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Business Analyst Resume

Richmond, VA

SUMMARY:

  • Over 15 years of professional achievements throughout a wide spectrum of health care and related insurance information environments.
  • Proven ability to provide high quality employee benefit services for large national corporations coupled with a background that clearly demonstrates an ability to analyze and streamline health information processes.

TECHNICAL SKILLS:

Core competencies include: Healthcare Delivery Systems, Medicaid/Medicare/Health Insurance, Healthcare Research, Claims Audit, Reimbursement Methodologies, Enrollment Systems, User Acceptance Testing, Benefit/Premium Calculation, Benefit Plan Interpretation/Design, Provider Contracts, Claims Systems, System Audit

Systems: SMS Invision, SSI, MS Office, Claims Administration, UCS, IMCS.

PROFESSIONAL WORK EXPERIENCE:

Confidential, Richmond, VA

Business Analyst

Responsibilities:

  • Clarify MMIS requirements for Provider Subsystem.
  • Write business user stories.
  • Assist in ROM sizing and estimates.
  • Assist in mapping Use Cases to Requirements in Confidential .
  • Participate in all Pre - concept work sessions.
  • Research and clarify MMIS Pharmacy Benefit Management ( Confidential ) Requirements
  • Write Confidential Concept Stories for Flexible System until completion of Confidential Concept Phase

Confidential, Silver Spring, MD

Sr. Business Consultant

Responsibilities:

  • Write business, functional user requirements for both Epic Tapestry Claim and Diamond Claim system to support the implementation of Medicare Advantage HMO line of business. Identify potential Diamond to Tapestry claims system migration implementation issues.
  • Identify Medicare Advantage Quality Improvement (i.e. Confidential ) initiatives and requirements mandated by CMS.
  • Coordinate, research and resolve product implementation and regulatory issues.
  • Identify opportunities for improvement for NoVA Individual State Exchange processes.

Confidential, Raleigh, NC

Business Analyst

Responsibilities:

  • Assist in the development of requirements, procurement library, RFP, workflows, vendor evaluation/ selection and change requests for the DHSR Business Process Automation System ( Confidential ) and the Medicaid Management Information System known as Confidential .
  • Review Confidential Claims and Provider Subsystem business rules, design, development and implementation documentation for accuracy as well as touch points against the Confidential System.
  • Assist in review of initial Medicaid Enterprise Certification Toolkit ( Confidential ) Checklists against the Confidential MMIS Replacement RFP requirements for compliance via below steps during procurement:
  • Identify appropriate checklist to correlate to the MMIS Subsystems
  • Primary focus on the Industry Best Practice (IBP) Requirements
  • Review State Objectives, RFP Requirements and any addendum source documentation
  • Indicate whether or not the Business Objectives or the System Review Criteria were met
  • Cross reference the Business Objectives, System Review Criteria to the appropriate State RFP requirements, Statement of Objectives, State Medicaid Manual
  • Monitor Vendor DDI and Service Level Agreement tasks.
  • Mapped the ASPEN Central Office data dictionary data elements to interface with the required MMIS Provider/ Confidential Data Exchange data elements.
  • Research missing and/or aged Daily Tasks to resolution.
  • Monitor and create Confidential Weekly Action Item Report.

Confidential, Richmond, VA

Business Systems Analyst

Responsibilities:

  • Create premium and broker commission calculation tables based on broker status, lives covered and annual sales for parallel testing in UAT.
  • Identify, log, track, analyze and monitor resolution of UAT and functional test defects in Test Director for broker administration, benefits, and billing and membership subject areas.
  • Customer data extraction from various databases and data submissions used to create and validate user test cases in Amisys test environment.

Confidential, Denver, CO

Financial Analyst / Confidential Implementation Coordinator

Responsibilities:

  • Perform Provider Contracts Audits and System Audits of provider demographic and reimbursement fee schedules in the PMHS, CPF, ProClaim, Confidential Claims, Medicom claim systems, Bulletin Board systems against Confidential files.
  • Work extensively with local Confidential Implementation Managers (CIM’s) and Provider Data Organization (PDO) to load accurate provider information in the appropriate systems.
  • Perform claim reimbursement audits against provider reimbursement contracts loaded in claims systems.
  • Excellent working knowledge and understanding of Provider Reimbursement methodologies and market trends.
  • Review claims data extracts to detect claim system payment anomalies
  • Review and resolve Service Requests for Confidential related issues in iTrack System.
  • Assist and coordinate the efforts of the Confidential implementation managers who implement and oversee all network provider contracts including the installation of risk arrangements and development of provider agreements. Responsible for responding to inquiries from claims and other units regarding specifics pertaining to assigned contracts.

Confidential, Denver, CO

Implementation Coordinator / Carrier Systems Analyst

Responsibilities:

  • Revise and integrate implementation procedures and business rules to enhance accuracy of end product.
  • Perform preliminary interface mapping for medical and dental carrier eligibility feeds.
  • Extensive business analysis to improve workflow and integration of procedures.
  • Expand data requirements for testing purposes for use by multiple users. Extensive Internet healthcare research.

Confidential, Denver, CO

Statistical Researcher

Responsibilities:

  • Increased Medicaid HMO reinsurance reimbursements for 1999 by $290,000; Reinsurance reimbursements for year 2000 exceeded $660,000. Redesign/revise/reformat comprehensive business processes for capturing and analyzing Medicaid/CHP Plus financial data. Review claims data for eventual HIPAA compliance.
  • Financial Analysis - Identified approximately $1,000,000 in non-reimbursed deliveries for Medicaid eligible mothers that had not been captured and reimbursed.
  • Collect and report inpatient data for Disproportionate Share Hospital (DSH) Adjustment.
  • Train lead trainers and multiple departments on WINASAP software for real time eligibility verification. Extensive research on Medicaid/SCHIP programs.
  • Work with Denver Department of Human Services and perform comprehensive business analysis of Eligibility and Enrollment Processes for Potential Medicaid Members and Newborns for a Quality Improvement Process initiative and State Children’s Health Insurance Plan (SCHIP) programs.

Healthcare/Billing Consultant

Confidential

Responsibilities:

  • Perform quality review and cleanup of old account receivables utilizing the SMS Invision Patient Accounting System and SSI Billing and Claims Transmission software for correct claims administration.
  • Perform trouble shooting on SSI, SMS, chargemaster, claims administration and system related issues as warranted.
  • Identified major electronic claims transmission problem causing claims transmission failure. Corrective action resulted in substantial cost savings.
  • Advise chargemaster analyst of changes in Medicaid/Medicare codes to update billing system.

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