SUMMARY:

• Proficient and well qualified Business Analyst skilled in healthcare payer management, benefit management (EOB’s, deductibles, co - insurance, out of pocket, copays and more) claims process (CPT, HCPCS, ICD, NPI, Tax ID, NDC, modifiers) Medicare, Medicaid and commercial health plans/providers, vision, dental and behavioral health, eligibility, enrollment and disenrollment, research, overpayment recovery, billing, customer service and the Affordable Care Act.
• Skilled in gathering and creating business requirements, workflows and processes.
• Experienced in provider documentation and management including new provider creation, current provider updating, validating and input of NPI and assigning members.
• Experience working with 834, 843, 270 EDI transactions. Experience working as a liaison between provider, members, clients and vendors and CMS and DOM with excellent customer service skills.
• Experience and working knowledge of local, state and federal laws governing medical records, health insurance dealing with CMS and DOM rules, deadlines and turnaround times.

TECHNICAL SKILLS:

Tools: PeopleSoft, File net, MS office, MS Project Management and Kofax.

Database Software: Ingenix Encoder Pro, Emdeon, Resolver, McKesson, Caremark, ABF, Basic SQL, Alchemy and EDI.

Application Software: AMISYS Advance, UMV, QNXT, Diamond, Share Point. CRM, Portico, AWD, Cypress, SalesForce, PowerStepp, Zendesk.

PROFESSIONAL EXPERIENCE:

Confidential

Application System Analyst, Senior

Responsibilities:

• Working as project lead on the automation process of Vital authorization for Star kids. Manual tested the new Vital App. process on the Texas Medicaid website using FileZilla.
• Working on Authorization load process and running SQL query to complete loading the Auth automatically in the system.
• Working on 834 files for Chip, Star and Star Kids and making sure all the information is entered in the system correctly with working all the resubmissions.
• Working with EDI transactions like x12 to pull up information on 835 and 83 7 claims data.
• Working DST Cases/Issues to create ticket and worked on resolving ticket when having system generated issues.
• Worked with the implementation of the Go Live of Harmony and Vital applications.
• Worked on Star Kids go live projects with handling issues like Medsys, Data Logic, Pointdexter and NVA Daily Automation.
• Worked actively on Star Kids go live working on the state daily and monthly files.
• Coordinate with vendors like MED assets and Availity to make sure all the business initiatives and solutions across the company meet and exceed goals.
• Working with updating Provider mapping and Provider term in the system as needed.
• Created and submitted the yearly compliance Report/Deliverables to the State after reviewing and updating the Business Continuity/Disaster Recovery Plan, JIP (Joint Interface plan) System Quality Assurance plan, Risk Management Plan, Security Plan and so that we adhere to state compliance and regulations.
• Worked on the implementation of Smart Data project explaining the vendor with the correct location, data drop, Network and the possible timeline and more.
• Working on creating and resolving Salesforce tickets with both system generated issues as well as department issues.

Confidential

Business Analyst

Responsibilities:

• Identified and analyzed user business requirements, procedures and problems to improve existing processes and workflow in AMISYS Advance and surrounding systems and applications.
• Documented requirements and workflows for AMISYS Advance modules/subsets including Provider, Member, Claims and Benefits.
• Documented provider updates, verified and input NPIs, assigned members to particular providers and completed automated ‘mass-moves’ of new members to corresponding providers based on location and plan-type (PPO, HMO, etc.) through Amisys advance.
• Also responsible for documenting and performing manual provider and member coordination.
• Performed detailed analysis on assigned projects, recommended potential business solutions and assisted with implementation.
• Responsible for all Medicare, Medicaid and CHIP requirements gathering and documenting for Washington and Mississippi.
• Worked on 834, 270, and 820 EDI file transactions, and was responsible for all eligibility/information entered correctly into the database system for all state files.
• Duties included being able to accurately process enrollment / disenrollment, deletions, termination, change of groups, reactivations for Medicaid and Medicare members.
• Coordinated with the PDM team and work on member moves to different providers as needed and send out provider term letters when needed.
• Processed PCP auto assignments and made sure all the members are assigned to correct participating providers close to their zip codes, working all the errors through Amisys Advance.
• Collaborated with many vendors including US Scripts, NIA, Opticare, Univita, DHW and Harvey Dallas, and different internal departments like IT, Finance and PDM to drive key business initiatives and solutions across the company to meet and exceed goals.
• Coordinated and worked with DOM (Dept. of Medicaid) to ensure all the daily and monthly files were processed correctly in compliance with health plan, corporate, state policies, procedures and guidelines.
• Analyzed and completed monthly eligibility reports to ensure accurate and timely submission to DOM meeting deadlines and turnaround times.
• Supported business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems.
• Worked on CRM issues like eligibility, PCP change, and external fulfillment and error\welcome packet.
• Worked on eligibility files with the Claims dept. ensuring all the data and enrollments were correct and updated in AMISYS Advance.
• Work alongside IT department and the health plan to implement and resolve eligibility issues.
• Coordinated with Xerox and DOM to implement and resolved any eligibility related issues.

Confidential

Business Analyst

Responsibilities:

• Recruited and developed network for a region and set of providers.
• Led assigned recruitments (i.e. physician, hospital and ancillary) and ensured they resulted in complete and accurate standard contracts that meet objectives by following up and provided accurate information on missing documents on credentialing and made sure all documents were received accurately in a timely manner.
• Facilitated, documented and oversaw the provider set-up and contract configuration in AMISYS Advance.
• Initiated contact and identified potential providers by geographic and specialty needs and update database.
• Coordinated with internal departments and contracted providers to implement and maintain contract compliance.
• Helped provider understand the whole contract and credentialing process by providing them with correct forms and information to complete the credentialing process.
• Prepared and submitted a weekly report on the missing information data to the manager and leads.

Confidential

Business Analyst

Responsibilities:

• Assisted in the completion of several projects and implementation of plans by utilizing data gathering tools such as SharePoint, EDI, Caremark, and ABF and application software such as QNXT to ensure that the work met and exceeded quality standards.
• Responsible for gathering and documenting requirements for eligibility entered into the QXNT system.
• Duties included being able to accurately process enrollment and disenrollment, deletions, termination, change of groups, reactivations and contact service forms within the department.
• Worked as a team lead, responsible for assigning daily and weekly work assignments to the team members, making sure all the work met Centers for Medicare & Medicaid Services and mercy rule.
• Provided support to the team members and worked with them to resolve any complicated enrollment issues with research and investigation.
• Analyzed and prepared weekly team report and submitted to the manager for review.
• Served as the primary contact for providers as a liaison between the provider and Confidential .
• Educated providers and worked with them to resolve all kinds of insurance related issues.
• Communicated with members and providers and explained the medical benefit structures, claims adjudication process and discuss regarding different payment methods.
• Knowledgeable in local, state and federal laws governing medical records, health insurance and Centers for Medicare & Medicaid Services.
• Proficient in medical records department processes including release of information correspondence, personal health information and HIPAA regulations.
• Worked with CPT, ICD codes and medical insurance process.
• Reconciled all member eligibility, enrollment and disenrollment data accurately between Centers for Medicare & Medicaid Services and Mercy rule.
• Researched and processed outstanding eligibility and enrollment, claims and research issues in accordance with company policies and procedures in a timely manner.
• Adjudicated medical claims and assignments which often involved use of queries using QNXT system.
• Worked in high stress environment meeting all deadlines.
• Trained new employees in Medicare eligibility, enrollment and disenrollment rules and regulations.

Confidential

Business Analyst

Responsibilities:

• Processed provider appeals for claims denied for untimely filing, pre-existing condition, pre-authorization and other disputes regarding underpayment and contract rates.
• Researched, investigated and adjusted complex claim issues identified from customer service calls and correspondence submitted by providers.
• Provided excellent customer service to providers, commercial members and Medicare members regarding benefits and eligibility.
• Advised and educated providers regarding the policies and procedures to bill claims correctly upon rejection or denial of claims by suggesting appropriate modifiers, bill types, correct procedure codes or diagnosis codes, tax identification numbers, national provider numbers and referrals.
• Trained around five new hires per hire session for benefits, claim, overpayment recovery and more as required by the provider relation department.
• Constantly received high scores (99% or more) for productivity, schedule adherence and quality standards, and awarded as Employee of the Month for June 2009 among 30 0 employees.

Confidential

Operations Business Analyst

Responsibilities:

• Reconciled and verified different mortgage documents for quantity and quality standard.
• Entered all mortgage file data electronically using the BA Tools: File net, Kofax and PeopleSoft.
• Facilitated, coordinated and documented new processes.
• Identified process gaps and maintained process changes to accommodate new product integration throughout the organization.
• Utilized project-planning tools to ensure timely completion of projects.

Confidential

Research Assistant

Responsibilities:

• Worked on multiple stages of a project life cycle, which included formulation, analyzing existing operations, and developed procedures to solve problems.
• Created spreadsheets, gathered data, analyzed test records and documented business requirements.