SUMMARY

• Demonstrated history of working in information technology and variety of service industries.
• Oversee all aspects of life cycle system phases and methodologies, including planning, design, analysis, testing, and implementing business and configuration technology solutions.
• Flexible and focused analyst comfortable working collaboratively or individually in work - at-home or office environment.
• Leverage strong research and analytical skills to troubleshoot and resolve problems. Approachable and consultative workstyle.

PROFESSIONAL EXPERIENCE

Business Analyst / Configuration Analyst

Confidential, Phoenix, AZ

Responsibilities:

• Provide support on client and/or internal projects such as product implementation, design support staff augmentation and assisting in the development of configuration solutions for Core/Networx product systems.
• Coordinate the review of customer/member deliverables against customer requirements with plan services and product configuration specialist for completeness and accuracy of interpretation.
• Responsible for gathering, analyzing, and defining business requirements for various parties within organization.
• Review new business applications for accuracy and obtaining missing application information.
• Interacting with internal customers and application users to translate business requirements into technical requirements
• Used the Medical Agreement Configurator application in Networx to build and update agreements using Agreement Subsections and Contract Sections.
• Performing system configuration analysis, design, unit testing on medium to complex specific solutions during client implementation.
• Create client specific design documents and/ or communications.
• Used Facets Networx to update fee schedules, contact terms and agreements
• Performing testing and validations for multiple products.
• Handles multiple products while effectively managing inventory to meet deadlines.
• Proactively identify and implement process improvement opportunities to improve service and increase efficiencies
• Performing task on the Nimsoft Ticketing software.
• Processed and audit claims HMO, PPO, Medicaid, and Medicare Lines of Businesses. System while maintaining 99% or better accuracy and production standards.
• Validating the procedures are under the listed SESE ID. Updating SESE descriptions and sending TOS update sheets. Updating Revenue codes RCCT/SRCT and CPT TPCT/SPCT. Checking and updating SERL for correct copay
• Updating CO’s and building PCA’s.
• Configured Benefits and Pricing from scratch.
• Updated existing configuration for HMO, PPO, Medicaid, and Medicare Lines of Businesses.
• Analyzed all Benefit Plans for State ready testing.
• Made the appropriate updates after testing.
• Grouped together Plans that were similar in structure.
• Created a Benefit Plan matrix to include relevant information for configuration load.
• Analyzed and built new Benefit Plans to support the ACA.
• Verified existing Benefit Plans to make sure all the accumulators, pends, denials, copays, coinsurance, deductibles, and out of pockets are set up correctly.
• Updated and loaded benefits using and creating the appropriate SQL queries.
• Using the appropriate SQL queries to validate complex objects.
• Data analysis, testing when needed using SQL queries.
• Processed, audited, and adjusted Medical, Dental, Vision, Enrollment, DRG, APC, APR and COB claims while maintaining 100% accuracy.

Business Analyst / Configuration Analyst

Confidential, Phoenix, AZ

Responsibilities:

• Processed and audit claims HMO, PPO, Medicaid, and Medicare Lines of Businesses. While maintaining 99% or better accuracy and production standards.
• Documented and executed test plans for configuration testing and validate accuracy of data loaded.
• Modified the provider contract, authorization rules and benefit plan configuration as required.
• Loading new contract agreements, authorizations, benefits plans configuration into processing and pricing systems.
• Used the Medical Agreement Configurator application in Networx to build and update agreements using Agreement Subsections and Contract Sections
• Review new business applications for accuracy and obtaining missing application information.
• Used Facets Networx to update fee schedules, contact terms and agreements
• Used MACESS workflow to monitor contract updates and contracts matrix/grid.
• Created and executed test plans for configuration testing and validate accuracy of data loaded.
• Performed final testing to ensure the Provider was configured correctly.
• Involved in writing Test plans and creating Test scripts. Executed test cases spanning multiple systems and validate against expected results.
• Performed Analysis of ICD 9 Procedure and Diagnosis Codes in accordance with ICD 10 CM and ICD 10 PCS Conversion Compliances
• Used CMU (configuration migration utility) tool, Oracle, Apex, Windchill, CMM2, PRD and HP Application Lifecycle Management systems to build product.
• Coordinates implementation of changes to existing workflows or applications.
• Builds rules in coordination within State and Federal guidelines
• Researches both State and Federal mandates and builds interpretation grids
• Resolves critical errors forwarded from the claims department.
• Validating the procedures are under the listed SESE ID. Updating SESE descriptions and sending TOS update sheets. Updating Revenue codes RCCT/SRCT and CPT TPCT/SPCT. Checking the SERL for correct copay
• Configured Benefit Packages from scratch using Benefit Summaries and Plan Documents using Amisys Advance.
• Reviewed and updated existing Amisys Benefits, Components, Riders, and Benefit Package configuration.
• Built new Benefit Packages for Custom Plans that include Benefits to Components, Components to Riders, and Riders to each Benefit Package.
• Reviewed existing Benefit Packages to make sure all the keywords, accumulators, pends, denials, copays, coinsurance, deductibles, and out of pockets were set up correctly for ACA requirements.
• Reviewed Benefit related reports including .Net Reports, Reveal, SQL, and Serena.
• Processed, audited, and adjusted Medical, Dental, Vision, Medicare, Medicaid, Enrollment, DRG, APC, APR and COB claims while maintaining 100% accuracy.
• HIPAA compliance regulations, transactions such as 270, 271, 276, 277, 278, 820, 834, 835, 837, 997 and code sets. Awareness of HIPAA 5010 and ICD-10 regulations and requirements. Insured Data migration into the system was correct. Checked variables