Business Analyst

Business Analyst - HealthAxis Group

• Extensive years of experience as a Business Analyst / System Analyst with exposure to domains such as
Healthcare, and Insurance.
• Excellent understanding of the Agile Software Development Life Cycle (SDLC), STLC and the role of Quality
Assurance, RUP and Agile Methodologies, Agile PLM
• Good knowledge of Health Insurance Plans managed care concepts (Medicaid and Medicare) and Revenue cycle
experience within life and disability in health plans.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims
pricing and testing, HIPAA, enrollment, EDI, Medicare, Medicaid, CDHP (consumer driven health plans)
• Have good exposure to QNXT for claim processing.
• Have also worked on all the environments of QNXT and Facets which includes the Test Environment, Development
Environment and Production Environment. Experience in performing GAP Analysis between AS IS and to be
workflow models.
• Testing and implemented existing extractors to ensure error-free data loads, which include custom user exits for
data enhancements.
• Business and data analysis to determine integration issues to provide solutions.
• Reported bugs and worked with development team to resolve issues
• Expertise in Project tracking, Defect Tracking, Report generation and requirement tracking throughout the test life
cycle using HP QC / ALM.
• Attended/conducted meetings with the IT team, vendor, business team, project program and other application teams
to accomplish project goals
• Prepared UAT scripts for UAT/SME groups and schedule UAT in a timely manner.

Work Experience
Business Analyst
HealthAxis Group
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Lubbock, TX
April 2018 to Present
The project was related to Build Provider Agreements for Medicaid/Medicare/DME/SNF types along with to build
Benefit Plan for Commercial, Medicaid Plans.
Responsibilities
• Review all Medicaid / Medicare agreements, changed if there is change in rates with eff dates
• Document all provider rates and reimbursement methodologies
• Coordinate with QNXT implementation analyst on validating provider rates and reimbursement methodologies
• Work with Claims Configuration to ensure provider contracts are accurate based on the contractual obligations,
• Develops an expertise in provider data, reporting, fee schedules, contracts, capitation, vendor setup and member
assignments in the QNXT claims platform.
• Coordinated with the developers and IT architects to design the interface of the new system according to the X12
(834, 835, 837 (I, P, D) standards.
• Assists with the auditing functions related to fee schedule and vendor set up through internal reporting tools.
• Assists with the development of internal policies and procedures with regards to QNXT ensuring compliance with
nationally accepted accreditation standards
• Works closely with the implementation team to validate provider mapping and contract configuration.
• Validated configuration through various claim scenarios and quality processes.
• Worked closely with all levels of personnel at the client site.
• Provided ongoing support and mentoring of staff, in addition to performing periodic performance review.
• Performed a wide range of claims testing scenarios in order to ensure proper configuration and claims payment.
• Worked closely with other client-based testing and configuration staff.
• Configured Providers (IPA, Group Practice and Facility), agreements for group practices, and pricing into the
provider agreements
• Involved in load and maintenance of QNXT Reference information: Claims Finance Codes, Medical Codes, and
Configuration.
• Involved in overall System updates and testing: loading and updating Fee Tables, Provider Configuration, Provider
demographics, Service group configuration etc.
• Contract Configuration - creating new contracts of all types (Facility, Physician, DME, ASC, SNF, DRUG)
• Contract Type (Medicare, Medicaid, Commercial..etc) and enhancing existing contracts with knowledge of various
payment methods, Custom DRG, Per diem, etc.
• Use of Term Restrictions and Restriction Groups in Contract/Benefit Modules.
• Benefit Configuration - setting up new Benefit Plans, making changes to existing benefit plans in the all areas
including co-insurance/co-pay, deductible, out of pocket maximum, accumulators.
• Resolving Service Groups with benefit terms and addition of service groups to all Plans.
• Analyze changes across all benefits plans (e.g: SNF to all Plans, benefit terms, contract and contract terms) in order
to configure complete solutions for Medicare (example changes in RBRVS rates) and Medicaid
• Provided changes to configuration, to support various line of Business, were done prior to migrating to PROD.
• Ensured correct pricing/configuration of each benefit plan and contract
• Helped create Reports for reporting of errors and fault finding.
• Undertook fault-finding and process improvement with technical and non-technical users and ensure that provider
groups and individual providers are entered and setup in the QNXT system so that other downstream processes will
function effectively.
• Reviewed the range of approaches used to undertake key tasks such as; adding providers, or configuring provider
groups and then develops written guidance and training materials.
• Participated in and lead groups in operational fault finding and remediation for providers in the QNXT application.
Environment: RUP, Rational Rose, Requisite Pro, MS Visio, RUP, MS Project, SQL, Oracle, MS Access, MS Excel
and MS Word.
Business Analyst/Claim Analyst
SCAN Health Plan
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Long Beach, CA
January 2017 to March 2018
Founded in 1977, SCAN serves members in California. Scan work hard with the doctors and other healthcare
providers in network to ensure members get the preventive care and screenings that will help them stay healthy - and
receive the care they need to help them get well. The department needs to make the claim process more efficient and
automated. This Business Process Redesign (BPR) project involved interaction with the entire department to
understand the workflow and the scope of the improvement.
Responsibilities:
• Submitted and gained approval of EDI encounter transactions.
• Worked on claims, Claim adjudication Membership, Eligibility, Accumulators.
• The process included importing claims into QNXT that had been adjudicated and setting them in a "PAY" status so
that a payment cycle could be run to create checks on QNXT.
• Allscripts Touch Works (EMR) Electronic Medical Records.
• Responsible for system integration testing of 837 claim files, 834 eligibility files and 270/271 interface files to ensure
required interactions are met during the SDLC process.
• Validated Inbound and outbound 837 transactions, including but not limited to the loading and correcting any errors
with the process of EDI inbound and outbound files.
• Validated outbound 835 transactions including but not limited with vendor on QNXT mapping and system
configuration.
• Verified demographics, personal insurance and claims data.
• Business Process Analysis/End User Education/Business Requirements Documentation.
• Validated System configuration, including enrollment, provider and benefits modules.
• Creation of queries and reports to assist Health Plan Operations with the analysis of data relating to claims,
members and providers.
• Execution of daily, weekly and monthly reports and processes and the creation of ad-hoc reports.
Environment: RUP, Rational Rose, Requisite Pro, MS Visio, RUP, MS Project, SQL, Oracle, MS Access, MS Excel
and MS Word.
Business Analyst
Cambia Health Solutions
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Portland, OR
October 2015 to December 2016
Identifying PHI (Protected Health Information) data 837 under HIPAA and coding the internal system such that only
necessary information is reveled. To understand both HIPAA and Clinical Practice Guidelines and use them for
system update.
Responsibilities:
• Conducted weekly meetings for deciding the Policies and Procedures to be followed while constructing new sites.
• Conducted complex documentation and user needs analysis. Interface with team and staff to develop HL7
integration.
• 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.
• Developed the strategy for developing and implementing new EDI (HL7 and X12) interfaces and converting
historical clinical and data.
• Used Team Foundation Server (TFS) and MTM for defect tracking and maintaining test cases.
• Reviewed EDI companion guides for all payers to ensure compliance, edit integrity and maintain up-to-date list of
payer contacts.
• Performed testing for Medicare, Medicaid and X-Over claims for Medicaid Management Information System (MMIS)
• Developed and implemented the MMIS Third Party Liability (TPL) Subsystem.
• Conducted business-impact assessment and the results were compared with the new HIPAA 5010 standards to
determine the current level of compliance and developed an action plan for approval by the project steering
committee.
• Developed plan for data feeds and data mappings for integration between various systems, including XML, to follow
ICD 10 Code set and ANSI X12 5010 formats.
• Involved in gap analysis and implementation of HIPAA 5010, ICD 10 and Claim Validations.
• Conducted Gap Analysis, and Gathered User Requirements by Interviews, user meeting, JAD session, and
Requirement Elicitation Sessions.
• Worked on CRM (Customer Relationship Management) project to implement Microsoft Dynamics.
• Worked with the Marketing Management/team members to understanding their needs and requirements in regards
to picking the right CRM system.
• Part of the project management team responsible for SWOT analysis.
• Used Scrum Work Pro and Microsoft Office software to perform required job functions and prepare Product back log
and sprint back log and conduct all the meetings and discuss and help scrum master.
• Involved in mapping data from SWIFT securities reporting messages.
• Responsible for cost estimation and timelines for various Business Intelligence reports.
• Involved in analyzing activities for a variety of major projects including Medicare Plan part D, Coordination of
Benefits, New Client Implementations, Consumer driven and regularly scheduled system upgrades.
• Used UML and OO discovery methods to perform discovery for new enterprise wide installation of Trizetto FACETS
(both core and extension requirements) using Rational Rose.
• Implemented a mechanism to incorporate business-required data which is not in the core Facets system. NFE (Non-
Facets Elements) proved to be of major business importance in implementing state-customizations and underwriting,
needs not encompassed by the Facets system.
• Extensively interacted with the stakeholders and the IT Department in finalizing the requirements according to the
CMS Compliances/Regulations and HIPAA Regulations.
• Assisted to develop the Test Cases and Test Scenarios to be used in testing based on Business Requirements,
technical specifications and/or product knowledge.
• Prepared graphical depictions of User stories, Use Case Diagrams, State Diagrams, Activity Diagrams, Sequence
Diagrams, Component Based Diagrams, and Collateral Diagrams and creation of technical design (UI screen) using
Microsoft Visio.
Environment: HL7, FACETS, EDI, Microsoft Office, SharePoint 2007, Agile, Rational Requisite Pro, MS Office, SQL
Server, TFS, JAVA, MS Project
Billing Specialist
United Regional Health Care System
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Wichita Falls, TX
August 2014 to September 2015
Duties included Installing various applications for physicians, clearinghouses, billing services, and hospitals who
submit or receive electronic claim data. Duties included working with Web Based systems, Desktop Applications and
other Clinical Applications.
Responsibilities:
• Perform daily charge reconciliation to ensure all charges are entered into patient accounting system. Maintain daily
Excel based workbook to record/track discrepanciesAssist Billing/Coding Manager in conducting root cause analysis
to prevent systematic recurrence of edits/issues
• Knowledge of the complete EDI format used in electronic documentation which was part of the knowledge transfer
program to the vendors as per the requirements.
• Worked with Source system Subject Matter Expert (SME) to ensure that the extracts are properly mapped.
• The process included importing claims into Facets that had been adjudicated and setting them in a "PAY" status so
that a payment cycle could be run to create checks on Facets.
• Defined Data Maps to validate and customize Claims daily load into FACETS for processing the transactions.
• Involved in various types of Audits and the Financials involved through different stages.
• Gained Compliance audit experience due to exposure to the legal/audit consulting groups.
Environment: MS Word, MS Excel, SQL, MS Access, MS Project
Education
Bachelor of Business Administration in Information Technology
Texas Tech University
-

Tech, Texas, US
August 2019

Skills

 MICROSOFT PROJECT (5 years)

Additional Information
SKILLS:
Requirements: MS Office 2010/2007, Visio, SharePoint, Requisite Pro, Caliber, Doors
Project Management: MS Project, Clarity
Process Management: BPMN, Visio, Information Mapping, process analysis/re-engineering
SDLC Methodologies: Waterfall (BRD/SRS), Iterative/RUP (Use Cases), Agile/Scrum (User Stories)
Technical Writing: Analysis (Business Case), Requirements (Vision, Scope, BRD), Analysis (SRS), Testing (UAT
Plans & Scripts), Training (User guides, Job aids)
Languages: UML, Visual Basic, SQL, XML