SUMMARY

• My professional experience has given me the skills and exposure to communicate with business and technical members, researching and interpreting information for business and IT projects.
• My analytical skills allow me to see the big picture and break it down into action steps while skills in client relationship management, leadership and aptitude for technology allow me to make my business analysis role more cohesive and portable into different industries.
• Following is a brief summary of skills and knowledge that will allow me to contribute greatly for your organization:
• About 4 years experience with Medicaid Managed care organization: Analysis of CMS regulations, its impact on payment policies, claims reimbursement and provider contracts.
• Participated in implementation of CommonwealthCare plan - a plan set up to include members eligible in MA Healthcare Reform Act of 2006
• Role of Claims SME during implementation of NewMMIS - New Medicaid Management Information systems for Executive office of Health and Human Services of State of Massachusetts. Understanding and experience with Software Development Life Cycle, SDLC.
• Consultant for Revenue Management project: Analysis of regulatory compliance, infrastructure and revenue management of Local Health Departments LHDs of New York State.
• Analysis of patient data for market expansion, financial reporting and patient and service analytics for Partners Healthcare.
• The common denominator throughout my career is my success in connecting the dots to put together the big picture from fragmented details. My experience proves that I have a natural ability to analyze and correct inefficiencies in processes and systems to save money and time while achieving the set goals.
• The attached resume summarizes my experience and demonstrates my successful advancement I look forward to meeting with you so we may further discuss how my extensive skills and experiences can benefit your organization. Please contact me at your earliest convenience so this meeting can be scheduled.

Profile

• Over 15 years of experience with various types of Healthcare organizations: insurance plans, hospital administration, Medicaid MCO and healthcare consulting firm.
• Solid understanding of Managed Healthcare industry, provider contracting related operations, TPP Third Party Payments and reimbursement methodologies, government regulations compliance and healthcare claims processing systems.
• Over 8 years of experience in business analysis of Medicaid systems, payment methodologies, State and Federal CMS, DHCFP regulations and reimbursement policies.
• About 4 years as Business Analyst for Medicaid MCO that was one of the six contracted to work with Commonwealth Care plan - covers members eligible under MA Health Care Reform Law of 2006.
• Experience monitoring, auditing and reviewing contract terms, configuration of those terms into Claims adjudication systems and reconciling federal statutes and regulations with internal policies.
• About 1 years as Business analyst for implementation of New MMIS, a web based Service Oriented Architecture SOA Claims Management system for State of Massachusetts.
• About 9 months of experience analyzing infrastructure, revenue cycle management of Local Health Departments of State of NY. Demonstrated strength in analysis and documentation of deliverables for stakeholders.
• Superior skills with documentation of requirements, business process flows and payment policies.

Experience

Confidential

Business Analyst / Revenue Analyst

• Consultant role analyzing infrastructure and revenue cycle management of Local Health Departments - LHDs of New York State Health Department. Gained knowledge and applied federal healthcare regulations, statues which impact health care revenue operations.
• Prepared business requirements narrative report for client New York State health Department.
• Analyzed business processes, state and federal regulations compliance, healthcare claims and revenue cycle of six local health departments of New York State.
• Provided gap analysis between as-is and to-be processes and made recommendations.
• Created a sample workflow based on requirements, best practices and recommendations.
• Compiled reports summarizing findings and recommendations for each of sample counties. This allowed them to make immediate changes and use it as a benchmark for all LHDs.

Confidential

Business Analyst/ Test Analyst

• Claims SME role for implementation of a web-based, SOA , claims processing system, New MMIS - New Medicaid Management Information system for State of MA.
• Applied knowledge of medical codes and terminology, provider benefit rules, provider reimbursement methodologies, service limitations, member eligibility of different plans and government regulations compliance to analyze Claims Adjudication system for State of MA.
• Utilized knowledge and researched federal and state regulations to ensure accurate Claims adjudication and TPP reimbursement.

Confidential

Business Analyst / Provider Contract Analyst, Reimbursement and Contract Administration

• Key role in configuring provider contracts into claims processing system for Medicaid MCO. Key role in configuring member benefit plans, business rules, payment rules and service limitations into implementation of new Claims adjudication system, HealthTrio. Gained knowledge of medical coding and terminology as it applies to claims adjudication and third party payments.
• Reviewed contract agreement terms and configured benefits plans, fee schedules and processes into claims processing system to ensure accurate provider payments.
• Implemented tools and strategies to reconcile reimbursement methodologies and healthcare claims processing systems.
• Researched, communicated information to align federal health care regulations that impact health care revenue operations.
• Managed Payment Policy Project plan to ensure compliance with governmental regulations CMS, DHCFP - and aligned provider billing practices with Network Health's payment policies.
• This communication resulted in increased efficiency and accuracy of claims billing and payments and improved provider relationships.
• Analyzed and manipulated health care data to improve insurance adjudication processes to ensure accurate TPP Third Party Payments.

Confidential

Business Analyst, International Operations

• Managed and analyzed patient demographic and financial information for Partners International Program. Partners Healthcare is a integrated healthcare system founded by Brigham and Women's hospital and Massachusetts General Hospital.
• Analyzed patient data and payment trends for profit and market analysis resulting in expansion of new markets and increased revenue.
• Demonstrated ability to learn and apply medical coding, medical terminology and TPP reimbursement to analyze and manipulate data for senior management.

Confidential

Team Lead Product Implementation

• Led new product implementation that reconciled and recovered capitation non-payments or partial payments to various medical groups. Audited Claims activity of several clients for capitation overpayments and recovered 60,000.
• Conducted on-going monitoring of contracted and non-contracted Third Party Payment TPP trends.
• Identified and assisted with software enhancements resulting in increased efficiencies of analytics reporting by 30 .Managed automation of data processing and reduced system run times by 90

Confidential

Business Systems Analyst

• Analyzed business requirements for GUI application development for efficient monitoring licensing and registration of associates.
• Created and executed test cases for LARS Licensing and Registration based on functionality analysis resulting in reduced errors and improved functionality.

Confidential

Project Coordinator

• Managed internal projects for senior management.
• Created an office management infrastructure to monitor profitability and develop income projection matrixes by analyzing and performing data and workflow analysis.

Confidential

Business Analyst / Team Leader

• Led new products/functions from inception to maintenance stage: defined processes, analyzed their applicability, and enhanced them to meet anticipated needs, resulting in time and money savings.
• Redesigned a provider database after extensive data analysis, data mapping, process mapping and work flow analysis. Increased report accuracy rate by 50 , decreased annual costs by 60,000.
• Key role in the implementation of a new product / new business, GIS application, GeoAccess.

Technical skills

Microsoft Office, Microsoft ACCESS, MS Visio, SOA Claims processing systems, Health Care Reform related system setup