TECHNICAL SKILLS

OPERATING SYSTEMS: Windows 7/8/ XP, OS390, AS400, Mainframe, Citrix, Client Server

DATABASES: SQL, Access, FoxPro, Oracle, DB2, RDBMS.UNIX

OTHER SKILLS: ANSI X12, 837/835 EDI, ICD - 9/ICD-10 Code Sets, Edifecs, Claredi HP Quality Center 10.0, Rational Tools, ClearQuest, MQ Series, HIPPA Clear Quest, Cognos, Crystal Reports, AS 400 Query, Visio,TSO/ISPF, CICS, COBOL, AS400, File-Aid, QMF MS Access, MS Excel, MS Project, MS Outlook, SharePoint

PROFESSIONAL EXPERIENCE

Confidential

Lead Business Analyst\QA

Responsibilities:

• Participated in the Business Requirements gathering process for the Confidential Blue Chip and ITS Claim Adjudication Systems for the ICD - 10/ ANSI 5010 Projects.
• Analyze, define and document Business Requirements for Business Stakeholders and Development for ICD-10 Remediation and Conversion.
• Defined and analyzed system impacts and gaps related to government mandates such as ACA, ICD-10 and Healthcare Reform initiatives.
• Involved in testing activities and analysis of Medicaid Fee for Service, reimbursement payments and electronic billing for ICD-10 and integration with MMIS.
• Analysis of Benefit Administration for Medicaid, Medicare and, Managed Care products against contractual requirements.
• Analyzed 4010/5010 side by side document and 5010 changes and impacts to Blue Chip Application, ITS and NASCO Claims Functionality.
• Reviewed 837 P/I and 835 Implementation/TR3 Guides for electronic claims submissions during the analysis phase
• Created User Acceptance Claims and Billing Test and Use Cases based on Business Requirements
• Participating in testing support for ICD-10/ ANSI 5010 implementation and ICD-10 Pilot Testing
• Cross functionally coordination with various Corporate departments including Confidential, EFE, HCM, EPPO and ITG to mitigate risks and issues
• Help define and design future state processes for ICD-10/5010 transaction processing for 837, 835 and NCPDP electronic transactions.
• Participated in analysis of ICD-9 TO ICD-10 conversion to determine impacts on Claim Adjudication and electronic billing Systems.
• Participated in Requirements & Test Cases Walkthroughs with Development, Business and QA Staff members for 5010 and ICD-10 projects.
• Assisted QA team during the testing effort and to make sure coverage for the Requirements were captured in the Test Cases.
• Participated in the ICD-9 TO ICD-10 and ANSI 4010 to 5010 ICD-9 Gap Analysis studies.
• Utilized Edifecs and Claredi compliance checker tools to verify 837 ICD10/ANSI 5010 compliancy.
• Significant Exposure to 837I/837P Claims Submission Processing and 835 Remittance Advice electronic processing and structure.
• Participated in troubleshooting and analysis of ICD-10 defects found during testing.
• Familiarity with ICD-9/ICD-10 Diagnosis and Procedure Code Sets and mapping.
• Develop Test Strategy and Approach documentation and workflows.
• Participated in Requirements gathering implementation activities for Confidential Health Care Exchange and ACA initiatives.
• Familiar with Healthcare mandates, CMS guidelines and ACA.
• Participated in Requirements gathering activities for Healthcare Exchange initiatives.

Confidential

Clinical Business Analyst

Responsibilities:

• Participated in the Implementation process for the Installation of Epic Software at three Network hospital sites.
• Collaborated with various departments to create process and system workflows.
• Gathered Business Requirements from various departments.
• Participate in re-engineering and validation sessions with users and SME’s.
• Participated in System Build of new application in be installed.
• Participated in software conversion activities.
• Provided Application support and served as liaison between IT and user community.
• Completed Epic training at Epic University in Wisconsin in Inpatient Modules.

Confidential

Systems Analyst

Responsibilities:

• Responsible for creating and developing test plans and scripts and executing test scenarios on-line and in Batch for Claims System Enhancements, software bug fixes and updates.
• Analyzed User Requirements and Functional Specifications for ITS Claims Processing and PTS applications to indentify and evaluate Test Scripts and data needed and gaps.
• Participated in (UAT) User Acceptance Testing and coordination.
• Assisted with creation of Test Beds and created own test data and perform data manipulation through File-Aid.
• Utilized Rational Tools and in-house testing utilities for high volume data loads and testing.
• Assisted Automation Group with automating tests scripts for enhancements and Regression purposes.
• Identified, documented, reported and tracked software defects for Development Team through ClearQuest.
• Investigate and troubleshoot Production application problems. Participate in all phases of the Test Life Cycle including Integration, Regression, Conversion and Automation. Create Test Strategy documents.
• Participate in Development, Design meetings and workgroups for Enhancements and software releases.
• Interact closely with Business Analysts and User groups to resolve functionality discrepancies.
• Projects include those related to claim pricing, billing, Healthcare compliance, HIPAA, Medicare Advantage, Blues Plan Network changes and reporting.
• Utilized Cognos for querying and reporting off of large claim and provider databases and performed SQL queries.
• Assisted with the gathering, determination and update of Functional Requirements and Specifications.
• Created statistical and metrics reports related to performance indicators and utilization for Plan Data.
• Participated in multiple testing projects including testing enhancements, re-creating and investigating production defects/bugs and taking ad-hoc requests simultaneously.
• Used Quality Center to load test cases, link defects, reporting and test planning activities.
• Mentor junior staff and create training documentation.

Confidential

Sr. Quality Assurance Specialist

Responsibilities:

• Principal responsibilities include the creation of Test Plans against Requirements and execution of Life and Health Insurance Products test scripts.
• System functionality tested includes Claims Processing, Billing, and Carrier Administration.
• Responsible for analyzing application specifications, gathering business requirements from users and UAT.
• Issue tracking and use of Reporting tools such as AS400 Query for querying were other tasks.

Confidential

Technical Support Analyst

Responsibilities:

• Responsible for compiling, analyzing and validating the accuracy of provider data in BCBSIL networks.
• Extracts data from several large databases and use various report development and analytical techniques to perform statistical data comparisons and tracking.
• Perform routine monthly and quarterly processes for quality checks and to ensure organizational compliance to set guidelines.
• Maintained, created databases and queried with use of MS Access.
• Participate in audit preparation activities and table maintenance.

Confidential

Sr. User Support Analyst

Responsibilities:

• Responsible for providing application support to end-users of McKesson HBOC proprietary and third party Healthcare & Managed Care software at Hospitals, Clinics, Medical Groups and TPA’s.
• Troubleshoot application errors on multiple platforms including client server and IBM mainframe environments.
• Assisted in User Acceptance (UAT), Regression and Performance testing.
• Participated in Managed Care software implementations, upgrades and conversions.
• Responsibilities include system testing, training, and analyzing claim payment errors.
• Required development of procedural documentation. Involved table maintenance, plan/provider contract load setup and custom reports development.
• Heavy exposure to diverse applications utilized in a hospital, managed care and physician practice settings with exposure to claims, EDI batch processes, patient care, physician billing, eligibility and credentialing software.
• Performed system maintenance and application issue tracking. Maintain communications with vendors and administrative personnel within user groups on projects and system or software related concerns.
• Served as lead Analyst in requirements gathering and testing EDI claims conversion project.
• Coordinated hardware and equipment upgrades and performed software application installations.
• Participated in Performance and Stress testing.
• Responsible for database reporting utilizing Crystal Reports.