Hemanth R

Healthcare Business analyst - Coventry Health Care

FL - Email me on Indeed: indeed.com/r/Hemanth-R/ec835650e905a82c

Sr. Business System Analyst with 9 years of work experience in Marketing, Mortgage and Financial Services.
Experience with CRM systems in general (SAP, Oracle, Siebel), ModelN.
Experience working with web applications and supporting a corporate web-site for a marketing perspective.
Experience of requirement gathering and analysis process in a client facing role.
Experience of creating Functional Specification Documents (FSD), Business Requirement Documents.
Solid understanding of Relational Database Management Systems and proficient in SQL.
Proficient with campaign management/execution tools (e.g., Unica, SAS MA, Alterian)
Proficient with Business Intelligence tools (e.g., Business Objects, Cognos, MicroStrategy, Microsoft
Reporting/Analysis Services)
Solid understanding of Marketing concepts, Direct Mail.
Experience working in Blueprinting sessions and used various tools and technologies.
Understanding of data warehouse and data mart concepts.
Knowledge of Windows Server, SQL Server, SQL Server Management Studio and T-SQL.
Extensively used ETL methodology for supporting data extraction, transformations and loading process, in
a corporate-wide-ETL Solutions.
Understanding the specifications for Data Warehouse ETL Processes and interacting with the data analysts
and the end users for informational requirements.
Proficient knowledge of Complex SQL queries using clients like TOAD and SQL Plus
Understanding of Credit Risk and Market Risk concepts such as PnL and finance control function.
Wrote BRD, FRD, use cases, test scenarios, test cases for testing the functional and non-functional aspects
of both ETL jobs and Reporting jobs.
Knowledge of foreign exchange rates, currencies, and other trading markets.
Experience in SEO/analytic support for web sites and digital/social media marketing campaigns.
Knowledge of consumer lending product and life cycle such as auto origination processes, pricing, mortgage,
marketing.
Familiarity with SQL Server stored procedures, triggers and functions.
Strong understanding of quickly gain such, of applicable laws, regulations, and guidance in the subject area
as well as the desire to keep up with changes in a complex environment
Ability to work on multiple project requests simultaneously while meeting tight deadlines
Strong working experience in the Data Analysis, Design, Development, Implementation and Testing of Data
Warehousing using Data Conversions, Data Extraction, Data Transformation and Data Loading (ETL)
Good analytical, conceptual and problem solving skills to evaluate business problems and apply knowledge
to identify appropriate solutions.
Ability to communicate effectively both orally and in writing; ability to communicate with customers, associates
and management.
A track record of working effectively as part of a team.
Involved in gathering requirements for creating web services supporting the SOA effort.
Knowledge in the ETL (Extract, Transform and Load) of data into a data ware house/date mart and Business
Intelligence (BI) tools like Business Objects Modules (Reporter, Supervisor, Designer, and Web Intelligence)
Willing to relocate: Anywhere

WORK EXPERIENCE

Healthcare Business analyst

Coventry Health Care - Richmond, VA - January 2014 to Present
Project description:
The project was regarding the Electronic Medical Claim Software System that facilitates providers to send
electronic claims in short time, and thereby ultimately increase the revenue cycle efficiency. The primary feature
of the software included Electronic verification of insurance eligibility, Electronic claims status inquiry, Financial
Ledger, Essential system reports and automated reminders. The system's goals were to maximize the value
of online health information; expand utilization of programs, services and products. The project scope also
included ICD 10 Care Management Impact Analysis including Care Management that utilized multiple software
systems to support the intake and processing of authorization requests. The authorization requests consumed
ICD 9 codes that needed to be replaced by ICD 10 codes to meet the mandate date.
Responsibilities:

Gathered Business Requirements through brainstorming sessions on global calls.

Facilitated JAD sessions for Requirement Validation with HPA to gather requirements for the new MMIS.
Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for
processing of Medicaid Claims.
Analyze, and document business and functional requirements via uses cases for Medicare billing transaction-
based middleware/database layers with SOA & XML.
Validating the EDI 837 claim billing (professional, institutional and dental claims) & 835 (remittance advice
or payment) claims adjudications.
Mapped provider data from source to target Facets data layout for the claims and benefit configuration.
Assisted in monitoring ancillary data transactions and addressed problems with HL7 messages.
Exposed to using ICD 9/ICD 10 coding standards in Medicare and Medicaid domains of the healthcare
systems and industry for inpatients, outpatients, reimbursement methodology.
Designed and developed Use Case Diagrams for the Facets process modules.
Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems
are impacted by the EDI X10 Transaction, Code set and Identifier aspects of HIPAA.
Documented and tracked requirements in Mercury Quality Center.
Designed and implemented HIPAA 835 Payment Advice Transaction, 837 Health Care Claim Transaction.
Populated ICD-9, NDC Disease code sets as per the standards. Experience with transaction sets 835, 837,
270, 271, 276, 277 and 5010.
Provided suggestions and ideas more from a strategic and long term perspective.
Developed data conversion programs for membership, claims, and benefit accumulator data converted
thirteen corporate acquisitions. Developed data field mappings. Provided programming and support for claims
processing functions and auto-adjudication.
Effectively implementation of the System Development Life Cycle SDLC, the BABOK and RUP methodologies
from Initiation to Deployment.
Used Requisite Pro for the Requirement Documents Preparation and Prepared Business Process Models
that includes modeling of all the activities of the business from the conceptual to procedural level. Followed
top down, leveled technique for building Business Process Models.
Designed and developed Use Cases using UML and Business Process Modeling.
Used MS-Visio for flow-charting, process model and architectural design of the application.
Designed and developed project document templates based on SDLC methodology
Analyzed and translated business requirements into system specifications utilizing UML and RUP
methodology

Business analyst
Molina Healthcare - CA - October 2012 to November 2013
Molina Healthcare is a managed care organization that delivers health care services to persons eligible for
Medicaid and other programs for low-income families and individuals through a network of primary care
clinics, physicians, hospitals, and other providers. The project was to design an application with a simple and
responsive user interface that will make online enrollment an enjoyable experience for the customers. And
also convert existing systems and applications to ICD 10 and integrate HIPAA 5010 (deadline June 30 2012)
changes.
Responsibilities:
Developed various use cases to come up with the front end application design.
Worked with AML analysts, SME's and high level regulatory managers to identify data elements and report
types.
Performed GAP analysis and analyzed EDI 837 (Health Care Claim) transaction from 4010 to 5010.
Developed crosswalk between ICD 10 and ICD-9 to assist with transitioning to ICD 10 and identify the
differences between the two versions.
Conducted JAD sessions involving SME's, business users, data administrators, system architects, managers
and development team in order to create a good business process model.
Identified the project scope, business objective, feasibilities and risks based on Scope/Vision documents.
Used Requisite Pro to organize and catalog requirements.
Created Data Flow Diagrams and process diagram using MS Visio.
Developed Business flow diagrams, use cases and activity diagram; assisted developers in creating
sequence diagrams and collaboration diagrams.
Generated Functional Requirement specifications (FRS) and User Requirements Specifications (URS) that
helped to guide the design of the application.
Maintained Requirement Traceability matrix throughout the project.
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.
Functional testing of the application was performed as per the ICD10 changes.
Identified bugs during the test phase and reported them using ALM.
Helped in conducting User Acceptance Testing (UAT), Unit and System Integration testing (SIT)
Environment: MS SQL, RUP, MS VISIO, MS PROJECT, ALM, Windows.

Business analyst
Solaris Health System - Edison, NJ - January 2011 to September 2012
Solaris Health System encompasses a wide array of organizations, services and facilities in the Central NJ
area. They provide a wide variety of services which include acute care hospitals, inpatient and outpatient
rehabilitation centers, nursing and convalescent facilities and specialized treatment programs.
Responsibilities:

Interviewed various SME's for detailed business processes and to understand the Collections and Recoveries
side of the business segments. Interacted with the Business Team through JAD sessions, to gather
requirements and develop complex business maps.
Managing various levels of Projects in accordance with SDLC standards, worked as a project lead/PM for
various projects.
Acted as project manager/lead with creating detailed project plans and assisted in developing, scheduling and
tracking project timelines using MS Project. Functioning as a primary POC and IT liaison for various projects.
Maintaining a Traceability Matrix to ensure that all Functional Requirements are addressed at the Use Case
Level as well as the Test Case Level.
Mapping client's requirements and providing them with the best IT solutions involving evaluation and definition
of scope of project.
Performed GAP analysis to derive requirements for existing systems enhancements.
 Designed and developed Use Cases and Use Case Scenarios using UML methodologies.
Auditing of medical codes (CPT, ICD, HCPCS) coded by team.
Development of business rules and testing for HIPAA compliance certification of healthcare standards.
Provide solutions on Claim Processing Application for the implementation of HIPAA mainly used for AR
(Accounts Receivable) claims.
Directed and managed the Change Management Control process for the projects by facilitating group
meetings and/or one-on-one interviews/meetings with work stream owners to discuss change request impact
on timelines and scope.
Environment: SDLC, Agile, Scrum, UML, Clear Case, XML, MS Office (MS Word, MS Excel, MS PowerPoint,
MS Visio), MS Access, MS Project, MySQL, Requisite Pro

Healthcare Business analyst

Minnesota Department of Health Services - Saint Paul, MN - June 2009 to December 2010
Minnesota Department of Health Services, the State Medicaid Agency (SMA) is responsible for the Medicaid
Incentive Program. The System developed, leverages department to manage the whole Medicaid Management
System effectively by adding the Medicaid Incentive program along with updating the different functional areas
- Provider Enrollment, Claims Status and Prior Authorization EDI transactions following HIPAA Regulations
and Implementation Guidelines. The Present System (Inter Change) for the Medicaid Management Information
System (MMIS) was enhanced with HP as the implementation partner.

Responsibilities:
Facilitated sessions to collect User Requirements and Business Requirements
Business/User/Functional/Technical Requirement Specification using MS Project, MS Word and MS Visio
that provided appropriate scope of work for technical team to develop prototype of the overall system
Created Use Cases, various UML Diagrams and Data Flow Diagrams to determine the data flow via various
systems
Proposed the change and reengineering of the 'AS IS' Business processes into the 'TO BE' process flow
Involved in the day-to-day implementation of the Agile methodology of application development with its
various work flows, artifacts and activities.
Gathered requirements from the administrative staff and business rules for determining member eligibility
and successfully converted them into functional requirements for the developments team.
Have played a role of Project Manager in the absence of assigned project Manager and have lead monthly/
Quarterly review sessions on project status with Vice President - PMO
Responsible for resource planning, cost benefit analysis and risk analysis and present the same to senior
management.
Able to take a large conceptual problem or project, break it into components, establish plans and a critical
path, achieve incremental goals and deliver project on time and at or below budget.
Created web Page mock ups for clients using wireframes.
Developed and maintained the Requirement Traceability Matrix (RTM) for the project deliverables using
Rational Requirements Composer
Analyzed if the system abides HIPAA regulations as portal displays member's private information.
Reviewed and approve technical recommendations related to software and hardware proposals from
technical team.
Participated in leading and executing user acceptance test scripts.
Assisted BI developer to build and maintain SQL queries for data extraction and analysis
Assisted in designing test plans, test scenarios and test cases for integration, regression and UAT to improve
overall quality of the Application.

Business analyst
AmeriHealth - Princeton, NJ - August 2007 to May 2009
The project was contributed to the early phase into conversion of ICD-9 to ICD 10 compliant with HIPAA
5010. (HIPAA) require that all health insurance payers in the United States comply with the EDI standards
for health care as established by the Secretary of Health and Human Services. The Addenda version of the
ANSI ASC X12 837/835 transaction set was selected as the HIPAA-mandated format for electronic enrollment
and disenrollment in a Health Plan. Along with that also managed claims processing for the entire enterprise
of EDI X12 837/835 (I/P/D)
Responsibilities:
Assisted in identifying project scope, to conform to the regulatory compliance related to X12 837 (I/P) and 835.
Responsible for soliciting and eliciting requirements for 4010-5010 conversions.
Carried out Risk Assessment, GAP analysis, Impact Analysis and experience in determining and writing
functional specs for the 4010-5010-conversion project.
Involved in one-to-one interview sessions and JAD sessions with stakeholders, SME's and business owners
to discuss the scope of the conversion.
Produced for transaction sets 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented
application 5010 enhancements, as well as prepared mapping documents ensuring the upgraded application
included the required changes and additions for 5010 compliancy.
Involved in up-gradation of 4010 transaction to 5010 by conducting Impact Analysis and Risk Assessment
and worked on the mitigation plan to avoid the risks.
Tracking and addressing the problems on timely manner encountered on Acknowledgement 997, Claim
Status Inquiry/Response 276/277, Remittance Advice 835, Eligibility Inquiry/Response 270/271, Prior
Authorization 278 claims.
Worked as a liaison among stakeholders both business and IT side in order to elicit, analyze, communicate
and validate requirements for changes to business processes.
Involved in creating Reports and Documents like Requirements Documents, and Management Plan, Issue/
Alternatives documents, Project Summary and Plans with formats like PDF, HTML, Excel and Word.
Prepared UML diagrams (Activity diagrams, Sequence Diagrams, Use case diagrams) for Extensions.
Involved with reviewing defects reported from UAT efforts and analyzed for root cause and took actions
based on the findings.
Identified the master file changes and builds needed to enable the 5010 format to be utilized.
Conducted Business Process (As Is/To Be) sessions with various department directors and staff to ensure the
Testing Plan and Test Approach would meet the identified Business Requirements, and the Training Program
covered all identified new and changed processes.
Gathered requirements for impacted system and business areas for ICD 10 and their needs to embrace the
changes.