Summary of Qualifications

Healthcare Business Analyst specializing in systems implementations, configuration, business process management, process optimization and data analysis

Professional Experience

Confidential

• Configure provider contracts for Aetna as business is moved to the HealthEdge software platform.
• Prepare contract templates for loading to HealthRules and participate in Proof of Concept.
• Ensure that client goals for contract loading are met, anticipating heavy volume and quick turn-around time throughout 2015.

Confidential

• Configure complex Medicaid healthcare benefits on the QNXT platform.
• Prepare claims testing scenarios and ensure that all benefit requirements are properly captured and tested.
• Review and resolve Medicaid claims that do not pass auto adjudication.
• Project manager for Provider Network credentialing for SC Medicaid Sep thru Dec 2013. Ensured that providers submitted all necessary paperwork and site reviews conducted as needed. Ensured that contracts were signed and files completed.

Confidential

• Contracted with NASCO to test claims processing for a Blue Cross Blue Shield BCBS plan running on the NASCO Processing System.
• Input claims for adjudication in NPS and reviewed results that were moved into the Blue Cross Association Interplan Teleprocessing System for claims payment.
• Maintained testing log, noted expected and actual test case results and followed up on test cases that did not return results as expected.

Confidential

Participated in the Integrated Customer Platform project for State Farm bringing together health, life, auto, property casualty insurance and financial services. Preparing to conduct stakeholder interviews in order to gather information and complete documenting business requirements for the health product.

Confidential

Business Analyst Senior Consultant

• Member of project team for BCBS Plan implementing new sales software designed to update IT handling of new products.
• Prepared current state and future state process flows, updated end user forms and prepared training materials for IT resources utilizing new technology.
• Interacted with clients and worked closely with team members to test potential new process workflows.
• Identified impacts, opportunities and risks related to the implementation of ICD-10 coding for a Blue Cross Blue Shield Plan.
• Utilized SQL Server to analyze claims history and identify coding priorities for ICD-10.
• Implemented and utilized 3rd party software to develop ICD-9 to ICD-10 crosswalks.

Confidential

Business Analyst

• Contracted with NASCO to provide technical and business application support for claims operations and pricing.
• Assisted with initial EDI conversion activities to ensure HIPAA 5010 compliance.
• Responsible for business process modeling and process flow analysis using MS Visio and SharePoint and working jointly with the NASCO technical team.
• Responsible for system testing matrix including use cases for all identified potential issues.
• Maintained system log identified in use case testing and followed up with technical analysts and programmers on open items.

Confidential

Business Analyst

• Contracted with HP to develop and implement a claims processing system for CIGNA utilizing best practices in healthcare operations.
• Assigned to the pricing and contract verification segment of the project.
• Responsible for information gathering and writing business requirements and business rules.

Confidential

Business Analyst

• Assisted in implementing a new Medicaid client, working effectively in a rapidly moving environment.
• Worked with Facets data modeling and attended Facets Technical boot camp.
• Attended Facets End User boot camp and learned to navigate the software applications and tie GUI fields to the data model.
• Utilized SQL Server and Oracle databases to query the claims processing system.
• Identified information gaps for new business requirements based on government directives.

Confidential

Business Analyst

• Provided technical and application support during the implementation of the Blue Cross Association web-based software for processing Inter-Plan claims, designed to improve the flow of provider payments.
• Conducted stakeholder interviews to confirm end user expectations.
• Reviewed iterations of ITS software release documentation, translated technical requirements into business solutions.
• Prepared testing matrices. Conducted software testing, managed test problem resolution.
• Identified opportunities for product development and customized solutions.

Confidential

Data Analyst

• Prepared financial and business related reports for senior management. Conducted focused data analysis upon request.
• Developed business models to evaluate proposed changes in provider reimbursement. Evaluated the potential impact of proposed reimbursement changes on revenue and utilization.
• Prepared spreadsheets and documentation to drive discussions concerning benefit administration and revenue management.
• Assisted in identifying security and access issues within data warehouses.

Confidential

Consultant

• Responsible for new customer implementations on the QNXT product.
• Proficient in all aspects of QNXT configuration including eligibility and enrollment, provider reimbursement and network management, referral and authorizations, claims processing, and premium billing and accounting.
• Assisted with development of detailed specifications for project tasks such as EDI interfaces, code set updates and system configuration.
• Conducted workflow analysis and business requirements gathering sessions.
• Responsible for system testing utilizing appropriate coding, including CPT and ICD-9.
• Provided recommendations for redesign or integration of existing processes.

Skills

• Microsoft Access
• SQL
• Excel
• Project
• Word
• Visio
• SharePoint
• PowerPoint.