Professional Summary:

Seeking a position as where my experience and knowledge of the Information Technology industry will enable me to contribute to the company's objectives.

Skills and Experience:

• Experience with user needs and business requirements
• Over 20 years of experience in the Healthcare Management Industry
• Requirement Change Management
• Analyzed procedures surrounding the Provider Fee Scheduled, Appeals Processes, and denial data
• Knowledge of the Transaction Data gap analysis
• Knowledge of 508 compliance guidelines
• Test case review/User Manuals development/UI Wireframe/Prototype Design
• Broad understanding of the CMS business operations
• Fluent with ICD-9 and ICD-10 code sets and their uses for coding diagnoses
• Extensive experience with billing/rebilling, appeals, third party billing, and coding
• Experience with retro authorizations approval
• Medicare Secondary Payer
• IT Help Desk Analysis and Resolution
• Provider Support Call Center training

Professional experience:

Confidential

• Participate in meetings with CMS stakeholders to elicit and develop business requirements, system process diagrams, and user stories.
• Track parking lot and action items from requirements elicitation session.
• Elicit and author requirements specific to the quality healthcare programs.
• Develop and document system process diagrams and screen mock.
• Create, reviews and contributes to meeting minutes.
• Prepares meeting presentations.
• Reviews and analyze business process models BPMs .
• Create and deliver business analyst artifacts as outlined in the project's schedule/plan.
• Participates in peer reviews on deliverables.

Confidential

• Provided support with creating and maintaining wireframes for system reports/UI mock-ups/screen designs, update, and wrote use cases.
• Created User Manuals and user interface for SDD document.
• Served as the liaison between the business processes and requirements into technical requirements and specifications.
• Supported clients in the development and implementation throughout the full system development lifecycle SDLC .
• Tested the functionality of the system and document problems, errors and bugs.
• Usability testing of the system by performing a series of task and document the system response time and problems the user may encounter.
• Defined and track user requirements for applications and reports throughout the SDLC.
• Worked with development and maintenance teams to correctly interpret business requirements into accurate design documents.
• Analyzed and documented customer business requirements and processes and communicated these requirements into CMS-approved templates for conceptual data and process models.
• Participated in JAD sessions, and requirements elicitation meetings with customers to gather and document requirements and explore potential solutions and process improvements.
• Supported requirements elicitation effort be providing feedback from the application development standpoint.
• Presented a list of open questions and gaps in the requirements as they are developed.
• Analyzed user needs, assist in requirements definition.
• Created and maintains accurate Requirement Traceability Matrix RTM documentation.
• Participated in technical reviews as needed.
• Assisted with the creation of Logical and Physical Data Models, and create test data.
• Assisted with identifying required data elements using various data sources IDR, CrownWeb, Crown CDC .
• Utilized Quality Center for reporting incidents in the database maintain accountability and assign ownership.
• Created defect reports using Quality Center.
• Provided information regarding functionality of COTS tools consumed by the application.

Confidential

• Participated in the creation of PRD Project Requirements Document write, edit, and produce SOP's. Created training manuals, training material, user requirements and provided training.
• Troubleshoot and provided analytical support for existing application issues as well as participates in the design and implementation of new systems.
• Liaison between Operations and the vendors as it relates to the secure file transfer of enrollment for Facets, EAB NASCO.
• Investigated file integrity and accuracy of data elements from the appropriate legacy system.
• Analyzed and validate data, review and validate vendor enrollment error reports.
• Researched benefit plan codes at group level to determine if a benefit related issue is a CF issue or Vendor issue.
• Monitored, validated and worked with IT to resolve enrollment file errors.
• Provided user support and coordinated resolution of issues to include change management, root cause analysis, and appropriate escalation as needed.
• Facilitated meetings and participates in implementing of new groups.
• Coordinated with vendors within area of assigned responsibility or as an assigned project task to ensure that vendor dates are met.
• Reviewed benefit summaries in Facets and ensure benefits are converted into Vendor's software requirement.
• Collaborated with staff to ensure benefit codes are sent to the Vendors.
• Updated Pharmacy claims processed DMR's and pre-loads using Pharmacy GUI system.
• Created reports for auditing purposes.

Confidential

• Updated, edited, and reviewed benefit booklets. Produced documents to be sent to Congress and OPM.
• Demonstrated excellent written and oral communication skills. Interacted by telephone, mail, and/or email, regarding contractual provisions, federal law and regulations, and insurance law.
• Researched and developed written responses to disputed claims, legal inquiries and OPM issues.
• Revised, developed and maintained an up-to-date knowledge of the Plan, FEHBP statute and regulations, and legislation that impacts Plan benefits.
• Handled all health information in accordance with established regional, state and federal guidelines.
• Responded to information requests from OPM regarding disputed claims and escalated issues.
• Reviewed, drafted, and approved letters outlined by the regions, Clinical Management and the plan's mental health vendor that are giving OPM rights to a member or provider to ensure contractual obligations are met.
• Assisted with billing/rebilling, appeals, third party billing, coding and Retro-authorizations, approvals.
• Conducted on site health fairs and provided members with information as it relates to the Plan.
• Investigated and researched and handled Medicare Secondary Payer correspondence.

Confidential

• Verified coverage with insurance companies, provided coding and billing guidelines, assisted with claim denials and appeals, and provided product and COB information.
• Created and designed documents for product based on FDA indication to be given to customers.
• Evaluated and monitored provider agreements with managed care payers.
• Provided managed care insurance Medicare guidelines to the customer. Enrolled members in assistance programs.
• Served as a liaison in educating, training and assisting external and internal clients to efficiently work within Managed Care, Medicare, Medicaid and FDA guidelines regarding coverage.
• Entered data and maintained control records on incoming correspondence and follows through on the actions to ensure prompt response and proper handling.

Confidential

• Implemented the company's provider service and retention strategies through routine telephone interactions.
• Responded to telephone inquiries, written inquiries, and automated inquiries from subscribers, group administrators, providers, brokers, medical professionals, and internal staff.
• Responsible for assuring all claims are processed and coded correctly.
• Worked all final appeals for payment.
• Developed and applied the ability to analyze customer contracts and needs involving current product mix, risk assessment, and revenue impact. Provided billing guideline, maintained health plan physicians hospitals database.
• Trained and provided education to staff, and managed care providers on Care First policy and procedure.

Confidential

• Wrote and created authorization request to be submitted to health plans.
• Operated reimbursement hotlines/indigent patient programs, researched health insurance policies to address patient coverage concerns, assist with billing claims and assist customers on behalf of pharmaceutical companies.

Confidential

• Assisted clients with resolving technical errors with the ACS software package.
• Provided phone and email support in the areas regarding ACS software, new user setup, login difficulties, and password issues standard Windows desktop applications. Email, fax and mail correspondence to the customer.
• Installed and assisted with installs network configuration remotely and on site.
• Provided assistance with printers and protocols problems for their network.
• Team Leader, Interviewed trained support staff pertaining to software.
• Created and prepared training material and rough drafts for the help files for review with the project staff.
• Updated, edited and maintained knowledge base system. Logged correspondence onto client tracking database.

Confidential

• Adjusted and processed written correspondence and claims provided insurance info, and performed research using MMIS and BCBS legacy system.
• Prepared documents for credentialing of physicians, and negotiated of payer contracts in a timely manner.
• Assisted in conduction of background investigation, filed and maintained UR documents medical records.
• Verified and assisted customer with referral, pre-authorization process, and appeals.
• Planned, developed, and coordinated the execution of program policy, procedures, and operations.