SUMMARY:

• 15 years Healthcare Payer Experience
• 10+ years Facets and NetworX Pricer experience (versions, both front and back end expertise for configuration and testing)
• 10+ year experience in HSD Diamond 950, Xcelys, Amysis, Amysis Advance, QNXT and Health Rules
• Comprehensive experience in healthcare data analysis encompassing systems reporting and testing. Superior claims adjudication and auditing expertise resulting in excellent performance evaluations.

PROFESSIONAL EXPERIENCE:

Confidential

UAT Testing Analyst, Configuration Analyst

• Ensure updates of CPT, HCPCS, DRG, and ICD - 10 codes as well as pricing, billing rates, analysis, data entry, testing and documentation of configuration set up for all Facets applications.
• Translates business rules into effective and efficient Facets configuration
• Gathering and analyzing data in support of business cases, proposed projects and system requirements.
• Prepare and deliver reports, recommendations or alternatives in an effort to streamline processes and improve operational efficiencies
• Define and deploy operational requirements and system goals based off of conducted analysis and agreed upon recommendations

Confidential

Testing Analyst, Sr. Facets Configuration Analyst

• Set up & configure ITS; Synchronize ITS Home- Facets Configuration Analyst; Configure MQ series
• Configure SA/Security; ITS Product Security; ITS User Security
• Facets to ITS code Conversions; ITS COB Method Conversion; ITS Codes Description; ITS Error codes description
• ITS Home Administrative Rules Application; ITS HRA Administrative Rules
• ITS Home Products; ITS Proxy provider applications

Confidential, MA.

Business Analyst, Amysis Advance & Facets Configuration Analyst, UAT Testing Analyst

• Provides oversight of business system requirement/ specification analyst & maintenance in accordance with customer deliverables.
• Document and test Facets test scenarios, cases, and step-by-step instructions based on Harvard pilgrim health business functions.
• Developed and maintained business system configuration solutions in accordance with provider/employer contracts and customer requirements.
• Conceiving and delivering Claims Mass re-Adjudication (CMA)
• Administered the data/ configuration maintenance of systems parameters, specifications and data linkages to other systems involved in SOA component based architecture.
• Query and analyze data backend table data from Facets and NetworX tables.
• Developed, maintained, and disseminated internal and external system documentation, including status updates; prepared procedural and customer documentation when required.
• Responsible for data maintenance in Facets Tables which includes but not limited to backend tables, writing queries through data dictionary and stored procedures
• Test and quality analysis validation of configuration building test claims
• Able to convert CORE Facets pricing to NetworX pricing

Confidential, Houston, TX

Facets Configuration Analyst, Facets Testing Analyst, Senior Appeals and Grievance Specialist

• Implementation of Medicare Line of Business into Facets 5.01
• Performed Facets front and back end configuration and inquiries activities using SQL
• Responsible for timely and accurate configuration build and test activities related to Benefits, Payments, Pricing, Claims, Provider contracts & Membership/Enrollment, including ITS.
• Creation and maintenance of documentation related to build, test, policies and processes related to implementation efforts
• Provided status reports on weekly basis
• Responsible for monitoring effectuations of all resolutions as a result of appeal or grievance.

Confidential, Rochester, NY

Senior Facets Claims Specialist and Adjustment Representative

• Researched, analyzed and adjusted claims in accordance with the plans provision and provider contracts
• Produced high productivity and accuracy rate processing claims using Facets version 4.81
• Adjudicated and adjusted claims using Facets Medicare, Medicaid, Manage Care and PPO claims
• Strong problem solving techniques with excellent verbal and written communication skills
• Outstanding organizational skills and ability to meet deadlines

Confidential, NM

Facets Testing and Configuration Analyst, Appeals and Grievance Rep.; Senior Claims Processor

• Followed established requirements and design for Facets configuration, testing and debugging, provided build and release project/product components
• Facets membership (enrollment) and adjudication of test claims for eligibility and benefit configuration validation
• Responsible for identifying necessary steps and processing claims of various complexity levels for Medicare, Medicaid, HMO, PPO, SNF, Rehab etc.
• High productivity and accuracy rate processing overturned appeals; processed and adjusted claims in accordance with the plans guidelines

Confidential, GA.

Senior Biller and Collections Specialist

• Providing appropriate coding on the patient’s medical history, diagnosis, tests and treatments
• Using the coded medical records to create invoices that are sent to the patients and insurance companies.
• Responsible for submitting and following up on all claims which includes electronically filing Medicare, Medicaid, Commercial claims
• Liaison to insurance companies, accepting and posting payments
• Accurately recording the patient’s and insurance company details into the system.
• Facets patient enrollment, Billing, case management and follow-up

Confidential, Atlanta, Ga

Biller and Collection Specialist

• Used coded data to produce and submit claims to insurance companies
• Worked directly with the insurance companies, healthcare providers, and patients to get claims processed and paid
• Reviewed and appealed unpaid or denied claims; handle collections on unpaid accounts
• Manage the facility’s accounts receivable reports; answer patients billing questions