OBJECTIVE
- To apply and enhance my claims knowledge, auditing and resolution skills at a reputable and stable company which encourages growth and advancement for their employees.
TECHNICAL SKILLS
- ICD - 9; ICD-10, CPT, HCPCS, CMS-1450; CMS-1500
- Facets, NextGen, Macess, Amisys, Clear Claim Connection, Diamond, Xcelys
- Webstrat, Encoder, Sidewinder, Quest; ClearQuest, ClaimMiner, Racer Admin, Rally, Safari, TruCare, Cenpas
- HIPPA, Facets Certified, UAT Testing; Claims Detail Reporting, Reading SQL
PROFESSIONAL EXPERIENCE
Sr Business Analyst
Confidential
Responsibilities:
- Assist to develop, implement, and/or evaluate health information technology applications and tools, processes and structures to aid with the development of new enterprise care management from current legacy system to enhance outcomes of quality indicators.
- Responsible to review, analyze and create Utilization and Care Management workflows to design, develop, and build best practices documentation.
- Assist with defining detailed information for Authorization and Appeals and Grievance workflows.
- Review workflows for gaps and provide possible solution.
- Create Use Cases and Test Cases. Provide click by click instructions for Use and Test Cases.
- Performed and provided Time Study details and reports.
- Assist with translating Health Plan authorization grids into configuration tables.
Sr Business Analyst
Confidential
Responsibilities:
- Identify patterns of claim payment abnormalities that will lead to new rule development through data analysis. Research new leads for viability.
- Create client test files and gather all supporting documentation for trend approval.
- Develop metrics to provide forecasting on new client rule profitability.
- Maintenance of existence rules to drive maximum performance output.
- Facilitate new rule kick off calls with Operations, Centers of Excellence, and the Recovery Team.
- Focus on developing concepts in partnership with Analytics and Operations partners to identify and research potential claim trends.
- Gather data requirements for SQL queries. Write SOPs.
