BUSINESS/TECHNICAL SKILLS:

MS Office Suite; MS Project, MS Visio, MS, SharePoint; WebEx, Confidential NPS, ClaimsXTen, Blue Squared, SAP Reporting Tools, BlueCard ITS Software, Clarity, QuickBase, Waterfall, Agile, Jira, Facets, EDI ANSI Transactions, Medicare CMS, HealthCare D Confidential Analysis, Change Management, IT Audits and Compliance

PROFESSIONAL EXPERIENCE:

Confidential, Detroit, Michigan

Business Analyst

Responsibilities:

• Create and update Business Requirement Documents and Functional Requirement Documents
• Act as a liaison between the business units, QA and the technology teams. Lead JAD sessions and act as the lead facilitator for various projects from start to finish through the SDLC.
• Participate in Code Reviews, System Testing and UAT followed by production verification, post production testing and support.
• Conduct BRD walk thru session with the entire finance team, business, testers and developers after the completion of the BRD. Organize meetings with the SMEs of the dependent systems. Conduct weekly issue meetings with customers.
• Reviewed, analyzed and created detailed documentation of business systems and user needs, including workflow, program functions and steps required to develop or modify application programs
• Process and workflow development for Medicare and Medicaid.

Confidential, Owings Mills, Maryland

IT Auditor

Responsibilities:

• Performed Audit of Confidential and Claims platforms.
• Provided Feedback and Guidance to Senior Leadership on process and departmental workflows.
• Performed of Audits of Systems to ensure protocols were followed.
• Performed Audits of Claims, Groups and on Facets Platform
• Performed Audits of Claims, Groups and on Confidential Platform.
• Communicated and interacted with, internal departments, Claims, Customer Service, Enrollment and Billing, Contracting, Quality Assurance &, Networks Management, and the Special Investigations Unit.
• Reviewed EDI ANSI 835/ /271 Files for Facets and Confidential Self Service Portal Inquires
• Reviewed all system d Confidential as well as payment methodologies to ensure compliance with all contractual obligations as agreed to by the Group, Subscriber and Provider

Confidential, Exton, Pennsylvania

Medicare Business Analyst

Responsibilities:

• Reviewed claim d Confidential files to determine Medicare Pricing
• Facilitated Daily Checkpoint meetings
• Reviewed Confidential to determine correct fee schedule for In Confidential t, Out Confidential t and Physician claims
• Provided high level overview of claims d Confidential to identify trends of under/overpayments.
• Reviewed contracts to determine payment methods to reprice Medicare Claims.
• Lead Analyst on Medicare Claims audit project.
• Performed audit on Anesthesia, Out Confidential t, In Confidential t claims based on provider contract.
• Audited Medicare contracts based on CMS guidelines

Confidential, Detroit, Michigan

Business Analyst

Responsibilities:

• Worked with the business users and subject matter experts to gather business requirements using JAD Sessions, group meeting and one - on-one meetings
• Created scope documents, business requirements documents, detailed design documents, process flows, swim lanes, and use cases
• Performed GAP analysis
• Created test plans and test cases.
• Created requirement traceability matrix to insure test coverage
• Planned and Facilitated Operational Touchpoint Meetings
• Scheduled and Facilitated Deep Dive and Pre/Post Deployment Meetings
• Created Business Use Cases and User Stories
• Schedule and facilitate cutover planning meetings
• Managed Work Plans and Projects using Agile and Waterfalls

Confidential, Livonia, Mi

Senior Project Analys

Responsibilities:

• Maintained communication with and acted as escalation point for applications team analyst located in the Confidential Francis Command Center.
• Designed Command Center and Back up Command Center
• Responsible for Command Center phone lines and their direct communications into the Confidential Francis Support Command Center.
• Performed notifications of status of Go-Live Check list and progress
• Updated and distributed Go-Live Dashboard
• Coordinated staff levels according to support levels requested.
• Collaborated with Analyst and Subject Matter Expert for trouble shooting and issue resolution.
• Dispatched resources to departments in hospital as situations required.
• Created Playbooks and project documentation.

Confidential, Detroit, MI

Senior Systems Analyst

Responsibilities:

• Maintained, tracked and assigned all Systems and Technical issues from customers received via support mailbox.
• Created Reports via SharePoint site for Stakeholders and senior leadership.
• Facilitated implementation meetings and Joint Application Sessions.
• Responsible for the tracking and coordination of Milestones for 4 platforms (Medicare Advantage, Blue Care Network, ITS BlueCard Host and ITS BlueCard Home.)
• Gather requirements, created high-level test plans and executed UAT and Regression Testing
• Created and customized weekly and monthly MS Excel/Access reports for Issue inventory and analysis.
• Reviewed Providers issues in to Provider Status for correct pricing and network affiliation
• Collaborated with business customer and technical areas to resolve technical issues submitted to department mailbox for resolution.
• Created documentation and workflow, technical resolutions and departmental process.
• Resolved Complex Claims and System Issues submitted by business partners.
• Group Leader of Workgroup responsible for transitioning Access based reporting tool to a SQL reporting tool.
• Gatekeeper responsible for tracking, resolution and communications between departments, vendors and internal customers.

Confidential, Brooklyn, NY

Group Integrity Auditor

Responsibilities:

• Ensure coverage continuation only for those groups/subscribers that continue to meet Empire’s small groups Under Writing Guidelines.
• Audited and removed ineligible Groups/Subscribers from Empire’s books with proper termination and cancelations notices.
• Worked with Managers and Teams to improve the audit credentialing process.
• Processed and review fraud alerts weekly to help reduce risk of potential fraudulent activity by reviewing payroll, company roster and other company documents.
• Conducted monthly audit sample reviews (5%) of newly enrolled small groups to ensure enrollment accuracy and that small group met Empire’s underwriting requirements.
• Provided detailed information about Confidential to enrolled groups members and administrators.

Confidential, Owings Mills, MD

MTM Auditor

Responsibilities:

• Performed and participated in the coordination of statistically valid operational audits in accordance with the Member Touchpoint Measures Program (MTM) or Licensee Desk-Level Audit guidelines (LDLA).
• Reported the Confidential Association ( Confidential ) as a part of their Standards on a quarterly basis.
• Analyzed the performance of the operational departments assists in identifying potential areas of risk that may impact both our providers and subscribers
• Communicated and interacted with, internal departments, Claims, Customer Service, Enrollment and Billing, Contracting, Quality Assurance &, Networks Management, and the Special Investigations Unit.
• Reviewed all system d Confidential as well as payment methodologies to ensure compliance with all contractual obligations as agreed to by the group, subscriber and provider.
• Created Spread Excel spreadsheet that reflected the progress and production of the work group. Spread sheets also tracked the progress on the Focus Audit initiative and production of each auditor.

Confidential, NJ

Enrollment Benefit Analyst

Responsibilities:

• Assisted with Open Enrollment for Confidential Employees via call center.
• Enrolled participants in Benefits plans and Life Insurance and Accidental Death and Dismemberment, Long Term Disability, High Deductible Health plans
• Enrolled Members in HMO PPO EPO POS Health Plans.
• Explained in detail the pending Health Care Reform Act.
• Enrolled Participants in Health, Dental and Medical Benefits Plans.
• Assisted Benefits Specialist with the loading of Confidential Accost and HSA Accounts.
• Provided online and call center help in regard to Deductions and Contributions.
• Responsible for the Administration of Confidential and HSA accounts.

Confidential, Visalia, CA

Plan Implementation Senior

Responsibilities:

• Added new Hospitals and Professional Providers to Confidential Health Network.
• Ensured that all Providers were loaded correctly for proper pricing and discounts.
• Created and maintained networks and delivery systems in provider file system
• Assigned rate coding to ensure the system appropriate discounts, per diems, case costs, and fee schedules.
• Examined fee schedules for proper coding.
• Prepared the Confidential Healthcare claim system to adjudicate contract provisions.

Confidential, Dallas, TX

Claims Consultant

Responsibilities:

• Investigated medical claim d Confidential in conjunction with insurance payer contracts to identify payment errors.
• Analyzed contracts with healthcare providers to identify overpayment opportunities.
• Reviewed implementation materials to create documents, policies, s, riders or prepare summaries of coverage.
• Examined and processed claims and adjustments.
• Managed escalated claim issues.
• Analyzed, investigated, and authorized payment of claims within established guidelines.

Confidential, Newark, NJ

Claims Process Auditor

Responsibilities:

• Analyzed monthly reports for over-payments, duplicate payments, retro disenrollment’s, COB issues and provider pricing issues
• Communicated with other Confidential BCBSNJ departments to identify overpayment opportunities for financial reconciliation.
• Coordinated and prepared written error reports to assure accurate reporting
• Reviewed and analyzed systemic and processing methods to identify claim processing problems and recommended modifications for the improvement of accuracy and efficiency.
• Reversed engineered claim process to determine over/underpayment.

Confidential, Newark, NJ

Claims Specialist

Responsibilities:

• Full Service Customer Service and Provider Service Rep, ITS Claims Specialist and Call Center Confidential Full Service Claim Adjuster.
• Responsible for the correction of SF’s, NF’s and DF’s for the BlueCard Confidential
• Responsible for the of Pricing Rules and Methods associated with the Blue Card Association
• Performed QNXT and Confidential Claims resolution in a call center environment.
• Provided in back end systems and manual processing of claims (class instructor) Qblue, QNXT and Home Plan Aid systems.
• Reviewed contracts for provider and facility to determine correct reimbursement,
• Processed complex claims on Qblue (QNXT Systems, Coordination of Benefits, claim policy, authorizations, and referrals in accordance with Plan policies, procedures and contract provisions.