♦ Adhered to all HIPAA rules and regulations regarding the protection of personal health information.
- Healthcare Business Analyst at Rosary Home Health, Inc
- Quality Test Analyst at A&T Multi-Healthcare Services LLC
- Client Service Representative at A&T Multi-Healthcare Services LLC
2 years, 2 months at this Job
- Bachelor of Science - Healthcare Administration
Project description: The project was to make enhancement to care radius which is a Point of care application which supports to organizations to manage all clinical documentation, including comprehensive assessments, physician orders, visit notes, medication profiles, labs and X-ray reports, pictures and maintaining the EHR. Agile Scrum methodology was used throughout the project. Responsibilities:
• Develop business process models for projects and demonstrations at the Centres for Medicare and Medicaid (CMS) using business process model notation and enterprise architecture.
• Worked extensively with developing business rules engine enabling the business rules such as referral, prior authorization, eligibility, claims processing and billing essential.
• Utilized Agile Software Methodology using Scrum framework. Actively participated in creating the user stories and prioritizing user stories along with tracking of burn up, burn down charts to estimate sprint delivery.
• 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.
• Wrote user acceptance testing (UAT) scripts and led testing/ quality assurance for both HL7 ADT interface and the application.
• 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.
• Creating documentation such as BRDs and FSDs (Business and Functional design specs) with elaborate Use Cases and process flows
• Worked on FACET claim processing system and gathered and documented functional requirements in the Functional Requirements Document (FRD).
• Performed GAP analysis by performing the system analysis between the scheduling systems and documented the gap items.
• Analyze and document Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensure these issues are documented and addressed in the approach to the HIPAA 5010 version.
• Conducted JAD sessions, meetings, workshops to gather requirements from various stakeholders and SMEs.
• Prepared Business Requirements Documents, Functional Requirement Documents.
• Worked on analysis of FACETS claims processing system and gathered requirements to comply with HIPAA 5010 requirements.
• Facilitated all Aspects of scrum framework, including product backlog, release backlog, sprint planning session, daily scrum meeting, sprint reviews and sprint retrospectives.
• As scrum master communicated dependencies and potential risk to the completion of the sprints including resources, costs and systems.
• Created data mappings to transform the data according to business rules.
• Developed Test Cases for unit testing, prepared spreadsheet for testing criteria, including regression, positive and negative testing, process flow testing and screenshot for test results to complete expected and actual results.
• Prepared various diagrams by using MS Visio.
• Prepared documents for the wireframe and prepared a data dictionary for the same
• Managed testing for various functionalities using Quality Center tools.
• Worked closely with QA and Developers to clarify/understand functionality, resolve issues and provided feedback to nail down the bugs.
• Maintained a close and strong working relationship with teammates and management staff to achieve an expected QA result for the project team.
• Conducted project related Presentations periodically to the management and end users during various phases of Software Development Life Cycle SDLC.
- Sr. Healthcare Business Analyst at Scripps Health
- Business Analyst at Kaiser Permanente
- Business Analyst at Atlantic Health
2 years, 7 months at this Job
• Coordinate all processes and phases of the project management lifecycle
• Drive internal planning, execution, and implementation of technical and critical business-related projects
• Manage and coordinate the efforts of internal and external teams to ensure on-time successful software installation and product implementation
• Develop and maintain project documentation including project plans, project charters, status reports and escalations
• Prepare and deliver customized implementation project plans and timelines with a heightened focus on accuracy and seamless communication
• Plan activities to identify, mitigate, and manage risks and dependencies. Maintain detailed project documentation
• Participating in workflow design and system build to achieve optimal system functionality and ultimately adding new modalities to the services offered.
• Building, testing and maintaining the training environment, as well as developing and maintaining training materials.
• Tracking issues and bugs related to the software and Mobile apps.
• Field work tickets and address end user problems and escalate any application problems as necessary to the programming team.
• Consolidate and regularly distribute overall project status reporting and dashboards for key stakeholders, and executive management
• Coordinate schedule for builds/fixes and test planning efforts
• Drive the overall QA planning /tracking and reporting for assigned project(s)
• Conduct research relating to the development of the modernization systems
• Deliver end-user training and go-live support for credentialing software designed for hospitals, physician practices, surgery centers, ACOs etc.
• Lead training for any new hospital, physician and staff members and providing ongoing training opportunities.
• Assisting Sales Director by providing Demo for the Portal over Web meetings and live presentations.
- Healthcare Business Analyst at Acorn Software Solutions
- Healthcare Business Analyst at
- Credentialing Coordinator at St. Mary's Medical Center
- Medical Staff & Quality Coordinator at Palms West Hospital
2 years, 4 months at this Job