PROFESSIONAL SUMMARY:

• Dedicated business professional with 18 years of healthcare experience working within Operations, Finance, Health Care Management, Pharmacy Network Management and Project Management Office.
• Supported Medicaid State Agencies with meeting CMS guidelines for enhanced Federal Funding Participation and certification of Medicaid Management Information System (MMIS) modules.
• Successfully implemented process improvements and system enhancements that recovered multi - million dollars in healthcare savings for all lines of business including, but not limited to Managed Care, PPO, Indemnity, Medicare and Medicaid products.

PROFESSIONAL STRENGTHS:

• Medical claims management
• Managed Care Organization
• Provider management (credentialing/enrolling & rate code)
• Project Management skills (as Lead Business Analyst, PM & SME)
• Management and leadership skills (direct managing 5-15 team members)

EXPERIENCES:

Business Analyst

Confidential

Responsibilities:

• Confirm Confidential alignment with the MMIS Financial Module and Provider Network Management request for proposal (RFP) requirements.
• Assist with facilitating and tracking SS-A workgroup activities including Confidential training.
• Assist PMO Confidential workgroup with development of the Concept of Operations and Roadmap document.

Sr. Business Analyst

Confidential

Responsibilities:

• Identified, logged and tracked risks, issues, and mitigation activities relative to project risk.
• Ensured that the Provider module Design, Development, and Implementation ( Confidential ) deliverables and processes were aligned with the client’s contractual agreement for Confidential project.

Sr. Quality Assurance Specialist

Confidential

Responsibilities:

• Managed team effort in the validation of Medical Information Technology Architecture ( Confidential ) framework and clarified requirements alignment with MMIS modules; confirmed traceability of requirements, use cases, workflow diagrams, functional and nonfunctional evidence via Dynamic Object-Oriented Requirements System ( Confidential ), which is the requirements management application; validated certification traceability via Medicaid Enterprise Certification Toolkit ( Confidential ); validated functional and nonfunctional artifact traceability for Pharmacy Benefit Management (PBM), Provider, Member, Finance, Claims modules.
• Lead analyst required to ensured quality and sign-off of project document deliverables including, but not limited to the planning phase, design development and implementation ( Confidential ), work instructions, policies and procedures, testing and training materials; validated requirements to ensure the service level agreements and contractual obligations are met.
• Assured ongoing compliance with quality and industry best practices; collected and compiled statistical quality data; completed quality sampling of user acceptance testing, regression testing and system integration testing.

Pharmacy Network Analyst

Confidential

Responsibilities:

• Monitored provider credentialing for Pennsylvania State Medicaid pharmacy benefit manager to ensure providers met all government regulations and statutes, and client performance guarantee.
• Managed project plans, project documents, researched specifications for Request for Quotes (RFQs) for a provider credentialing vendor and Request for Proposals (RFPs) to solicit new clients.

Confidential

Support Analyst

Responsibilities:

• Facilitated weekly and monthly project status meetings; communicated status updates, risks, issues and remediation plans to applicable stakeholders; leveraged Project Management Body of Knowledge (PMBOK) best practices to accomplish project success.
• Collaborated with the business groups to develop Business Requirements Document (BRD), wrote requirements, documented standardize procedures to support operational improvement and corrective action plans (CAP); facilitated Joint Application Design (JAD) sessions.
• Coordinated workgroup sessions by translating business requirements to develop technical specifications technical requirements documentation; facilitated user acceptance testing (UAT) activities; managed team deliverables and activities; provided weekly and monthly project reports.

Business Analyst

Confidential

Responsibilities:

• Initiated and tracked bulk medical claim adjustments for medical cost saving projects; recover overpayments; assisted with internal and external audit assessments; completed data analysis of claim reports before and after bulk claim adjustments to validate meeting individual and team $3 million yearly target goal.
• Ensured compliance with CMS, State and Federal guidelines when adjusting large volumes of medical claims; implemented process improvement initiatives; created training material; trained and mentored employees on policies and procedures.
• Interviewing subject matter experts to gain insight current state processes (as-is processes) and developed future state processes (to-be processes); wrote business requirements (BRD) and assist with the development of technical (TRD)and functional (FRD) requirements documents.

Benefit Coding & Test Analyst

Confidential

Responsibilities:

• Analyzed test output and reported results for internal and external audit (Deloitte, SOX, and PricewaterhouseCoopers during business as PwC).
• Interfaced with the Benefit Coding, Audit, Sales departments and other Business Partners to ensure quality results and customer satisfaction; peer review benefit coding activities for Indemnity, PPO and Managed Care products.
• Created audit material, trained new hires and less seasoned team members on industry best practices, policies and procedures (including managing remote offshore team consisting of 10 people).

Claims Auditor

Confidential

Responsibilities:

• Assisted with external audit by investigating inquires cited to the company