SUMMARY:

• Over 10 years of experience in the health insurance industry which includes a working knowledge of HMO, POS, PPO, TPA, Traditional, HRA and HSA plans
• Extremely knowledgeable in HIPAA and CMS guidelines
• Possess expertise of industry standards for healthcare providers including organization of groups, healthcare systems, and NPI
• Retains an understanding on the structure and requirements of Confidential claims transactions including 837I, 837P, and 837D transactions
• Team lead on collaborating projects delivering creative and effective solutions to clients
• Detail oriented and accurate in d Confidential collection and research techniques
• Strong analytical background incorporating the translation of business needs to Business Requirements for systemic solutions.
• Able to manage multiple high profile projects simultaneously
• Able to create and move team toward a project plan
• Utilized AGILE and Waterfall methodologies for gathering and documenting business requirements
• Experienced in all aspects of User Acceptance Testing (UAT) inclusive of test plans, scripts, and use cases for business, QA and release requirements
• Performed tests on new functionalities in system and maintained records of system defects
• Directed process improvements, reengineering the processes
• Analyzed business requirements and adapted workflow to core functions, enabling error reduction
• Maintained and updated documents for system and business processes
• Extensive computer, including knowledge of multiple networking environments, SPSS, Microsoft Office Suite (including EXCEL, ACCESS, PowerPoint, Project and SharePoint) and business software packages.
• Prepared PowerPoint presentations for various complex issues and prepare visual and written interpretations for business projects
• Skilled at learning new concepts quickly, working well under pressure, and communicating ideas clearly and effectively.
• Demonstrated achiever with exceptional knowledge of basic legal concepts, business practices, and sociological theories.
• Enthusiastic and multi - cultural work experienced.
• Educated in team building by determining overall functions of behavior and motivating factors which can ultimately be used to change behaviors and increase job satisfaction and productivity
• Possess the ability of a team leader by identifying individual goals to motivate toward overall company goals
• Educated in overall theoretical and practical determiners of behaviors in employment and social settings which provides insight on creating cooperative environment

WORK EXPERIENCE:

Confidential

Senior Business Systems Analyst

Responsibilities:

• Assigned to several projects under the ICD-10 Program (, Medicare/Medicaid Growth, and Claims & Encounters)
• Elicitation of business requirements from stakeholders
• Gather and document business requirements from gap analysis of current “growth” process
• Develop acceptance criteria for requirements
• Document business requirements into Blue Print
• Extract all or portions of requirements ad hoc to create BRD
• Research possible vendors for corporate ICD-10 and provided a recommendation to project leadership
• Assist with the development of the project plan and timelines
• Schedule and conduct requirement walkthroughs with stakeholders

Confidential

Senior Business Analyst

Responsibilities:

• Elicitation of business requirements from stakeholders for all lines of business
• Create process flows of EFT and ERA process (current and future state)
• Completion of Scope document
• Develop acceptance criteria for requirements
• Document business requirements into Blue Print
• Extract all or portions of requirements ad hoc to create BRD
• Assist with the creation of use cases
• Assist with the development of the project plan and timelines
• Schedule and conduct requirement walkthroughs with stakeholders

Confidential

Business Systems Analyst

Responsibilities:

• Lead Subject Matter Expert on current provider file set-up and Confidential federal requirements which pertain to providers, HNPI, and transactions
• Analysis of source d Confidential to assist with source to target mapping for provider d Confidential elements for Master D Confidential Management (MDM) during Extract Transform Load (ETL) process along side of Gaine
• Analysis and utilization of Health Rules (future system)
• Determination of critical dependencies of Health Rules loader files based in enterprise needs and uses
• Determine best practices for provider file
• Lead internal requirement definition for “provider” in Health Rules
• Assist the creation of a cross-functional corporate provider d Confidential model which include uses in Health Rules and Medical Management
• Impact analysis of changes to source d Confidential on current, interim, and future state of provider model for MDM and Health Rules
• Facilitate meetings to ensure Proof of Concept (POC) of the Health Rules provider d Confidential model target is met
• Gather and document business requirements from gap analysis and business areas
• Analyze business processes and provide document functional requirements of processes
• Assist the development of an interim plan during the conversion for demographic and provider network updates
• Assist with the creation of business requirements, test scenarios, traceability matrix, and use cases detailing recommendations to improve processes
• Assist with the identification of changes, additions, and termination of desktop procedures

Confidential

Business Systems Analyst

Responsibilities:

• Triage Confidential Medicare Post-Production issues identified by the claims department
• Researched Medicare Federal regulations and guidelines
• Assist creation of technical solutions to production problems
• Analyze process and system and recommend improvements to rectify issues which have been identified or uncovered due to analysis
• Facilitate multi-departmental meetings to coordinate testing, develop testing approach, and all follow-up
• Create UAT test plan and test cases
• Execute and document UAT test cases with outcomes
• Report and follow-up on any testing defects via SharePoint

Confidential

Lead Analyst

Responsibilities:

• Performed gap analysis of HIPAA P transaction format which resulted in the identification of differences between HIPAA P transaction, claims systemic processing and screen design based
• Gathered and documented business requirements from gap analysis and business areas
• Analyzed business processes and provide consultation for functional requirements of processes
• Created Requirement Traceability Matrix in EXCEL format
• Manually created 837P transaction in Confidential format to execute the test scripts
• Designed new claim display screens to accommodate Confidential transactions required changes including but limited to member, provider, service, and COB information based on requirements and gap analysis
• Completed UAT test strategy, test plan, scripts and business cases
• Execute and document UAT test cases with outcomes
• Reported and followed-up on any testing defects via SharePoint
• Provided periodic project updates to management

Confidential

Lead Analyst

Responsibilities:

• Performed gap analysis of the use of NPI in the Confidential regulations which resulted in the identification of system design deficiencies
• Created detailed process flows for additions of NPI in automated provider claims search criteria
• Gathered and documented business requirements from gap analysis and business areas
• Analyzed business processes and provide consultation for functional requirements of processes
• Used iterative methodology toward completion of requirements
• Created Requirement Traceability Matrix in EXCEL format
• Manually created 837P, 837I (institutional), and 837D (dental) transactions in Confidential format to execute the test scripts
• Designed new screens to display all NPIs associated with a provider, re-design of provider demographic screen to accommodate NPI, and created the logic for display of NPIs for provider.
• Created manual search criteria to use NPI
• Created systemic search criteria to use NPI to identify a provider on a claim
• Identified overlap between this project and Confidential and provided a plan to merge portions of projects to management via a PowerPoint presentation
• Completed UAT test strategy, test plan, scripts and business cases
• Execute and document UAT test cases with outcomes
• Reported and followed-up on any testing defects via SharePoint
• Coordinated release management with IT and other analyst
• Managed project independently of corporate project management for Confidential Initiative
• Provided periodic project updates to management

Confidential

Lead Analyst/Project Manager

Responsibilities:

• Performed gap analysis of the use of the automated provider selection process and desired future state
• Documentation detailed “as-is” and “to-be” states highlighting modifications, additions, and non-preferred parts of the process
• Gathered and documented business requirements from gap analysis and business areas
• Analyzed business processes and provide consultation for functional requirements of processes
• Performed impact analysis identifying all affected departments
• Monitored all phases of project and created Project plan to ensure all key areas were aware of deliverables and dependencies
• Created cooperative environment between various departments to increase productivity and facilitated the exchange of ideas/approaches
• Used iterative methodology toward completion of requirements
• Created Requirement Traceability Matrix in EXCEL format
• Manually created 837P, 837I (institutional), and 837D (dental) transactions in Confidential format to execute the test scripts
• Designed new screen to assist manual selection process based on business need to reduce time in manual process
• Re-designed and created logic for the overall systemic search and match criteria for a claim to automate selection a provider in CICS
• Identified overlap between this project and Confidential Implementation- NPI initiative and provided a plan to merge portions of projects to management via a PowerPoint presentation
• Created an overview and detailed process flow overview of the claims automated provider selection process in VISIO
• Co-authored a detailed process document which included business and technical attributes
• Completed UAT test strategy, test plan, scripts and business cases
• Execute and document UAT test cases with outcomes
• Coordinated release management with IT and other analyst
• Reported and followed-up on any testing defects via SharePoint
• Provided periodic project updates to management
• Determined Key Performance Indicators (KPIs) measuring the success of project
• Monitored and provided statistical analysis of KPIs
• Business Process Improvement (BPI): Project reduced pre-pended claims for provider selection by 50%

Confidential

Business Systems Analyst

Responsibilities:

• Gathered and documented business requirements business area
• Analyzed business processes and provide consultation for functional requirements of processes
• Created Requirement Traceability Matrix in EXCEL format
• Completed UAT test strategy, test plan, scripts and business cases
• Execute and document UAT test cases with outcomes
• Reported and followed-up on any testing defects
• Provided periodic project updates to management

Confidential

Business Systems Analyst/Project Manager

Responsibilities:

• Performed gap analysis of current provider d Confidential feed from Confidential and future state
• Identified parent company was doing the same effort which resulted in the efforts be condensed to one and changing the course on the implementation (reducing actual cost)
• Gathered and documented business requirements from gap analysis and business areas
• Analyzed business processes and provide consultation for functional requirements of processes
• Execute and document UAT test cases with outcomes
• Completed UAT test strategy, test plan, scripts and business cases
• Reported and followed-up on any testing defects via SharePoint
• Provided periodic project updates to management