SUMMARY

• 10 years of working experience in the Healthcare industry with combination of Systems Analyst, and Claims Analysis experience.
• Expertise with Facets/NetworX Provider contract pricing and benefits configuration analysis.
• Proficient with contract interpretation, rate sheet/agreement development and design to improve claims first pass rate, qualifier group and fee schedule design, quality assurance, unit testing and processing control agent configuration.
• Hands on experience with user warning messages, claims adjudication, troubleshoot provider reimbursement and payment vouchers, problem resolution, claim re - adjudication and mass adjustments. Provided detailed analysis using access queries, troubleshoots, and correct issues.
• Focused on performance, Detail oriented and Logical & independent out of the box thinker.

TECHNICAL SKILLS

• Facets System 4.61
• 4.71
• 4.11
• 4.21
• 4.41. 4.61 & 4.81
• 5.1
• 5.2
• NetworX Pricing
• Amisys
• Advance
• CITRIX Gtess Imaging System
• WMDS
• HIPPA EDI
• 270/271 documents
• 835/837 Claims and Encoder PRO Clinical Editing System
• Member PRO for Eligibility
• Customer Focus.

PROFESSIONAL EXPERIENCE

Confidential, Pennington, NJ

Business Systems Analyst

Responsibilities:

• Experience with FACETS and/or NetworX.
• Experience with benefits, claims, and Payer & Provider Agreements, ideally experience doing provider configuration.
• Proficiency in Microsoft Office applications including Word, Excel, Access, Outlook, Project, PowerPoint and Visio.
• Experience with query building using SQL, MS Access, and/or other technical analysis tools.
• Prepared the Business requirement Document BRD and functional requirement document FRD for the enhancement of the existing services.
• Conducted JAD sessions with business units and stakeholders to define project scope, to identify the business flows and determine whether any current or proposed systems are impacted by the new development efforts.
• Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS.
• Designed and supported in Test cases, Test plan creation and Companion Guide from development stage to production, including both internal and external requirements.
• Documented the UAT Plan for the project and worked with the UAT Team to ensure every acceptance criteria for the requirements has been included in the UAT task plan.
• Create and communicated the prototype requirements to the development team in Excel formats as templates for the reports.
• Responsible for configuration/ compatibility and BA testing with the help of Facets, SharePoint and Tidal scheduler.
• Tested the changes for the front end screens in FACETS related to following modules, test the FACETS batches membership, Provider
• Create and managed requirement types and traceability relationships.
• Extensive involvement in data mapping using Facets data model.
• Extensive use of Facets back end tables and front end application system for data validation purposes.

Confidential, Durham, NC

Business Systems Analyst

Responsibilities:

• Acted as a liaison between the business stakeholders and delivery team through the project life cycle to communicate and validate requirements, and ensure that technical delivery team has full understanding of business goals and objectives as stated in the requirements.
• Translated Business Requirements into Technical specifications and documented Technical Requirement Document specifying changes to the workflows related to Claims, Coverage and benefits, Personal health records, ID card information and Drug Pricing.
• Configured EDI transactions (837, 835, 834, 270, 271, 276/277, 278, 820) through HIPAA Gateway and based on business need.
• Actively involved in the development, grooming and sizing of the product backlog, release backlogs and sprint backlogs to monitor the development process.
• Followed the UML based methods using MS Visio to create Process flows, Use Case Diagrams, State Chart Diagrams and Sequence Diagrams.
• Developed and maintained a Burn down chart to keep track of the efforts versus the sprint timeline to be achieved
• Involve in a team to developed UI wireframes and data element dictionary related to the screens related to Dashboard and Benefits modules.
• Prepared functional requirement/design documentation in support of business need/process.
• Facilitated requirements meetings and documenting outcomes/minutes and action items; ensuring appropriate follow-up for action items
• Actively involved in backend testing using simple and complex SQL queries for data validation purposes
• Assisted testing team with documenting Test Plans, Test cases and execution of test scenarios for the Mobile Application and clarified issues which may arise during testing.
• Supported SIT and UAT testing and issues resolution with both the users and SIT team.
• Worked closely and collaboratively with other team Business Analysts, System Architects, Data Architects, Development team, and QA team to clearly articulate defined requirements, and clarification when questions arise.
• Proactively and effectively involved in an issue and risk management, ensuring issues and risks is clearly documented and escalated appropriately in a timely fashion, and manage and track issues/risks until closure or corrective action has taken place.

Confidential, Las Vegas- NV

Amisys Advance Configuration Analyst

Responsibilities:

• Utilized Amisys benefit configuration options to improve provider and member benefit determinations consistently and accurately.
• Performed QA testing and analysis of Amisys configuration mapping to ensure certificate of coverage/business requirements were met.
• Install/Implement and train on Amisys releases
• Investigate to resolution extraordinary claim, eligibility, pricing, provider, benefit, medical management/authorization.
• Identify process, workflow, configuration and system-related issues requiring improvements
• Remain current with changes in business rules for all lines of business and Amisys/Facets systems
• Proven ability for identifying gaps in configuration and presenting configuration alternatives based on Amisys Library research.
• Creative ability to extract claims and configuration data into readable English format using complex SQL query writing.

Confidential, Baton Rouge LA

System Analyst

Responsibilities:

• Conducted extensive analysis on migration and conversion of Provider and Member data, Group configurations, plan codes, benefit set-ups, fee schedules, provider pricing, capitation set-ups, etc. from Legacy system to Trizetto Facets 5.2
• Facets Medical Plan configuration, manipulating service procedure, service revenue, supplemental procedure, supplemental revenue, medical utilization edits, service payment, limits, service rules, benefit summary, and class plan tables.
• Involved in configuration of Facets Subscriber/Member application.
• Performed data mapping and data modelling and used canonical data model to map data from X12 834 transactions.
• Forward and backward data mapping between the fields in mainframe and Facets.
• Analysed the mainframe reports for member/eligibility/claims and mapped the fields with Facets batch jobs and reports.
• Tested the changes for the front end screens in Facets related to following modules, test the Facets batches (membership).
• Developed logical & physical modelling as per business requirements.
• Assisted the team in Preparing Test cases.
• Conducted Integration tests and User Acceptance Tests.
• Create back end data loads through Access to upload tables into Facets system.
• Retrieve data through table queries within Facets.
• Prepared documentation and reference materials for team members for future reference of Facets configuration setup.
• Utilized Clinical editing system e.g. Encoder Pro for validation of ICD-10 diagnosis codes as well as CPT-4 procedure codes.

Confidential, Columbus, OH

Amisys Advance Configuration Analyst

Responsibilities:

• Benefit Plan Configuration in Amisys for Individual, Small Groups and Large Groups.
• Reviewed and Analyzed business processes, current system configuration, appropriateness of the original system design, efficiency of use of the AMISYS functionality and standards established for data processing for a Medicaid Health Plan.
• Built Pricers with Treatment Types, Per Diems, Fee Schedules in AMISYS
• Built Modifiers, Percentages, Super Tables, Pay Classes, Service Qualifiers in AMISYS
• Built Benefits, Copays, Limits, Co-Insurance in AMISYS
• Built Components, Riders, Counters, Benefit Packages in AMISYS
• Created mapping translations and crosswalks for data that was being received they may need to be changed before accepting the information in its current state.
• Daily work on test Design Documents for several of configuration related tasks.
• Perform testing in test environment before moving any configuration to production.
• Prepare requirements.
• Daily run Claims Impact Analysis due to configuration issues.
• SQL reporting, Database reporting.

Confidential, MA

Systems Configuration Analyst

Responsibilities:

• Updated service payment tables (SEPY) within Facets for new Medicare product offering, attaching appropriate service rules required for each benefit category, created new limits (LTLT) for benefits, peer reviewed other configurations, tested build configuration for each product offering.
• Updated and built new and existing supplemental revenue code tables (SRCT) for Amerigroups high dollar radiology project based on the criteria provided
• Set up and maintain deductible and limit accumulators in the Application Support Application group.
• Created new limit rules for specified preventive services (Summary of Benefits and other Configuration documents).
• Created 'carve-outs' to wellness benefits not counting towards family deductible
• Updated service definition tables (SEDF) to incorporate new service ids required for Amerigroup high dollar radiology project. Facets Medical Plan configuration, manipulating service procedure, service revenue, supplemental procedure, supplemental revenue, medical utilization edits, service payment, limits, service rules, benefit summary, and class plan tables.
• Create back end data loads through Access to upload tables into Facets system.
• Retrieve data through table queries within Facets
• Appointed as Lead for the self insured line of business. Work closely with Sales, interpreting benefits sold into business decisions and system configuration.
• Test, load and configure business decisions into system. Team lead for recent upgrade of Facets system.
• Test and implement quarterly fixes to Facets
• Involved in product configuration for commercial and government lines of business.
• Organized meetings with all department management to review benefits in depth discussing the payment type, coding and pricing before implementing Facets configuration.
• Prepared documentation and reference materials for team members for future reference of Facets configuration setup.

Confidential, NY

Systems Analyst

Responsibilities:

• Completed loading Facets 4.81 provider agreement, hospital contracts, CPT codes, and demographic data encounters, capitation, membership, provider setup, provider contracts, and benefit plan build.
• Build benefit grids for unit testing and UAT Configuration.
• Accessed ICD-10 for designing payment systems and processing claims for reimbursement.
• Supported client configuration changes and new requirements, including analysis, plan building, and test.
• Handled all Medicare, Medicaid for Facet configuration process.
• Analyzed complex business issues related to ICD-10 and developed systems requirement.
• Conducted detailed system analyst configuration; benefit contracts into the Facets system to ensure proper benefit payment.
• Provided detailed analysis using access queries, troubleshoots, and correct issues.
• Accessed numerous billing systems: NetworX Pricer, Facets, Amysis, and along with utilizing Microsoft Access, SQL, Excel for analysis, reporting and updating FACETS data to ensure proper configuration process.
• Used Microsoft Outlook for incoming mail and respond to inquiries.
• Worked on Claims processing software’s include EZCAP, Medical Manager, Medisoft, Encoder pro, Facets Test Plan on new rates for 2011 and changes to the Facility and Professional agreements to insure correct payment.
• Analyzed and adjudicated pended claims generated from Ruby reporting system.
• Reviewed Benefit Matrix for specific details of product descriptions; run SQL Queries for each product associated.
• Utilized my in-depth knowledge of Agile and Software Development Life Cycle (SDLC) methodologies throughout the duration of this assignment

Confidential, NY

Trizetto NetworX Provider Pricing Configuration

Responsibilities:

• Accountable for NetworX configuration of Provider contracts for medical, ancillary and ASC based entities.
• Created rate sheets/agreements, qualifier groups and fee schedules.
• Worked on quality assurance of new or existing contracts/configuration to ensure appropriate/correct payment is made through unit testing on current and regression payment.
• Data Transfer of agreements from a testing environment into a production environment.
• Researched and corrected payment issues related to NetworX pricing through a Macess queue.
• Accessed queries and table loads.
• NetworX Data Model tables for updates and maintenance, processing control agent (PCA) and warning messages.

Confidential, NY

Medical Claims Analyst

Responsibilities:

• Assessed and distribution of work assignments, aging accounts, mass adjustments and special projects.
• Identified pricing issues whether processing, contract or configuration error. Implemented corrective action plan based on analysis.
• Validated reports for payment and recovery accuracy.
• Analyzed claim payments/recoveries based on claims re-adjudication whether the issue was due to provider configuration or member/benefit configuration.
• Worked directly with the provider relations department and provider offices during the Facets migration to ensure the posting of payments appropriately based on payments and recoveries on the provider's payment vouchers and collection processes.