SKILLS:

SQL Server, RDBMS, queries and creating databases in SQL Server and Access, data structures, creating and maintaining tables, some programming, Benefit Configuration, UAT Testing (Claims), IP/OP/DME/ER, Medicaid, Medicare, CPT, ICD - 9/10 and specialty coding, eClinicalWorks, A/R, A/P, month end and escalation reports, collections, medical records, SQL, Epic Oracle, APEX, QNXT, RALLY, Outlook, Excel, Word, Lotus Notes, Macess, MS Access, Windows, SharePoint, WP, Oracle, Java, MMIS, AMISYS, Cactus, QCCD, Epic, ERISCO, Facets, McKesson, RIMS, Eagle, IDX, IDRS, Webcare, AS400, CRT, Medex, Meditech, SMS, Affinity, FACS, Riverbend, Medisoft, SAP, Amtrust, Bloomberg, Medical terminology, 835 and 837, HIPAA 4010/ 5010, UB04 and CM-1500, Medicare, Medicaid, HMO, PPO, DME, coordination of benefits, POS and numerous other healthcare and medical systems.

EXPERIENCE:

Confidential, New York

Provider Relations Analyst

Responsibilities:

• Set up provider contracts and analyzed data in the system.
• Credentialed providers and ancillary providers.
• Documented system with updates, completion of credentials, and issues, and results.
• Performed data analysis of databases and created databases.
• Created a credentialing process and workflow for Provider Relations department.

Confidential eClinicalWorks Coder

Responsibilities:

• Audited health claims, claim scrubbing, and coded claims from provider notes and documentation. Verified insurance and patient eligibility.
• Updated system and corrected data. Worked que with pending and denied claims to complete them for submission and resubmission. Submitted and worked on weekly reports on claims worked, issues, and end results.

Confidential

Epic Implementation Consultant

Responsibilities:

• Successfully completed system configuration and assisted with the implementation process with provider offices throughout the hospital.
• Assisted the IT department with the workflow design for the end user.
• Trained office staff of provider offices and hospital departments on CAQH, billing, registration, and ambulatory operations on Epic and On Board applications.
• Troubleshoot, addressed technical support issues and errors.
• Performed functional testing on the system. Analyze problems and developed solutions to fix them.
• Addressed charge entry, referral, patient registration, scanning, billing, provider information, prescription order entry, patient accounts, documentation, call logs, and end user questions.

Confidential

Benefit Configuration Analyst

Responsibilities:

• System Implementation, data analysis on QNXT and AMISYS, successfully created, updated and configured benefits, benefit packages, components, riders, keywords, counters, cost shares, and provider information with a high success rate.
• Trained consultants to perform benefit configuration on Confidential and created workflow documentation and assisted with the workflow progression on Confidential and QNXT.
• Created and updated excel spreadsheet with benefit updates, limits, corrections, new products and benefits, components, keywords, benefit products, regimes, cost sharing and status via Confidential and CareNet.
• Create, configure and built benefit specifications, compared benefits and products via AMISYS, Service Request Tracker, MS Access and claims testing and adjudication, QA and functional testing, pulled data using Access and BP Reports.
• Build benefits, benefit and code sets, benefit and code groups, created benefit plans from draft products, coordinated configuration of products, policy, and claim information and approved all benefit configurations

Confidential

Benefits Configuration Analyst

Responsibilities:

• System Implementation, created, updated and configured benefits, components, pricing, riders, provider information via Confidential and CAQH, etc...
• Successfully completed the training of full time employees on Confidential for benefit configuration and assisted with developing a system module training guide.
• Performed QA on updates to the system and workflow on Confidential and QNXT. Tested the system for errors before GO live and gave written reports to upper management on the status of the testing.
• Created and updated excel spreadsheet with progression updates, limits, corrections, new products and benefits, regimes, cost sharing and status via AMISYS.
• Created, configured and built benefit specifications to the client’s request on Confidential AND QNXT, compared benefits and products via AMISYS, APEX and SQL, claims testing, QA and functional testing, pulled data using SQL

Confidential

Benefits Configuration Analyst

Responsibilities:

• System Implementation, Create, configure and built benefit specifications in Oracle, QNXT and CMM1, compared benefits and products via AMISYS, APEX, PDM and SQL, created Rally Stories for testing, QA and functional testing, pulled data using SQL
• Tested and created functional testing on products created, UAT testing on claims systems.
• Created and updated excel spreadsheet with updates, limits, corrections, new products and benefits, regimes, cost sharing and status via AMISYS. Compare benefits and products in AMISYS, QNXT, Oracle, PDM Reports, Schedule of Benefits and APEX.
• Checked and created functional testing, completed configurations in production and created queries in APEX.
• Created, updated and configured benefits, components, fee schedules, riders, provider information, etc.
• Worked at Confidential in Massachusetts via HealthTech Resources

Confidential

UAT Tester

Responsibilities:

• System Implementation, Created raw data, entered claims for testing, tested claims for production and regressions, pulled claims for quality assurance
• Trained employees on Confidential for benefit configuration and claims testing.
• Produced results of testing and documented findings, updated various systems to comply with testing regulations.
• Pulled queries via Access and SQL, performed pricing configuration via AMISYS
• Identified scenarios and data for scenarios, provided data for testing, test scenarios, test plans and test cases

Confidential

Credentialing Consultant

Responsibilities:

• Resolved facility, DME and medical claims, coding, database and contract issues and discrepancies via Epic and Cactus.
• Reviewed, configured and updated all contract requests and compliance requirements via Cactus.
• Updated database with fee schedules and provider documents, contract amendments, coded and corrected claims information and ran audits on credentialed work for completion.
• A/R, Provider reimbursement, configuration, set-up and maintenance
• Benefit configuration and coordination, queries, data abstraction and data mining.
• Responsible for configuration around conversion in Cactus for Managed Care, DME, Medicare and Medicaid.
• Produced all bi-laws, policies and procedures for DME, Medicaid and Medicare contracts. Responsible for testing Cactus.
• Some mapping, requirements gathering and provider agreements via Cactus and CAQH.
• Project Manager of credentialing, processed, corrected and added provider information and credentials

Confidential

Credentialing Consultant

Responsibilities:

• Resolved hospital, DME and medical claims, A/R, coding, billing, database and contract issues and discrepancies
• Reviewed, configured and updated all contract requests and compliance requirements via AMISYS.
• Benefit configuration and coordination, data abstraction and data mining via AMISYS
• Project Manager of Credentialing, processed, corrected and added provider information and credentials.
• Updated database with fee schedules and provider documents, amendments, coded and corrected claims and ran audits on credentialed work for completion
• Used Macess, Facets, QCCD, IDRS, Success, Medex, AMISYS, FACS, SharePoint and Medisoft

Confidential

Healthcare Consultant / Data Analyst

Responsibilities:

• Project Manager, UAT analysis, performed product validation activities including test planning, test development, issue/defect triage, data mining and abstraction, test execution for claims, benefits, fee schedules, provider information and go live support
• System Implementation, Analyzed data manually and online via SQL and Access while creating solutions and solving issues
• Conducted quality assurance tests on the claims and provider systems
• Processed new and existing provider and fee schedule information and rate inquiries in AMISYS
• Benefit coordination and configuration, updated, adjusted, and revised fee schedules, coding, rates, provider contracts, database, claims and information via AMISYS.
• Oversaw merger restructuring for GHI and Emblem Healthcare
• Used Eagle, IDX, SharePoint, Success, Webcare, Facets, AMISYS, QCCD and IDRS

Confidential

Credentialing Consultant

Responsibilities:

• Benefit configuration for DME, Medicare, Medicaid and Managed Care contracts, responsible for adjusting, updating and revising provider contracts via Facets
• Project Manager of Credentialing, analyzed database, go live support, information, DME and medical claims data on paper and in systems and provided solutions to issues
• Reviewed, configured and updated all contract requests and compliance requirements.
• Processed new and existing provider data and rate negotiations
• Performed quality assurance and resolved billing and payment issues, fee schedules and pricing via Facets
• Consulted with sales on enrollment issues and updates

Confidential

Healthcare Consultant / Data Analyst

Responsibilities:

• Claims analysis, A/R, A/P, claims entry, claims processing and claims auditing
• Performed quality checks on Medicare, Medicaid, DME and Medical claims to help with backlog
• UAT analysis, consulted with client on updates, issues and solutions and go live support
• Benefit coordination and configuration, responsible for medical records documentation, data abstraction, negotiations, adjustments and revisions
• Updated database and contracts in relation to billing, medical records, claims and provider relations
• Responsible for write-offs, contracts, reports, and correspondence using Epic, Facets, Eagle, Success, IDX, QCCD, IDRS, RIMS, SharePoint, Confidential and NASCO

Confidential

Provider Relations Representative / Data Analyst

Responsibilities:

• Responsible for pricing, fee schedules, audits credentialing, adjusting and revising provider contracts and updating database
• Oversaw provider relations, managing contracts and follow-up with the records and merging between Oxford Health and Confidential
• Reviewed, configured and updated all contract requests and compliance requirements.
• Performed quality assurance on billing, medical records and payment issues
• Consulted with providers on rates, contracts, merger information and obligations
• Used QCCD, AMISYS, Success, RIMS, Eagle, IDX and SMS
• Responsible for A/R, A/P, collections, write-offs, fee schedules, data abstraction for medical records and reimbursement

Confidential

Medical Biller / Patient Accounts Representative

Responsibilities:

• Responsible for provider relations, contracts, and month-end reports for various insurance clients
• Responsible for A/R, A/P, reimbursement, adjustments, write-offs and collections concerning medical records for medical, DME and workers' comp claims. Medicare and Medicaid. Posted payments, setup agreements and updated pay rates
• Performed billing, coding, customer service, collections, claims follow-up and revisions for HMO, Managed Care.
• Completed product validation activities, including test planning, test development, issue/defect triage and test execution
• Responsible for payment negotiations, pricing, fee schedules, referrals and pre-certifications
• Used Eagle, IDX, SharePoint, Riverbend and SMS