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Qnxt Configuration Supervisor Resume

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CA

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SUMMARY:

  • An accomplished Scrum Master Certified QNXT Configuration Manager with over 20 years of experience and a well - earned reputation for providing strategic guidance to cross-functional configuration teams, ensuring transparency, scalability, and continuity while capitalizing on revenue opportunities.
  • Continuously identifying alternative solutions to reduce operational costs and meet changing business demands. Skilled in introducing best practices, strengtaning processes, and leading highly technical teams.

PROFESSIONAL EXPERIENCE:

QNXT Configuration Supervisor

Confidential, CA

Responsibilities:

  • Accurate understanding and configuration knowledge of Optum's CES DDR Rules and Integration Manager.
  • Utilized developer knowledge and experience to successfully create over 30 rules to meet QNXT CES configuration claims processing compliance with Medi-Cal, California's Medicaid version.
  • Established controls to avoid costly claim processing errors; added SQL scripts to validate results, fee schedules, and possible configuration conflicts, ultimately stabilizing the QNXT claims processing auto adjudication to 75-78% daily which previously varied about 15%. On track to increase auto adjudication by 3% of claims processed.

Environment: QNXT 5.5, Optum CES (DDR Rules and Integration Manager), SQL Server, Agile Methodology

QNXT Configuration Manager | IT Business Analyst

Confidential

Responsibilities:

  • IT Business Analyst leading IT teams in support of Catamaran Pharmacy Benefits interface for members and providers based on the Medicaid business line for Long Beach, CA IT teams; remediated processes to correct the membership of Puerto Rico’s Medicaid system, changes ultimately avoided a $4,000,000 penalty by the Medicaid regulations office.
  • Implemented co-payment processes to avoid overutilization of payments by members of Medicaid, resulting in Medical Loss Ratio profitability of 97%.
  • Provided data, maintenance analysis, and recommendations for proper Provider/Benefit/Contract configurations. Environment: QNXT 5.3, SQL Server

EDI Manager | IT Business Analyst

Confidential

Responsibilities:

  • Applied IT Developer and Business Analyst expertise to develop a Healthcare Electronic Enrollment division including processing of HIPAA 834 (5010), AON/Hewitt, US Government and other proprietary formats to generate electronic enrollment transactions for QNXT 5.1. Provided Business and Technical Requirement documents for B2B and QNXT/Mainframe interfaces used for Membership applications. Enhanced controls and audit reports related to the Electronic Enrollment process.
  • Provided projects and maintenance analysis based on the SDLC (Software Development Life Cycle) methodology for programming personnel responsible for Healthcare Insurance applications.

Environment: QNXT 5.1, QConnect, SQL Server, Informatica, Axure, IBM Mainframe Z890 Server, Z/VM, Z/OS, COBOL 370, CICS, VSAM, JCL, TSO, Intertest, Xpediter, FTP, NDM, Serena’s TeamTrack and Version Manager

Senior Programmer Analyst

Confidential

Responsibilities:

  • Responsible for on-line and batch project analysis, cost estimates and programming support for the Popular Bank of PR MIS department. Acting as Project Director implementing Baker Hill’s One Point software. Led the analysis and programming support for the Computer Associate’s Analysis Mainframe package and supported Computrol’s Investment (CD and IRA accounts) on-line programming.

Environment: IBM Mainframe, MVS, COBOL II|COBOL 370, CICS, VSAM, JCL, TSO, Intertest, ChangeMan and JCL DB2

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