SUMMARY:

Proven professional with deep expertise in Medicaid systems and policies including management, analysis, policy advisory, billing of claims of all provider types, and training of staff and the provider community. Experience implementing three Medicaid contracts with the fiscal agents. Expert knowledge of State and Federal regulations, policies, and MMIS processing system include Medicare and commercial billing and follow - up experience. Experience training and managing a billing department with over 30 employees, an inventory of $14 million, and over 10,000 accounts. Formal training in project management principals.

SKILLS:

Data Analyst

Mapping

SQL, SQL Queries, UAT

Data Warehouse, Cognos, CODA

WEB Based, Change Control

Requirements Management

Team Lead, Version Control

Enterprise Architect, Coding

Visio, Billing, Medicaid

Reconciliation

Account Reconciliation

Claims

Payments

Audit

Audits

Managed Care

Medicare

Claims Processing, Claims Processing System, Claims Resolution, Subject Matter Expert

SME, Business Analysis, Business Consultant

Business Requirements, Test Cases

UAT Testing, User Stories

Mock-Ups

Healthcare,Pharmacy Contracts, Problem Solving, Operations

TOPO, Pricing Proposals, Disability, excel, Microsoft Office, Microsoft Outlook, Outlook, Word, Medical Review

CPT, EDS

AR, Posting

Mentoring

Inventory

Training Manuals

DXC

Educating

Change Orders

EXPERIENCE:

Confidential

Business Analyst/Data Analyst

Responsibilities:

• Creating requirements for various new data reports/requests and existing reporting
• Work directly with State staff clarifying requirements and processes
• Attend all stakeholder meetings with the State.
• Creating user stories for developers
• UAT testing of changes Creating SQL queries and Cognos queries
• Ensure all policy and procedures are being met for compliance
• Monitoring the state business and system requirements

Confidential

Senior Business Analyst

Responsibilities:

• Work directly with State staff clarifying requirements and processes
• Attend all stakeholder meetings with the State.
• Creating user stories and feature documents for developers
• Creating business process flows
• Creating user stories for developers
• Prioritizing work for UAT testing
• Training of internal staff that will be responsible for this project
• Ensure all policy and procedures are being met for compliance
• Creating member communication documents
• Monitoring the state business and system requirements

Confidential

Provider Enrollment Analyst/SME

Responsibilities:

• Work with new vendor creating requirements for approval.
• Acting SME for enrollment processes
• Reviewing and approving design documents
• Assisting vendor with development tools to perform enrollment and credentialing processes to ensure they are within the scope of Medicaid policy and State and Federal laws
• Reviewing and approving process flows Creating policy documents for provider enrollment and credentialing
• Other tasks as assigned or needed

Confidential

Program Integrity Analyst

Responsibilities:

• Worked with the Managed Care Entities on reporting of fraud, waste, and abuse.
• Created reporting documents each month for providers on the alert list.
• Monitored Scope of Work requirements document for compliance reporting.
• Assisted staff with prepay review for fee for service claims processing.
• Assisted with the implementation of prepay review functions to a new vendor.

Confidential

Business Analyst

Responsibilities:

• Perform role of Subject Matter Expert (SME).
• Define business analysis and requirements.
• Engage stakeholder to identify new idea and approach.
• Support critical thinking and problem solving.
• Develop diagrams/models for process flows.
• Facilitate communication between organizational units.
• Align the needs of business units with information technology.
• Assist in requirements validation for Provider Services/Enrollment with the customer.
• Mapping business requirements to system objects and panels.
• Provide requirement interpretation and guidance to technical and test teams.
• Assist in development of the web based tool for Provider Enrollment processes.
• Created process flows, letter templates, and report mock - ups.
• Review test cases

Confidential

BUSINESS ANALYST/SUBJECT MATTER EXPERT (SME)

Responsibilities:

• Assist in the development/formulation and validation of all requirement engineering processes, standards, procedures, and guidelines.
• Assist in the requirements management processes, including change control, version control, tracking & status reporting, and traceability.
• Providing leadership to requirement teams, serving as a central point of contact through mentoring and motivating other business system analysts in a positive manner.
• Guiding both project team members and customers in the development process; providing analysis and solution definitions, to ensure solutions meet customer objectives.
• Providing requirement interpretation and guidance to technical and test teams.
• Proactively identifying risks, issues, and action items leading to possible solutions.
• Interacting with internal and external organizations and persons as deemed appropriate by the Requirements Manager (i.e. vendors, State and Federal government agencies, State providers and beneficiaries, and other stakeholders).