SUMMARY:

Healthcare IT professional with close to 20 years’ experience in the Medicare, Medicaid, Exchange and Commercial/ASO healthcare information and technology systems and implementation. Experienced in business and technical planning, design, configuration and conversion of medical management systems for the payer market utilizing various methods such as SDLC and Agile, and tools such as SQL, .NET, Visio, and the Microsoft suite of products in order to plan, design, and execute project implementations in a timely, cost efficient fashion. Emphasis on data integrity, security, and performance from both government perspective as well as commercial lines of business. Excellent communication and interpersonal skills in order to efficiently run an implementation from alignment, confirmation, configuration deployment and realization stages.

PROFESSIONAL EXPERIENCE:

Confidential, Nashville, TN

Senior Business Analyst

Responsibilities:

• Senior Business Systems Analyst performing analysis, documentation, design analysis, requirements, and user stories to support Confidential ’s Core Claim Replacement Project. Responsibilities included end to end analysis solutions targeted for capacity of increased members as a result of the ACA Marketplace, Medicare, Medicaid, and TPAs.
• Analysis and reporting on server scalabilities, reporting functions, data warehousing, claims processing, for the State of PA, and CMS.
• Conducted meetings between business and technical parties to discuss upgrades and implantation of new solutions for membership, benefits, claims, provider, finance, and actuarial services for Medicare, Medicaid, and commercial lines of business. enhancements to existing business processes, and throughput efficiency of the RAPS process.
• Business analysis, data mapping, gap analysis, and writing SQL queries to determine gaps in data migration and transition.
• Conducted JOC sessions with various vendors such as TriZetto, Cognizant, DST, and Vistar Technologies to present customer requirements in order to create RFI and RFP documentation.

Confidential, San Antonio, TX

Senior Business Analyst

Responsibilities:

• Responsibilities included end to end analysis solutions targeted for capacity of increased number of Optum entities, server scalabilities, reporting functions, data warehousing, claims processing, and the RAPS submission process through the use of SACD diagrams and models.
• Responsible for running JOC meetings between business and technical parties to discuss enhancements to existing business processes, and throughput efficiency of the RAPS process.
• As the single BSA on the RAPS project a thorough working knowledge was required of business systems such as Ika Claims Processing System, ePRG (Provider Portal), TrueCare (Medical Management System, RightFax, and DataRAP V2, along with a thorough working knowledge of IT applications such as MS SQL Server, .NET, Control M, and Visio for analysis and documentation.

Confidential, Trenton, NJ

Business Systems Analyst

Responsibilities:

• Assisted business on conversion, and implementation of current Medical Management System to Landcorp’s CareRadius Application.
• Assisted NICU staff with both Business and Technical requirements for implementation of the Confidential NICU criteria.
• Responsible for business rule configuration of Complex Needs, Disease Management, Geriatric, and Pregnancy assessments, surveys, workbooks, and process flows.

Confidential, San Antonio, TX

Senior Business Analyst

Responsibilities:

• Responsible for data mapping and requirements for submission of electronic provider and eligibility extracts to vendor for processing of radiology claims.
• Provided business and technical requirements based upon business criteria.
• Created web wireframes mockups for web based application.
• Worked closely with off shore team to develop and program application based on business requirements and architecture.
• Responsible for writing SQL queries and report specifications for data extraction and presentation.
• Created business and technical requirements for implementation and go live of Confidential disease management plans of care.
• Responsible for data mapping of patient and provider data from EDW and automating the load process to Confidential on weekly and monthly basis.
• Created and specified automated pharmacy vendor process.
• This entailed creation of a reconciliation process between Confidential and their pharmacy vendors to ensure medication accuracy and billing.
• Tasks required data mapping of vendor specific fields to WellMed’s EDW, CMS medication listings, and eligibility data in order to process pharmacy claims quickly and accurately.
• Responsible for writing functional and technical specifications for SQL reports for all projects listed above.
• Responsible for conversion, data mapping, and ETL process of loading patient and provider data to CareWeb QI for inpatient services.

Confidential, Worcester, MA

Technical Analyst

Responsibilities:

• Responsible for writing business, scope and technical requirements for data warehouse and conversion from IDX claim system.
• Lead consultant for Fallon Clinic EDI eligibility and pharmacy extracts to and from health plan.
• Responsible for writing in process data specifications for vendor partner’s data mapping into Confidential these data maps included vendors regarding behavior health, dental, chiropractic, eligibility, senior plans, and 834/837 HIPAA transactions.
• Wrote and implemented interface and extract documentation Responsible for data mapping of existing data tables from IDX into SQL to support Confidential .
• Worked extensively with Confidential ’s ClaimCheck 8.5 and Integration Wizard for implementation and configuration with Confidential .

Confidential, Trenton, NJ

Senior Business Analyst

Responsibilities:

• Responsible for writing of Business and Technical specifications for Confidential insourcing project.
• Performed analysis of Medical Management workflows for implementation from CaseTrakker Enterprise to CarePlanner Web from MEDecision.
• Responsible for writing scope and technical gaps documents for Confidential ’s Integration Wizard, and ClaimCheck to Confidential 3.4 claims module.
• Responsible for creation of business and technical documentation for Confidential membership, and claims modules for communication with legacy systems.
• Implemented on online a HIPAA Electronic Authorization 278 process, utilizing SQL, and Business Objects.

Confidential, San Francisco, CA

Senior Business Analyst

Responsibilities:

• Assisted customer with data architecture and modeling.
• Created both physical and logical ERD diagrams for member WEB portal to access FSA (Flexible Spending Account).
• Created ERD diagrams utilizing both Erwin Data Modeler r7, and Visio 2007.
• Responsible for writing requirements, scope, and process documents for new software solutions, and implementation.
• Created data model documentation based upon the, 834, 835, and 837 Encounter Companion Documentation, for membership and claim transactions for FSA (Flexible Spending Account) participants.
• Worked with customer to format existing claims data utilizing the 837 companion guide.