SUMMARY:

• 14 years exclusively in the healthcare industry as a claims adjudicator, quality assurance analyst, business analyst, consultant, and contractor.
• 8 years’ experience with in Facets from first version to latest version(also working knowledge of HSD Diamond 950, Xcelys and Health Rules) with deep knowledge of healthcare transaction systems, the healthcare industry, and healthcare regulations.
• Expertise in using Facets both front end and back end ODBC tables.
• Sound Expertise with Trizetto NetworX - Pricer and Facets Configuration and Testing.
• Comprehensive experience in healthcare data analysis encompassing systems reporting and testing.
• Superior claims adjudication and auditing expertise resulting in excellent performance evaluations.

TECHNICAL SKILLS:

System Experience: HIX, Oracle, RFT/QTP functional automation tool, Soap UI, Soap UI Pro, AMISYS, NASCO, latest version of Facets( 4.51 and above), Rims, Xcelys, NextGen, QNXT, Diamond, TOPPS, SQL, CSC, Macess, EMDON, Electron and Navicure clearing house, Florida Shared Systems, Mutual of Omaha Electronic Claims, Trizetto, Care Planner, Citrix, ICD-9, ICD-10, HIPAA Compliance, Proficient in Microsoft Word, Excel, Powerpoint, Outlook E-mail, Database Management & Intermediate computer skills.

EXPERIENCE:

Confidential, Health Quincy, MA

Business Analyst, Facets Configuration Analyst, UAT Testing Analyst

Responsibilities:

• Provides oversight of business system requirement/ specification analyst & maintenance in accordance with customer deliverables.
• Document and test Facets test scenarios, cases, and step-by-step instructions based on Confidential health business functions.
• Develops and maintains business system configuration solutions in accordance with provider/employer contracts and customer needs.
• Conceiving and delivering Claims Mass re-Adjudication (CMA)
• Administers the data/ configuration maintenance of systems parameters, specifications and data linkages to other systems involved in SOA component based architecture.
• Query and analyze data from ODBC Facets and NetworX tables.
• Develops, maintains and disseminates internal and external system documentation, including status updates; prepares procedural and customer documentation when required.
• Responsible for application environments in facets which includes but not limited to backend tables, writing queries through data dictionary and stored procedures
• Test and quality check of configuration building test claims
• Able to convert CORE Facets pricing to NetworX pricing

Confidential, Houston, TX

Facets Configuration Analyst, Facets Testing Analyst, Senior Appeals and Grievance Specialist

Responsibilities:

• Establish a thorough understanding of Medicare Manual 2, 13 & 18
• Implement applicable processes using facets version 5.0 mandated by CMS
• Responsible for monitoring effectuations of all resolutions as a result of appeal or grievance.
• Extensive Experience with SQL
• Responsible for Data Model and business components with Facets expertise in the areas of Benefits, Payments, pricing, Claims, Provider contracts & Membership/Enrollment.
• Timely and accurate configuration and applying expertise in development or configuration

Confidential, Rochester, NY

Senior Claims Specialist and Adjustment Representative

Responsibilities:

• Research, analyze and adjust claims in accordance with the plans provision and provider contracts
• Produced high productivity and accuracy rate processing claims using facets version 4.91
• Adjudicate and adjust using facets Medicare, Medicaid, Manage Care and PPO claims
• Strong problem solving techniques with excellent verbal and written communication skills
• Outstanding organizational skills and ability to meet deadlines

Confidential, Plan Alb, NM

Facets Testing and Configuration Analyst

Responsibilities:

• Facets membership enrollment and adjudication of tested claims(version 4.7)
• Follows established parameters for Facets configuration, testing and debugging, provides build and release project/product components
• Responsible for identifying necessary steps and processing claims of various complexity levels for Medicare, Medicaid, HMO, PPO, SNF, Rehab etc.
• High productivity and accuracy rate processing overturned appeals; processed and adjust claims in accordance with the plans contracts utilizing facets version 4.7

Confidential, Stockbridge, GA

Senior Biller and Collections Specialist

Responsibilities:

• Providing appropriate coding on the patient’s medical history, diagnosis, tests and treatments
• Using the coded medical records to create invoices that are sent to the patients and insurance companies.
• Responsible for submitting and following up on all claims which includes electronically filing Medicare, Medicaid, Commercial claims
• Responsible for talking to insurance companies, accepting and posting payments
• Accurately recording the patient’s and insurance company details into the system.
• Facets patient enrollment, Billing, case management and follow-up

Confidential, Atlanta, GA

Biller and Collection Specialist

Responsibilities:

• Used coded data to produce and submit claims to insurance companies
• Worked directly with the insurance companies, healthcare providers and patient to get claims processed and paid
• Review and appeal unpaid or denied claims; handle collections on unpaid accounts
• Manage the facility’s accounts receivable reports; answer patients billing questions