Business System Analyst/Auditor Resume

SUMMARY

Accomplished healthcare professional with strong track record for excellence in devising and implementing cost - savings, revenue generating strategies and initiatives.
Highly skilled and trained, and in the analysis and interpretation of market trends in the health insurance industry.
Possess strong interpersonal and collaborative skills along with talent for assessing client needs to target cost-effective solutions.

PROFESSIONAL EXPERIENCE

Confidential

Business System Analyst/Auditor

Responsibilities:

Investigated service-related issues to identify root cause of issues; identify and communicate business needs assessments as necessary for the ClaimsXten software for correct coding.
Developed forecasting tools using current technology/systems (Access, Excel, Monarch, etc.)
Translated business requirements and assist IT with the development of technical specifications.
Developed solutions based on data analysis to increase business efficiency.
Lead and/or participated in internal and external project workgroup(s) and presentations.
Conducted User Acceptance Testing (UAT) for projects, implementations, system fixes and enhancements, etc.
Prepared materials for internal and external audit activities; reviewed audit findings/reports for accuracy and completeness. If appropriate, formulated rebuttal and/or corrective action steps.
Experience with Benefit and Membership Configuration by using FACETS and NASCO, and QBlue applications by creating new products setting up customizations to meet business requirements. The Benefits configurations allowed the setup of different lines of business, payment process for covered services, uncovered services for new implementations.
Coached/mentored less experienced staff, assisted in on-boarding of new staff and/or distributed, and followed up on work assignments.
Performed other relevant tasks as assigned by management.
Identified MCR and process improvement opportunities.
Conducted trending and root cause analyses.
Designed, developed, and monitored standard reports for metrics reporting and analysis.

Business Analyst/Auditor

Confidential

Responsibilities:

Managed accurate and timely validation of the system workflows for Medical Policy Integration department
Creating Business Requirements, gathering data by Current State Analyst for all systems FACETS, QBLUE and NASCO processing systems, loading Procedure/HCPC codes for criteria in Production region for QBlue modules for Medical Policy implementation.
Handling claim inquiries as a result of Department of Banking Insurance issues from errors during implementation.
Analyzing, approving, and denying test plans, test results, testing matrix, to ensure the logic and configurations are aligned for both systems outlined in the Business Requirements.
Medical Policy Post Production Audit Program, working with the Internal audit department by providing 15 samples medical policies to valid BRD moved into Production. Trending and analyzing claims 30-60 days post production.

Technical Support Specialist

Confidential

Responsibilities:

Managed accurate and timely validation of the system workflows and procedures to ensure their adaptability to Operations activities
Initiating and monitoring investigations of problem situations to assure prompt and effective resolutions.
Analyzing and evaluating reports to implement corrective action to trends or impending problems; compiling and issuing statistical reports where mandated and necessary
Analyzing business documentation of requirements and translation into proper system requirement specification
Developing individual test plans and detailed test case scenarios, validating test cases, and user acceptance

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