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Facets Configuration Analyst/senior Business System Analyst Resume

Grand Rapid, MI

SUMMARY

  • Experienced and distinguished Facets Configuration Analyst and Business Systems Analyst with experience in Software Development Life Cycle (SDLC) and Business Process Re - engineering
  • Experience working in various SDLC methodologies such as Waterfall, AGILE (SCRUM), RUP (Rational Unified Process), RAD (Rapid Action Development). Group and benefits installation in Facets
  • Facets Applications: Medical Plan, Application Support, Billing, Claims Processing, Provider, Subscriber/Member, Utilization Management, NetworX
  • Experience in Medical claims analysis and processing
  • Experience with Facets Tables and data model
  • Experience with Facets Application Groups: Claims Processing, Payments, Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member, Utilization Management
  • Proficient on creating artifacts such as Business Requirement Document (BRD), Functional Specification Document (FRD), Requirement Traceability Matrix (RTM), System Reference Document(SRD), System Manual and Operations Guide (SMOG)
  • Generated and Reviewed various documents including project scope, project objectives, business rules, test plan, change request, RTM (Requirement Traceability Matrix), Use Case, Test Case, Defect Report, SOW (Statement of Work), WBS (Work Breakdown Structure)

PROFESSIONAL EXPERIENCE

Confidential, Grand Rapid, MI

Facets Configuration Analyst/Senior Business System Analyst

Responsibilities:

  • Facilitated Sprint Planning meetings, Daily scrum, sprint review, product backlog refinement meetings and sprint retrospective meetings
  • Helped the team to write and split User stories, breakdown Epics
  • Used JIRA to maintain product backlog and sprint backlog and to create and track user stories, Sprint planning, tracking and managing sprints, created status reports and burn down charts
  • Confluence was used to maintain project documents such as project plans, project scope, and status reports and to assign tasks
  • Defined epic, features, product backlog and tasks on JIRA following Agile principles
  • Facilitated and participated in Agile rituals including, product backlog release, backlog stand-ups, and sprint planning, release planning, Iteration sprint review and retrospectives
  • Lead 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
  • Used JIRA to create and maintain User Stories and created UAT test scripts
  • Maintained knowledge of Medicare and Medicaid rules and regulations pertaining to the Facets configuration and evaluating the impact of proposed changes in rules and regulations
  • Responsible for configuring, benefits, contracts, providers, UM models, claims Analyze
  • Effectively test various applications to ensure that claim adjudication applies benefits according to the benefit plan and correspondence to provider and members meets all guidelines
  • Involved in various Facets Gateway, Claims, Membership, Provider, Billing, Capitation, Invoice, Benefits, Product and Plan
  • Configured and maintained benefit packages using FACETS system
  • Configured system to calculate appropriate claim reimbursement for multiple business lines according to the benefit summary
  • Benefit coordination and configuration, updated, adjusted, and revised fee schedules, coding, rates, provider contracts, database, claims and information via FACETS
  • Worked on Medicaid Claims Resolution/Reimbursement for state health plans using MMIS
  • Worked on EDI transactions like 270, 271, 834, 837 and 835
  • Gathering requirements and preparing functional documents for Facets
  • Worked with the business/functional unit to assist in the development, documentation, and analysis of functional and technical requirements within FACETS
  • Involved in Facets Output generation, Interface development and Facets Migration Projects
  • Worked on different modules of Facets such as Claims, Members/subscriber, commissions, provider, billing
  • Involved on HIPAA translation-based claim processing systems (claims and encounters) and other ANSI X12 EDI implementations
  • Validated the HIPAA/EDI transactions, tested the claims processing and Adjudication (EDI 837 & EDI 835)
  • Completed Data Analysis, Data Mapping for Medicaid projects and detailed report writing
  • Created, configured and built benefit specifications, compared benefits and products via FACETS, Service Request Tracker, MS Access and claims testing and adjudication, QA and functional testing, pulled data using Access and BP Reports
  • Prepared documentation and reference materials for team members for future reference of FACETS configuration setup. Worked on Process Flow Models and Captured Process flow diagrams

Confidential, Tampa, FL

Sr. FACETS Configuration Analyst

Responsibilities:

  • Responsible for the requirement-gathering phase and project plan
  • Responsible for requirements analysis, design and developing technical requirements
  • Documented Detail Business Requirements Successfully used Agile/Scrum Method for gathering requirements and facilitated user stories workshop. Documented User Stories and facilitated Story Point discussions to analyze the level of effort on project specifications
  • Prepared Business Requirement document to detail how Azure DevOps items maps to project Plan items for the technical system owners
  • Utilized JIRA Agile for managing requirements efforts while continuously completing RTM mapping against JIRA use case tickets
  • Facilitated scrum ceremonies (grooming, sprint planning, retrospectives, daily stand-ups, etc.)
  • Worked with Product Owner, especially in refining and managing the product backlog
  • Performed business process analysis on the details required to price a claim using NetworkX by interacting with the business users or claims operators
  • Co-ordinated with various teams involved to establish the connection between NetworkX and Pricing Systems Application
  • Worked on FACETS configuration and planned, developed and implemented the FACETS system and procedures by interacting with internal staff and outside systems vendors
  • Duties included conducting analysis, configuring, testing, quality assuring and documenting configuration solutions for all applications in the FACETS system
  • Worked on configuration of FACETS with Benefits, Claim processing and Enrollment
  • Proposed FACETS claim adjudication procedures, standards, and editing guidelines
  • Healthcare claims and payment advice transactions, captured all related EDI data in the repository using FACETS, supported integrated EDI batch processing and real-time EDI using FACETS. Accepted inbound transactions from multiple sources using FACETS
  • Involved in claim adjudication process of facets application
  • Worked with facets edits and EDI HIPAA Claims (837/835/820) processing
  • Assisted Information Management team with Implementations and Processing of 837 Encounter and 834 Member Enrollment transactions (both inbound and outbound)
  • Developed Business Crosswalks for EDI 837 I/P, 835, 834, 270/271 and 276/277 transactions per CMS - HIPAA implementation rules
  • Participated in all aspects of gathering and documenting requirements and analyzing those, transformed the requirements into functional specs and user stories, and after each sprint of development, then testing the New MMIS incremental development. Primary responsibilities were to ensure that the system functions as designed, meets the requirements of the business community and conforms to all applicable Federal and state laws
  • Worked on the claims and provider modules of the New MMIS system
  • Provider inquiry about the status of claims. This involved checking the MMIS claims subsystem to see the status of claims sent and informing the providers if the claims have been suspended/denied or paid

Confidential, Woodland Hills, CA

FACETS Configuration Analyst

Responsibilities:

  • Gathered requirements, developed Process Model and detailed Business Policies
  • Responsible for participating in the design sessions, reporting on project progress and identifying potential risks and issues
  • Followed agile methodology and participated/arranged daily sprints to keep the pace of task assignments and achieve desired target dates
  • Used Agile - Scrum methodology and worked in short Sprints to achieve goals
  • Involved in gathering data and provide Agile metrics
  • Operated in three week sprints with flexibility on length based on immediate functionality concerns
  • Wrote user stories based on requirements gathered from all the stake holders
  • Created Producr backlog, Sprint backlog and managed User stories
  • Designed source to target documentation, meta data documentation and data flow model
  • Reverse engineer FACETS benefit configuration design by researching, analyzing and validating existing benefit configuration. Create design documents to capture findings
  • Understood the benefit summary and built product configuration according to the benefit matrix
  • Created and modified queries (SQL) utilizing FACETS data tables
  • Tested product build to make sure claims hit the correct benefit rule
  • Moved configuration flow through team track
  • Troubleshot benefit configuration errors and corrected and tested related issues
  • Worked on EDI transactions: 270, 271, 834, 820, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrollment hence analyzing and documenting related business processes
  • Configured facets modules such as Claims, Membership, Billing, Benefit and plan
  • Electronically submitted Enrollment (834) data
  • Conducted analysis, configuring, testing, quality assuring and documenting configuration solutions for all applications in the FACETS system
  • Worked on FACETS Data tables and created reports using queries
  • Did the forward and backward data mapping between the fields in mainframe and FACETS
  • Consulted clients throughout system conversion/implementation. Analyzed complex benefit designs and provider contracts, configuring system software for maximum claim adjudication
  • Proposed FACETS claims adjudication procedures, standards and editing guidelines
  • Responsible for interacting with client for requirements gathering, analyzing requirements, and creating detailed specifications
  • Accurately loaded & updated plan benefit rules according to company policy, industry regulation, and contract specifications
  • Configured, tested, and maintained benefits system configuration rules, tables, edits, and files to support accurate claim adjudication
  • Actively participated in designing test plans, test cases and test scripts
  • Analyzes benefit explanation of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums and state/regulatory benefits
  • Involved in understanding the current business process, defining scope of the project along with position statement
  • Used SQL extensively in command objects of Crystal reports
  • Performed SQL queries for retrieving, organizing the database with general commands like select, create, update, and joins
  • Conducted Data analysis using SQL on the backend databases for producing mapping documentation and transformation rules for developers
  • Involved in preparing several Use Cases, Business Process Flows, and Activity Diagrams using Microsoft Visio

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