SUMMARY

• Knowledge of Procedure and DRG related impacts for ICD - 9 & 10
• Experience using PTC Windchill Life Cycle Management tool for migration and iterations
• Experience using Apex extraction tools.
• Experience in HP, ALM tool to resolve UAT defects. Identified medical coding (ICD-9/CPT)
• Utilizing Rally Agile and Scrum Life Cycle Management tool for system configuration and updates.Experience in Amysis claims processing and Unit Testing, UAT, Confidential, Q-Blue (QMACS), MCS,
• QNXT 4.81, ITS, QCARE, Metavance 2.8, 2.9 and Blue Cross local systems. Adjudicated in EEC. Used HRBK in Confidential to make updates to the Benefit File. Used the RBRVS (Resource-Based Relative Value Scale) for Benefit codes for group plans under Medicare, Confidential and commercial providers.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.
• Queried claims in test and reported any errors. Submit claims in RTCP for actual processing AS-400, Confidential, ITS, QNXT 4.81.
• Ran SQL quieires in Facets 4.51 to membership, claims, enrollment, provider files.
• Benefit and Provider Pricing File updates to QBLUE, QCARE, GenC, NCN, METAVANCE, MCS, MHS, and AMYSIS, Facets, QNXT.
• Facets 4.51 configuration for benefits, claims, accums, membership, and enrollment for new implementation and enhancements for accums, on several interim projects.
• Facets system enhancement to eidt accums for changes in existing plans.
• 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 Confidential . 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 and Out of State providers. ITS and BlueCard.
• Interpretation of Claim edits for adjudication. Utilized McKesson Claim Check for correct coding.

PROFESSIONAL EXPERIENCE

Sr. Business Analyst

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
• Running SQL queries to validate benefit configuration
• Benefit Configuration using Excel and Benefit Enhancement Tracking System (BETS)
• Defect Management and UAT using HP/ALM
• Medicaid and Medicare Avantage benefit analysis and validation
• Medicaid benefits analysis for Maryland, DC and Virginia

Quality 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.
• Validate UAT test case scenarios.
• 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.
• 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
• Commercial Insurance benefits configuration analysis and audit
• Medicare Advantage and Medicaid benefits for New England states

Confidential

Business Analyst

Responsibilities:

• Prepared and wrote Conceptual Specific Design (CSD) documents for Large Scale Implementation (LSI) from local system for migration to Confidential .
• Served as a liaison for IBM 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, and Reporting.
• Created and monitored statuses of Customer Service Requests (CSR) from inception until completion.
• Researched Systems Specifications (Spec-View) in order to assist the Plan in determining which new functionality was required.
• Tested Professional and Facility medical claims using Confidential system.
• Identified defects and errors on claims to allow adjudication.
• Gathered requirements and ensured that expected results were obtained to successfully finalize claims.
• 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.
• 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.
• Medicare Advantage benefits
• Medicaid benefits for the state of Mass.