SUMMARY

• Knowledge of Procedure and DRG related impacts for ICD - 9 & 10. Several years of experience working with SQL on various projects 12 years of experience with Data Profiling/Data Modeling with configuration Experience using PTC Windchill Life Cycle Management tool for migration and iterations Experience using Confidential extraction tools.
• Experience in HP, ALM tool to resolve UAT defects. Identified medical coding (ICD-9/10 gaps, CPT) Utilizing Rally Agile and Scrum Life Cycle Management tool for system configuration and updates. Experience in benefit configuration, claims processing, unit, UAT on NASCO, Q-Blue (QMACS), MCS, QNXT, FACETS, ITS, QCARE, Metavance, Epic/Tapestry, and legacy systems. Adjudicated in EEC. Used HRBK in Nasco to make updates to the Benefit File. Used the RBRVS (Resource-Based Relative Value Scale) for Benefit codes for group plans under Medicare
• Assignment of Employer and Provider Group plan codes, CPT, HCPCS II, ICD-9, ICD-10, DSM-IV coding. Claims processing in real-time. Tested Benefit Specification Codes and Medical Codes in Testing Environment prior to Migration to the Production region.
• AS-400, NASCO, ITS, QNXT Benefit and Provider Pricing File, QBLUE, QCARE, GenC, NCN, METAVANCE, MCS, MHS, MMIS, NETWORX, AMYSIS, SPIDER
• Facets configuration for benefits, claims, membership and enrollment for new implementation and enhancements. Build benefit plans from scratch as well as front end and back end configuration.
• Facets claim processing for benefit validation and defect management.
• Edited and Entered DRG rates, global rates, outliers, outpatient groupers and ER rates according to provider contracts. Revenue code assignment into fee schedules. Inpatient Billing.
• Worked Problem Logs (P-Logs). Used the ODL onto the EEC Worksheet and OLRX Application.
• Adjudicated and process claims in EFDE, HEHK, and HEUK (EEC). Used the Message File (MI) to enter internal notes.
• Edited and entered provider contract codes on various software. Used HINQ in Nasco. Processed HMO, PPO, POS, ASO, self-funded, Cafeteria plans, Capitation, and EPO claims.
• Entered CMS fee schedule tables on contract files and benefit file plan summaries.
• Billed secondary and Tertiary insurance carriers. Followed up/Collected on Self-pay, Medicare/Medicaid and Commercial Insurances using HBOC Stars and HANS system. Processed secondary insurance claims. Processed claims using Medicare, CMS 1500 and CMS-1450 Claim forms.
• Experience with EDI 835/837, 834, 270/271, 276/277 and accumulators, HIPPA 4010 and 5010.
• National Claims processing through various In State and Out of State providers. ITS and BlueCard
• Interpretation of Claim edits for adjudication. Utilized McKesson Claim Check for correct coding. Used Claim Check to correct procedures submitted by providers unbundled. Updated claims with bundled codes to avoid overpayments.
• A/R functions utilizing Lawson. Posting payments, claim adjustments and creating account receivables to recover and track overpayments.
• HR functions using Lawson and Vanguard for open enrollment and new hires.

PROFESSIONAL EXPERIENCE

Business Analyst

Confidential

Responsibilities:

• Creating User Stories/JIRA
• Gathering requirements for system migration for several clients
• Writing User Stories in Jira for system migration to Confidential
• Validating test results
• Updating Kanban/Confluence boards
• User Story refinement meetings
• Triage defects and assigned to developers

Business Analyst

Confidential

Responsibilities:

• Gathering requirements for system migration
• Review requirements for membership and benefits in Facets
• Writing User Stories in Jira for system migration to Spider for WGS, Facets, Blue Exchange
• Updating Jira/Kanban/Confluence
• User Story refinement meetings
• Review Technical design and liaison with technical and business

Sr. Denials Analyst/Business Analyst

Confidential

Responsibilities:

• Dispute payment amount with Insurers (Commercial, MVA, WC, VA, Medicare Advantage and Medicaid)
• Review Contract agreements to ensure payments are made accordingly.
• Calculate network discounts
• Request adjustments for underpayments
• Issue refunds for overpayments
• Provide Medical records for further review

Facets Product Build/Benefits Configuration Analyst

Confidential

Responsibilities:

• Configured, audited and manually loaded data including benefit plans and summaries, service definitions, service rules.
• Align Benefit Rules and mandates in PEGA with data in Facets
• Membership and enrollment groups and individual plans.
• Defect management using HP/ALM
• Developed and executed manual test scripts for Institutional and Professional for Facets Claim Processing System 5.1.
• Tested HMO, PPO, Indemnity, Medicare Advantage Part C, Medicaid, and COB claims.
• Updated States Mandate rules and Regulation
• SQL queries

Sr. Business Analyst/Testing/System Configuration/Claim Processing

Confidential

Responsibilities:

• Unit Testing for Component Group (CMG) system updates
• Validated System Configuration
• Validate ICD-9 and ICD-10 codes Crosswalk for system compliance
• Create Test Scenarios Validate ICD-9, ICD-10, CPT and HCPC codes
• Audit Benefit Plans and Benefit Component Groups
• Execute Test Claims using EPIC
• Appeals and adjustments for claims denied. Review benefits to determine if error in the configuration. Updated configuration and claims adjustments performed.
• Running SQL queries to validate benefit configuration
• Benefit Configuration using Excel and Benefit Enhancement Tracking System (BETS), Medicare Advantage, Medicare Part C and D.
• Benefit Plans Medicaid Maryland, DC, and Virginia builds and testing in Epic.
• Updated configuration of limits and accumulator rules.
• Defect Management and UAT using HP/ALM
• Claim processing utilizing test data.
• MAP CSS requests/response elements to backend source to BS or FGS.

Quality Analyst/ Defect Management/System Configuration/Business Analyst

Confidential

Responsibilities:

• Audit customized medical, dental, and vision product builds to validate accuracy of benefit specifications prior to migrating to the system’s testing region.
• Tracking Build schedule to delegate Quality Control Audits.
• Advised builders of the errors in configuration that required corrections.
• Validated configuration to ensure accuracy for migration.
• System configuration by coding benefit specifications in Oracle Health Insurance (OHI) development region.
• Incident management tracking to ensure defect triaged correctly and resolved timely.
• Identify and triage severity of incidents and defects.
• Evaluated defects identified by UAT team members using HP/ALM
• Research and resolution of defects by either disputing defect or updating configuration using HP ALM tool. Validate UAT test case scenarios
• Manage Product Builds using Rally Agile tool and PCT WindChill.
• Systems utilized were AMYSIS and OHI this involves complete knowledge of AMYSIS claim adjudication for conversion to OHI.
• Claims processing, appeals for claim denials, claim adjustments performed after configuration was corrected and updated.
• Validated plan benefits, limits, and accumulators configured correctly to insure correct claim adjudication and customer service operations.
• Medicaid, Tribal Benefits and Medicare Parts C and D.

Business Analyst/Claims

Confidential

Responsibilities:

• Prepared and wrote Conceptual Specific Design (CSD) documents for Large Scale Implementation (LSI) from local system for migration to NASCO.
• Created Requirements for Business Services (BS)
• Created Requirements for Customer Servicing Services (CSS)
• Served as a liaison for IBM/Cognizant and Confidential .
• Facilitated stakeholder meetings for JAD sessions, gathering and writing requirements, Technical Design Review (TDR) walkthroughs that included 837 mapping, MDE transactions.
• Worked with Membership Business Analysts, HP and IBM Technical Teams on Metavance Member’s Edge for Customer Requests on Claims, Finance, Plans and Reporting.
• Created and monitored statuses of Customer Service Requests (CSR) from inception until completion.
• Researched Systems Specifications (Spec-View) to assist the Plan in determining which new functionality was required.
• Tested Professional and Facility medical claims using Nasco system.
• Identified defects and errors on claims to allow adjudication.
• Gathered requirements and ensured that expected results were obtained to successfully finalize claims.
• McKesson Claim Check to ensure system functionality within Model Office for defect management.
• Monitored CSRs to update and watch progression to insure time lines were met. (SDLC) methodology.
• Triaged and monitored Defects after system updates were made Model Office (testing region) using HP/Quality Center. Recommended system configuration updating after appeals from testing team.
• Aided in training team members on LSI procedures in PDM, CSR, Defects and CSD.
• Performed Impact Analysis of ICD-10 Coding and Reporting Regions to system change scheduled for deployment.
• Utilized NShare to access resource materials and documentation.
• Incident management tracking to ensure defect triaged correctly and resolved timely.
• Identify and triage severity of incidents and defects.
• Evaluated defects identified by UAT team members using Clear Quest

Benefit Configuration/Benefit Coding/UAT/Claims Processing

Confidential

Responsibilities:

• Used HRUK in Nasco System Configuration to update benefit strings and create Ded/Max files for new and existing groups.
• Executed a Gap Analysis between NCN, NASCO CSR, and BTRD for non-par provider discount program.
• Handled claims processing using EFDE and EEC in NASCO and FACETS
• Reported inconsistencies between business/technical requirements for implementation team.
• Update Plan configuration to ensure member and family accumulators and limits reflect sales’ contracts documents.
• Created test scripts and scenarios.
• Tested and validated claims for ded/max, accums, and lifetime max, coinsurance, and other out of pocket expenses for Genic and Membership project using Metavance.
• Reviewed and audited of E.O.B. to validate accumulations, payment and provider checks.
• UAT testing and Regression testing on Nasco. QNXT and Facets claims processing and provider pricing for small group products line of business.
• Created benefit grid design test scripts for template involving researching the most current provider contracts for accuracy. This process involved creating test cases for all eligible providers of service.
• McKesson Claim check used during Unit Testing and UAT
• Incident management tracking to ensure defect triaged correctly and resolved timely.
• Identify and triage severity of incidents and defects.
• Evaluated defects identified by UAT team members using HP/ALM
• Execution of test cases documenting expected and actual results and the recommended issue resolution for any defects resulting from the execution of the test.
• All line of business that included PPO/PFFS, HMO, Capitation, Medicare Advantage/Medicaid, and Medicaid, Managed Care.
• Validate Limits and Accumulators for correct claim processing and adjustments.
• Review and update accumulators to plans that were configured incorrectly.
• Test execution for all providers of service included inpatient and outpatient providers, PCP providers of service, independent laboratory and radiology providers, ambulatory service providers, DME service providers, and Skilled nursing home services provided by VNA’s such as physical therapy etc.
• Clean up claims backlog processing and adjustments in Facets

Medical Coder/Benefit Configuration/Claims Testing

Confidential

Responsibilities:

• Updated group benefit files for Mental Health and Substance Abuse as mandated by the Federal Government.
• MAP DD elements to corresponding request/response elements.
• MAP CSS requests/response elements to back end source.
• Tested mental health and substance abuse claims to ensure that same guidelines as Medical/Surgical.
• Processed and Adjusted live claims for backlog.
• Applied experience in mental health and substance abuse claims as well as knowledge in DSM IV coding
• Tested Claims using NASCO for dedicated groups. McKesson Claim check tool utilized.
• Used HRBK in Nasco System Configuration to make changes to Benefit File. Accumulated benefit codes in benefit file to calculate correct benefit services.
• Utilized extensive knowledge of benefit grids, summaries, group booklets, contracts and benefit group coding.
• Analyzed Nasco benefits by group, package, and section.
• Uploaded benefit codes to repository and tracked benefit codes in test environment after loading to repository.
• Derived accumulation rules from uploaded PDF. Files and from management.
• Tested benefit codes in queries. Converted to benefit Mnemonics.
• Reported information to project managers and software configuration department.
• Benefit Coding P-logs for National and Corporate Groups.
• Updated Benefit, Limit and Accum Strings.

Implementation UAT Testing/Claims Processing

Confidential

Responsibilities:

• Tested and Processed Professional, Facility and dental claims for client using Metavance.
• Processed live medical claims, facility and dental using Metavance 2.8. meeting all production standards.
• Gathered dental benefit documentation and requirements.
• Distinguished accidental dental, medical dental and dental Codes.
• Corrected dental codes and reported systems errors.
• Made recommendations for system upgrades and enhancements to IT staff.
• Incident management tracking to ensure defect triaged correctly and resolved timely.
• Identify and triage severity of incidents and defects.
• Evaluated defects identified by UAT team members using HP/Quality Center
• Created test scenario templates for UAT test execution on the Metavance system for lines of business that included PPO, HMO, Medicare Advantage/Medicaid.
• Execution of test process included full documentation for expected and actual results and issue resolution for defects found.
• Utilized Medicare CMS for fee schedules and provider contracted specific and ala carte benefits.
• Provider of services included all facility services, specialty providers and PCP’s.

Business Analyst/Medical Coder/Benefit Configuration/Claims Processing

Confidential

Responsibilities:

• Review Benefit Tables and NAEGS.
• Knowledge of Benefit File Mnemonics, Grids and Booklets. Successfully completed Analysis of Medical Coding and Prior Authorization Requirements within the Q-Blue System (QNXT) and Nasco Database for all lines of business.
• Completed Comparisons of the for the NJ Future, DOBI, Contract, and Systems’ lists.
• Identified the inconsistency in Coding and Reports for all PPO, POS, HMO, Medicare, and Indemnity Products on Q-Blue, QNXT, NetworX, and Blue2.
• Prepared Reports for all POS, PPO State, and Direct Access and Fully Insured groups on Nasco.
• Identified and prepared all required coding updates for all products for IT for both Nasco and Q-blue systems.
• Updated Project Tracker with findings and completion Prepared Weekly Status reports for management.
• Successfully met all deadlines and updates as requested.
• Incident management tracking to ensure defect triaged correctly and resolved timely.
• Identify and triage severity of incidents and defects.

Psychiatric Claims Specialist/Audit

Confidential, Columbia, MD

Responsibilities:

• Responsible for coding, audit and adjudicating psychiatric claims using QNXT, Nasco, and AS-400.
• Claims processing meeting all production and quality standards.
• Processed backlog of claims for outstanding receipt dates.
• Managed audit of contract benefits for limits, pre-authorization requirements. Handled processing and adjustment of claims for Confidential BS because of appeals made by providers and members. Loaded and updated pre-authorizations for NJ State employees. Validated provider credentials.
• Priced and reviewed benefit maximums
• HMO, POS and PPO mental claims adjudication.
• Successfully completed assignment meeting all required production standards.
• Successfully met all DOI deadlines for 1st submission receipt dates.

Group Membership/Recovery Analyst/UAT/Claims Processing

Confidential

Responsibilities:

• Responsible for membership conversions from legacy system to Power MHS and AMYSIS for specific product lines of business.
• Accounted for system configuration for New Group membership, benefits, and enrollment.
• Processed unsolicited and solicited recovery of over payments from providers and subscribers.
• Posted payments, claims research and adjustments on MCS, Facets, Nasco, and Power MHS
• Incident management tracking to ensure defect triaged correctly and resolved timely.
• Identify and triage severity of incidents and defects.
• Evaluated defects identified by UAT team members using HP/Quality Center
• Created, posted and tracked A/R’s utilizing Lawson for overpaid claims.
• Managed COB with Confidential /BS and Medicare, MVA, W.C., and other commercial carriers.
• Audited claims for coding reimbursement accuracy. Benefit Coding.
• Researched/investigated and documented expected results and actual results regarding system functionality when a claim is processed, and an error resulted against current and newly implemented benefit configurations using Amisys.
• Researched provider contracts and benefits for accurate pricing and benefit information pertaining to the specific procedure code and type of service.
• Validation and/ or updating of accumulators in benefits plan configuration.
• Review of claim history to determine if limits and accumulators were calculating within the system correctly.
• Review of year end carry over deductibles for accurate accounting.
• Claim testing/auditing, research and investigation of benefit grid design.
• Documented results via Project tracking tools (Access and Excel).
• Tested current CPT codes, ICD 9 codes along with HCPC codes.
• Ensuring correct payment allowance for services.