Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • H: (555) 432-1000
  • C:
  • Date of Birth:
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  • Senior Business/Data Analyst Solving Complex Business Problems, as well as crafting and executing strategic initiatives Summary of Qualifications
  • Highly efficient and effective Business Analyst with 8 years of proven skills in requirement gathering, interacting with developers, documenting various business processes, coordinating various projects
  • Strong analytical and technical skills, create analytic platform that allows senior business leaders to take a look at the data, translate the data into business insights, and help making informed business decisions.
  • Experienced with integrating internal data migration and maintenance engineering teams to create best fit solution for manual data compilation
  • Perform detailed management requirements analysis
  • Provide data mapping and transformation rules development
  • Experienced in interfacing with stakeholders and senior management with excellent communication and interpersonal skills.
  • Experienced working in Medicare and Medicaid projects.
  • Excellent knowledge of Health Insurance Portability and Accountability Act (HIPAA) transaction and code set rules such as EDI 837,270,271,276,277,834,835.
  • Proficient in ICD-9-CM and ICD-10-CM coding and claims processing.
  • Involved in working at all stages of system development Life Cycle. Extensive experience leading, facilitating conducting Joint Application Development (JAD) sessions among user community, stake holders and technical management, creating project plans and schedules and managing changes.
  • Also Analyzed and synthesized results from Joint Application Development (JAD), proposed alternative tasks and transformed those into Business Requirement Document (BRD).
  • Experience in using methodologies such as UML (Unified Modeling Language), OOAD (Object Oriented Analysis and Design) and APM (Agile Project Management).
  • Experience in Rational Unified Process (RUP), and Microsoft Project.
  • Experience using Rational Rose and MS Visio for business process modeling and designing data flow diagrams (DFD).
  • Experience in conducting GAP analysis, User Acceptance Testing (UAT), SWOT analysis, Cost Benefit analysis, ROI Analysis and Requirement Traceability Matrix (RTM)
  • Preparing graphical depictions of use cases including State Diagrams, Activity Diagrams, Sequence Diagrams, Use Case Diagrams, Component-Based Diagrams, Collateral Diagrams, including the Business Workflow Chart.
  • Expertise in writing Requirements, Test Plans and Test Cases.
  • Prepared Functional Specification Documents, AS-IS and TO-BE workflows.
  • Experience in HPALM/Quality Center
  • Experienced in all phases of the Software Development Life Cycle (SDLC), Rational unified process (RUP) and SCRUM methodology.
  • Broad Knowledge in reviewing Test Procedures, creating Test plans and detailed test plans for UAT, Test scenario, defining Test cases, both System & Integration and executed many test cases Test Data reviewing and maintaining and executing detailed Test scripts for UAT, analyzing bugs, interacting with team members in fixing errors and User Acceptance Testing (UAT) and worked on Black box and White box Testing.
  • Thorough knowledge in Requirement analysis, Planning, Scheduling &Tracking projects.
  • Concrete understanding of Business Requirement gathering, Business Process flow, Business Process Modeling and Analysis, design documentation.
  • Strong problem solving and analytical skills with in-depth understanding of system development methodologies, techniques and tools.
  • Work with the development team to provide an environment ready for testers and end-users.
  • Facilitated test plan/test case walk-throughs for the Business and Development teams to obtain feedback and/or approval sign-off.
  • Excellent organizational, interpersonal, communications, teamwork with proven skill to interact across multiple levels of organization.
  • Business/Project Modeling Tools : UML CASE Tools, Rational Rose, MS Visio, MS Projects
  • Languages: Oracle, SQL, Java
  • Databases: MS SQL, MS Access
  • Test Tools: HP ALM/ Quality Center, Quick Test Pro (QTP), Rally,
  • Project Management Tools: Microsoft Office ( Project, Word , Excel (filtering, VLOOKUP, pivot tables, PowerPoint, Access , Visio), SharePoint
Business/Data Analyst, 06/2019 - Current
Affinity Solutions New York, NY,

Magellan Health Services, Inc. provides managed behavioral healthcare, radiology benefits management, specialty pharmaceutical management, and Medicaid administration products and services in the United States. The company provides services to health plans, insurance companies, employers, labor unions, and various governmental agencies The company’s radiology benefits management services consist of managing the delivery of diagnostic imaging services, which are provided under the contracts with managed care companies, health insurers and other health plans, Medicaid, and Medicare members. I was involved in updating an existing quoting and enrolling program based on the business requirements and also integrated eligibility check application so application can check before offering plans like Medicare.


· Gathered Business Requirements, analyzed data/workflows, and defined the scope

· Generate queries and data dictionaries, analyze data and create visualization/ dashboard related to audience and direct-to-consumer insights working with data sets.

· Work closely with development team to manage data warehouse, facilitate meetings and manage any new requirements/backlogs.

· Met with client groups to determine User Requirements and Goals, thus converting User Requirements into Business Requirements and User and Technical Requirement Specification

· Worked on IBM mainframe environment for Medicaid Management Information System impact assessment.

· Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.

· Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project. Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD). Developed Software Requirement Specification (SRS) document using Visio and MS Office.

· Extensively interacted with both business team and development team in coming up with a Sequence diagrams.

· Developed internal algorithms, condition-action tables and decision trees and tables that incorporate member’s personal and medical information.

· Actively involved in the creation of comprehensive resource center through collection, documentation and extensive editing of relevant medical literature.

· Participated in agile process – planned iterations, created tasks, assigned tasks to quality assurance team based on the priorities and estimated capabilities of quality assurance team for every iterations

· Core member for conception, implementation of Business Intelligence initiatives

· Prepared high level business use case and developed it into multiple system use cases and Activity diagrams.

· Used UML to perform Use-Case analysis to capture the dynamic aspect of the application.

· Developed UI document with UI designs and mock-ups through wireframes. Utilized Story boards and screen mock-ups to obtain client feedback and approval. Suggested changes when the user interface was confusing or needed rewording.

· Analyzed and studied the technical, structural and data content changes for EDI transaction sets 834 (Enrollment and Maintenance), 837 (Professional, Institutional and Dental Claims) and 835 (Claim Payment/Advice).

· Authored Companion Guide to support all the information needed to process HIPPA transactions with Dean Health.

· Worked in conjunction with the project manager, design team and developers to prepare project status reports and presented reports to clients in order to keep them current. Utilized prototypes and structured walkthroughs to ensure that all relevant requirements are properly addressed.

· Facilitated collection of Functional Requirements from system users, and prepared Business Requirement documents

· Responsible for claim adjudication like Medicare claims, professional claim, institutional claims.

· Applied the RUP model throughout the entire development and testing process.

· Involved in development of Business and Technical Requirements in preparation of Design and Functional Specifications for Business Needs and Processes.

· Worked closely with Business users to determine the workflow of the product.

· Performed walkthroughs of the prototype with end users to better understand user needs.

· Followed a structured approach to organize requirements into logical groupings of essential business processes, business rules, and information needs, and ensured that critical requirements are not missed.

· Followed the UML based methods using MS Visio to create Use Case Diagrams, State Chart Diagrams and Sequence Diagrams

Technical Environment: Windows XP, SQL, Business Objects, Microsoft Office(MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access), RUP, MS Project, Rational Requisite Pro, MS Word, Visio, SQL, MS Excel, HP ALM/Quality Center.

Business/Data Analyst, 12/2017 - 05/2019
Cdw Crofton, MD,
  • CNA Insurance with more than 40 years of experience in the healthcare industry, CNA is a trusted leader and one of the top five underwriters of healthcare insurance products and services for a wide spectrum of organizations. We offer extensive industry knowledge; valuable insight and core coverage’s tailored to meet the unique needs of healthcare providers. Involved in Claims Processing System, this project consisted of providing various reports to the management to track how many claims are we processing and what are the efforts being done to contain claims cost.


  • Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
  • Documented business requirements, and communicated these requirements with the development team for design and implementation of business solutions.
  • Worked with Business Analysis team to prepare a detailed Business Requirement Document.
  • Analyzed Business Requirements to develop Functional and detail Design Specifications of the application.
  • Conducted Requirement Gathering Sessions with the stakeholders.
  • Interacted with the project team to help define the Business and System Objectives, confirmation of scope, identify constraints and the measures of success for the system to be developed.
  • Conducted the JAD sessions, daily meetings, brainstorming sessions to solve the problems and enhance the workflow.
  • Documented, organized and tracked the requirements using Rational RequisitePro.
  • Documented the detailed business as well as technical requirements to upgrade the current system to 5010 transactions.
  • Involved in designing future state processes for HIPAA 5010 transaction processing EDI’s 837,835, 270, and 271.
  • Perform Gap Analysis of the processes to identify and validate requirements.
  • Performed GAP analysis to identify AS-IS a process EDI transaction set 834,837 and 835 of 4010A and TO-BE processes of 5010 standards and based on that developed Business Requirement Documents.
  • Used the DataStage Designer to develop processes for extracting, cleansing, transforms, integrating and loading data into data warehouse database.
  • Involved in the claims adjudication process of Facets.
  • Worked on Facets extensions mapping attributes.
  • Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
  • Responsible for integrating with Facets.
  • Designing test scripts for testing of Claims in Development, Integration and production environment.
  • Worked with Source System Subject Matter Experts (SMEs) to ensure that the extracts are properly mapped.
  • Used SQL for data mapping and querying.
  • Tracked and maintained Stakeholder requested enhancements and changes using Requirement Traceability Matrix (RTM).
  • Incorporated Rational Unified Process (RUP) and analyzed User Business Requirement Document (BRD), Technical Requirement Specification and Functional Requirement Specification (FRS) using Requisite Pro, Rational Rose and MS Visio.
  • Completed a review of existing documentation for orders, referrals and reports and compared it to the clinical details needed for HIPPA 5010.
  • Worked with technical experts to prepare test case scenarios for unit testing, integration testing, user acceptance testing and compliance testing.
  • Streamlined the Restatement Financial Data Warehouse access review Process.
  • Assisted in building a Business analysis process model using Rational Rose and Visio.
  • Did Technical documentation for the project using tools like Visio, Word, etc.
  • Used MS Project for managing schedules, resources and collaboration.

Technical Environment: Microsoft Office ( MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access),RUP, MS Project, Visio, Oracle, Rational Rose, UML, MS Project, FileHandler Enterprise

Business Analyst, 12/2014 - 11/2017
U-Haul Fayetteville, NC,
  • Molina Healthcare has grown into one of the leaders in providing quality healthcare for financially vulnerable individuals and families. Currently, Molina Healthcare arranges for the delivery of healthcare services or offers health information management solutions for nearly 4.3 million individuals and families who receive their care through Medicaid, Medicare and other government funded programs in 16 states. The focus of the project was the replacement of 22-year-old Medicaid Management Information System (MMIS).


  • Coordinated with the stakeholders and project key personnel to gather functional and non-functional requirements during JAD sessions.
  • Studied the existing business process and created AS-IS workflow to illustrate the existing system.
  • Recorded requirements in the Requirement Traceability Matrix (RTM) defining each technical requirement in detail from areas like: main hardware, application software, networks, servers, internet and desktop configuration.
  • Experience with AGILE Tool and methodology.
  • Responsible for the full HIPAA compliance lifecycle from gap analysis, mapping, implementation and testing for Medicaid Claims.
  • Responsible for gap analysis in changing old MMIS and Involved in testing new MMIS.
  • Also, accountable for Medicaid Claims Resolution/Reimbursement for peach state health plan using MMIS.
  • Involved in HIPAA EDI transactions such as 270, 271,837 (P, D, I), 276, 277, 834, 820, 278,999/TA1, and 277 CA.
  • Involved with System Tester for Facets Billing and Finance.
  • Defined Functional Test Cases, documented, Executed test script in Facets system.
  • Drafted the Physical Data Mapping document for the data flow from Facets to the data warehouse.
  • Performed extensive data modelling to differentiate between the OLTP and Data Warehouse data models.
  • Identify opportunities for the creation of algorithms and data models to detect incorrect or fraudulent Medicaid billings.
  • Manage EDI for business partners world-wide and was Responsible for new trading partner implementation including mapping and testing of various EDI transactions in ASCI-X12 and EDIFACT standards, to/from various internal processes and platforms.
  • Facilitate the process for requirements validation that follows the MITA process/sub F process business model.
  • Analyzed HIPAA 4010 and 5010 standards for 837P EDI X12 transactions, related to providers, payers, subscribers and other related entities.
  • Worked on IBM mainframe environment for Medicaid Management Information System impact assessment.
  • Dealt with the EDI transaction-835 claims payments and remittance advice, which deals the payment from payer to provider.
  • Worked closely with business team, and identified, analyzed the core requirements and key features of the ongoing project.
  • Extracted, discussed, and refined business requirements and developed comprehensive business requirement document (BRD).
  • Developed Software Requirement Specification (SRS) document using Visio and MS Office.
  • Worked into Healthcare claims process, EDI transactions, EMR (Electronic Medical Records), DSM (Direct Source Messaging) HIPAA (Health Insurance Portability Accountability Act), EOB, ANSI 837 UB92, 5010, HIX.
  • Responsible for creating business work flows and processes and creating management reports based on the analysis.
  • Experience in Rational Rose & HPALM/Quality Centre.
  • Followed the UML based methods using Rational rose to create Use Cases, Activity Diagram, Sequence Diagram, Collaboration Diagram that include Functional and Non-Functional specifications to hand off to development teams.
  • Actively involved in updating internal processes (submit claims, check eligibility), updating data collection and data reporting.
  • Defects and bug testing by using Rational Clear-Quest, Configuration management and Version control with Clear-Case.

Technical Environment: Microsoft Office (MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access), MS Project, NSI X12- EDI UML, Rational Requisite Pro, MS Word, Visio, SQL, MS Excel.

Business Systems Analyst, 01/2012 - 11/2014
Ibm Corporation Blue Bell, PA,
  • Universal Health Care is a Medicare/Medicaid health insurance provider based in St. Petersburg, Florida. It provides managed care services for government sponsored health care programs, focusing on Medicare and Medicaid. It offers a variety of health insurance products to our Members, including Medicare Advantage plans in 13 States, Medicaid in the State of Florida, and a Long-Term Community Diversion program in Florida (designed to enable seniors to live a healthy and comfortable life in their homes).


  • Implemented an integrated RUP solution with complete line of traceability for all the artifacts of web development projects.
  • Responsible for designing future state processes for HIPAA 5010 transaction processing EDI’s 837 and 835.
  • Analyzed HIPAA 5010 related to 837,835, 834.
  • Transactions and performed gap analysis between HIPAA 4010 and 5010.
  • KnowledgeofICD-9-CM and ICD -10-CM coding and claims processing.
  • Involved in the creation and maintenance of the Workflow plans and artifacts.
  • 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.
  • Experience with AGILE Tool and methodology.
  • Serve as subject matter expert with respect to the annual benefit changes and rules associated with the Medicare Part D program.
  • Documented Requirement Traceability Matrix(RTM) for requirement elicitation and linkup to deliverables.
  • Worked with the individual sub-project managers to translate these into PRDs (Product Requirement Documents) for the development teams.
  • Examined, analyzed and model Test plans, Use Case Model cases & Test procedures based on RUP methodology.
  • Used Rational Rose to visually determine the proper structure, key elements and optimal design for Database and to aid efficient creation of tables, stored procedures.
  • Evaluated the information gathered from multiple sources during requirement gathering and analysis and responsible for tracking, tracing and managing requirements using Rational Requisite.
  • Used MS Project for various planning and budgeting activities.
  • Wrote clear, concise detailed System Requirements Specification(SRS)documents and user documentation in accordance to guidelines and standards of a level where developers can interpret, design and develop the application with minimum guidance.

Technical Environment: Microsoft Office (MS Word, MS Excel, MS PowerPoint, MS Visio, MS Access),Rational Requisite, RUP, Oracle, SQL

Education and Training
Bachelor of Science: , Expected in 2008
George Mason University - ,
Computer Science: Computer Science And Programming, Expected in 12/2020
Harvard University - Boston,

Professional Certificate

  • A broad and robust understanding of computer science and programming
  • How to think algorithmically and solve programming problems efficiently
  • Concepts like abstraction, algorithms, data structures, encapsulation, resource management, security, software engineering, and web development
  • Familiarity in a number of languages, including C, Python, SQL, and JavaScript plus CSS and HTML
Activities and Honors
Certified Professional Scrum Master (09/2020 - Present) Certified AWS Cloud Practitioner (08/2020 - Present)

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