SUMMARY:

• Qualified professional with over 6 years of extensive experience in the field of Confidential Analyst working with the technical staff to implement management and staff's business requirements into the software application in Healthcare Industry.
• Adequate knowledge in Health Administration - Claims processing (auto adjudication), COB, EOB/Drafts, Claims pricing and testing, enrollment, Medicare, MMIS, Medicaid, CDHP (consumer driven health plans).
• Experienced with Medicare and Healthcare Insurance; as well as Medical Standards (HIPAA and HL7).
• Involved in planning, architecture, and implementation in PMO office of multiple projects in support of Affordable Care Act ( Confidential ).
• Worked on the conversion of existing legacy system to the FACETS 4.7 in accordance to HIPAA 5010 upgraded version from the HIPAA 4010.
• Excellent Knowledge in Electronic Medical Record (EMR) / Electronic Health Records (EHR) modules and process flow.
• Worked on different Confidential healthcare transactions like 837-Institutional, 837-Professional, 837-Dental, 835-Claim Payment/Remittance Advise, 270/271-Eligibility Benefit Inquiry/Response, 276/277-Claim Status Inquiry/Response Transactions.
• Deep knowledge of PPACA rules surrounding the Enrolment and Eligibility piece.
• Experience in Medicaid Management Information System (MMIS). Expertise in various subsystems of MMIS- Claims, Provider, Recipient, Procedure Drug and Diagnosis (PDD), Explanation of Benefits (EOB).
• Experience in MITA 2.01 (Medicaid Information Technology Architecture) business and technical architecture implementation including health information Exchange HIE concepts.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall and Agile.
• Conducted JAD sessions, created Use Cases, work flows, screen shots and Power Point presentations for the Web Applications
• Familiar with HIPAA Confidential transactions such as 843, 820, x12, 835, 837 (P, D, I) 276, 277, 278 etc.
• Worked as an Confidential Analyst and UAT Tester for ICD9 to ICD10 project on the Professional Claims side.
• Exposed to using ICD 9/ICD 10/ANSI/HL7 coding standards in Medicare and Medicaid domains of the healthcare systems and industry for both inpatients, outpatients, Reimbursement methodology.

TECHNICAL SKILLS:

Programming Languages: C, C++, HTML, XML, SQL.

Data Base: MS Access, Oracle (SQL Series), DB2

Reporting Tools: Crystal Reports 8.0

Operating Systems: MS-DOS, Windows95/98/NT/2000/XP, Apple McIntosh, Linux

Software: MS Office Suite(Word, Excel, Access, PowerPoint & Outlook), MS Visio, Rational Rose, Rational Requisite Pro, Confidential 834, 820, X12, Adobe Acrobat, MS Office FrontPage, Lotus Notes

Mainframe: COBOL, DB2, JCL, CICS, MVS

Processes/Technologies: Rational Unified Process (RUP), Waterfall, UML & Microsoft Office SharePoint 2007

Automation Tools: Requisite Pro, Win runner, QTP, Test Director, Quality Center

EXPERIENCE:

Confidential, Minneapolis, MN

Analyst

Responsibilities:

• Worked on verify that funds are received on all Confidential 820, 834, x12.
• Conducted Process Improvement Project for ADHD in efforts to raise our HEDIS rates.
• Knowledge of Medicare and Medicaid Services ( Confidential )/Affordable Care Act ( Confidential ) compliance. worked with data mapping team for ICD 9 to ICD10 for forward mapping of the diagnosis and procedure codes
• Analyzed the processes in medical coding and transition from ICD 9 to ICD 10.
• Analyzed issues with Confidential transactions and fixed IDOCs to be submitted into SAP for order fulfillment.
• Enrollment and Maintenance ( Confidential 834) standard to facilitate out-of-the-box BizTalk based HIPAA compliance during business activities such as transmission of enrollment records.
• Responsible for communicating to the collections department on old outstanding Confidential 820 transmissions.
• Created lists of ICD9 - ICD10 CM/PCS codes, with reference to the usage percentile and provided to Stakeholders to determine if codes were best-fit or all possibilities.
• Review daily Confidential transmission to ensure Confidential is being sent and acknowledged successfully, if not then determine what is the issue and follow up to resolve
• Also support Extol Integrator Confidential package and develop RPG/ILE interfaces for new trading partners.
• Worked on Healthcare system implementation including enterprise Electronic Medical Records (EMR) and Electronic Health Records (EHR) software.
• Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation, and testing for processing of Medicaid Claims.
• Worked on Confidential (Center for Medicare and Medicaid Services) checklist, MITA, HIPPA and GAP analysis.
• Working on x12 Confidential T-Sets and Confidential T-Sets. Integrated the Confidential 820 and Confidential 835 Payment Order\ Remittance Advice transaction

Confidential

Confidential Analyst

Responsibilities:

• Participate in Systems testing and UAT followed by post production support created a workflow to distinguish between ICD-9 & ICD-10 codes in cases of overlap.
• Tested the Confidential 834 interfaces, Developed test cases and test scripts for all 834, 835, 837 278, 276, 277, Institutional and Professional HIPPA Transactions
• Integrate complex Medicaid principles and policies into the Medicaid Management Information System (MMIS), requiring knowledge in areas of health systems and Medicaid information processing.
• Created, socialized and obtained approvals for three decision documents: ICD 10 Procedure Codes, Medicare, and Backward Mapping (ICD 10 - ICD 9).
• Ensure current Edits and Audits are applicable for ICD 10 Diagnosis codes and ICD-10-Procedure Coding System (ICD-10-PCS) PCS Codes.
• Tested claims Edits and Audits to ensure that the system would recognize and accept the ICD-10 changes.
• Participated in various Healthcare presales initiative for EHR applications, HIPAA 4010-HIPAA 5010 and ICD9 - ICD10 conversions.
• Develop and implement change control policies and procedures for EMR template change requests.
• Worked on HL7 to provide framework to carry out transfer of electronic healthcare information.
• Ensured billing and premium collection are modified to support 820 HIPAA transactions set.
• Facilitated JAD sessions to collect requirements from product owners and prepared user stories that provided appropriate scope of work to technical team to develop prototype and overall system for subscriber enrollment, claims and billing ( Confidential 834/837/835).
• Involved in requirement gathering phase (Provider, Claim components and HIPAA).
• Produced Gap Analysis documents for HIPAA 5010 and ICD-10.
• 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.
• Established questionnaires and resource leveling required for implementing HIPAA 5010 and upgrading ICD-9 diagnosis codes to ICD-10 codes.
• Involved in creating sample mappings for the conversion of Confidential X12 transactions code sets version 4010 to 5010 and translation of ICD 9 codes into ICD 10 codes.
• Analyzed trading partner specifications and created Confidential mapping guidelines

Confidential, Nashville, TN

Confidential Analyst

Responsibilities:

• Performed GAP analysis for ICD-9, ICD-10 and Confidential 5010 X12 Message Structure with the 4010 Structure.
• Performed and analyzed GAP Analysis of Confidential 834, 835, 837 transactions from 4010 to 5010.
• Leaded the development of Business Requirements Documentation (BRD) for analysis related to the ICD-10 mandate.
• Part of the project team to migrate existing vendors trading Confidential documents via Value Added Network (VAN) onto our FTP server to reduce operating costs.
• Met with relevant stakeholders to obtain Confidential contacts for all vendors to communicate testing schedules and ensured project completion.
• Participated in an enterprise level Electronic Medical Records (EMR) system implementation.
• Facilitate process for requirements validation that follows the MITA process/sub-process business model.
• Load and generate Business Reports for Enrollment files ( Confidential 834) and Claims files (EDI837 I & P).
• Substantial report development experience utilizing SQL Server Reporting Services (SSRS), Cognos Impromptu, and Microsoft Excel.
• Propose strategies to implement HIPAA 4010 in the new MMIS system & eventually move to HIPAA 5010.
• Responsible for claim processing in MMIS.
• Assisted quality assurance team to functional-test the new HL7 interfaces always keeping in mind HL7 and HIPAA guidelines, and coordinated user acceptance testing using derived test data
• Responsible for architecting integrated HIPAA, Medicare solutions, Facets.
• Identify Member, Provider, Coverage, Medicare, and Medicaid.
• Analyzed and documented ICD 10 requirements related to data elements, data exchange and data transmission.