SUMMARY

Healthcare Business Analyst highly experienced in ICD-10, Medicaid and Medicare policy, Claims and MMIS. Proven success in various phases of the SDLC, gathering and writing business requirements, BRDs and user training documents. Goal and results-oriented leader having thrived as a Testing Lead in UAT writing test plans, use cases, test cases, test execution and project reporting.

SOFTWARE/APPLICATIONS

• SpiraTest, DOORS, JIRA, RQM, Rational ClearQuest, FACETS NetworX Integrated Pricer, NetworX Modeler , Agile, Version1, Blueworks, Waterfall
• Business Objects, SQL
• SharePoint, MS Excel expert i.e. PivotTables, VLookup, Macros , Access, Outlook, PowerPoint

PROFESSIONAL EXPERIENCE

Confidential

Sr. Business Analyst/Testing Lead

• Sr. BA/UAT Testing Lead for the State of Georgia Medicaid MIS ICD-10 system remediation
• Assisted the PM in the project planning providing input of estimates of time, effort, resources, etc.
• Advise and mentor project team members on various project and BA functions i.e. facilitating client sessions, documentation, testing
• Liaison between the Business and Systems Owners for interpreting and documenting business rules and policy
• Facilitated client sessions to gather ICD-10 business requirements planning phase
• Developed and maintained the requirements via the Requirements and Traceability matrix
• Created BRDs, design documentation and test plans for various MMIS subsystems
• Developed test plans, scenarios and test cases for Change Order CO based testing for assigned policy contracts
• Work closely with systems, business owners and the MMIS vendor to resolve testing and policy and configuration issues
• Review and interpret policy manuals, system business rules, contract billing rules, edit/audit rule configuration and reimbursement rules to determine test pass/failure and to identify and track defects
• Assist with the Cross-Functional, End-to-End testing effort and QA Lead
• Administrator of the testing management software SpiraTest responsible for user accounts, developing and maintaining user documentation, as well as, data integrity QA
• Conduct User Training for Test Management application for project and client staff and
• Responsible for project data and statistical reporting via Business Objects, SpiraTest and MS Excel utilizing Pivot Tables, VLookups, Macros etc.

Confidential

Operations Business Analyst II

• Business Analyst for the Medicare LOB responsible for maintaining Medicare Advantage Plans MAPs covering seven 7 markets
• Performed requirements gathering and Medicare policy research via CMS online manuals, MLNs and transmittals to ensure company compliance of federal healthcare regulations
• Facilitated weekly Health Plan Services HPS meetings to discuss corporate compliance and impact and regulatory updates for the Medicare LOB
• Performed Benefits and Pricing configuration using the NetworX Integrated Pricer FACETS platform
• Maintained the Pricing and Benefits requirements documents through the initiation and tracking of Requirements Change Documents RCDs and Amerigroup Configuration Change Requests ACCRs for BRD and system configuration changes
• Developed and maintained the MAP annual Benefit Summaries and Plan IDs for system configuration
• Utilized Rational ClearQuest and FACETS applications to track, manage and test requirement and configuration changes prior to production migration and
• BA assigned to gather requirements and developed the BRD and DSD for several corporate projects including the Resource-Based Relative Value Scale RBRVS system implementation and the Trizetto NetworX Modeler application implementation.

Confidential

Business Services Analyst, Operations

• Manager of the Medicare Buy-In Dual Eligibles Operations Unit processing Medicare premium payments of 75M per month
• Business liaison between the State and external clients including CMS, SSA, and the RRB
• Defined and implemented the operations business process, structure and improvement strategies
• Created and maintained the State approved Buy-In Program BRD
• Developed and facilitated the program training and development to staff, internal and external clients
• Monitored system transactions and files and delegated work to ensure proper processing and program compliance of CMS and State policy and regulations
• Developed and implemented the QA initiative and audited program operations to ensure the integrity of the data and financials
• Consistently met and exceeded all monthly deliverables and contracted SLA requirements
• Assisted my HP State of Georgia counterpart in the GA MMIS implementation project.

Business Services Analyst, Development

• SME for Member functional and operational processes during the development and testing phase of the MMIS implementation
• Conducted client meetings to gather and document system requirements and specifications
• Performed system testing for the Claims, Member and Eligibility subsystems and
• Identified and tracked system defects utilizing the HP Interactive Portal, Information Tracking Repository Portal iTrace and SharePoint application tools.

Confidential

Billing/Collections Specialist Revenue Management

• Researched and analyzed managed care and provider pricing contracts for pricing logic, claims adjudication and collections
• Audited claims and patient accounts for proper reimbursement
• Performed account collections on commercial payers for underpayments
• Reviewed claim denials to identify and report issues, trends and process improvement areas
• Assisted in staff training on billing and reimbursement policy
• Gained expert knowledge in reimbursement methodologies i.e. DRG, APC, Fee Schedules and
• Developed reports via MS Excel and Access on financial and statistical trends for senior management.