Profile

Highly skilled and motivated Healthcare Business and Systems Analyst/ Configuration Specialist with 20 plus years experience in the healthcare insurance industry with excellent analytical, organizational, and management skills. Extensive experience working independently or part of a team on several healthcare management projects.

Professional Experience

Confidential

Senior Business Analyst/ Independent Consultant

• Evaluate current QNXT 4.7 system configuration for Medicare Advantage and Medicaid plans and recommend configuration improvements to increase auto adjudication of claims.
• Evaluate current configuration CCR change control request processes and develop more efficient measures to decrease CCR turnaround times.
• Analyze current configuration team SLA service level agreement and recommend more standard SLA across team members based on QNXT t knowledge levels.
• Develop training program and material for new hires and existing configuration team members to increase QNXT knowledge base and facilitate cross training within configuration department.
• Analyze and resolve claims payment, utilization management aka Health Services , enrollment, and/ or provider production issues when configuration team unable to resolve.
• Evaluate new business project requirements and develop project implementation plan.
• Assist IS team with QNXT infrastructure schema questions and solutions.

Confidential

Senior Business Analyst

• Responsible for configuration of QNXT 4.7 for Medicare provider contract and various payment methodologies for client in Coral Gables Florida.
• Configure all authorization and COB templates within QNXT.
• Assist with configuration of all Medicare HMO, POS benefits.
• Assist with training of clients QNXT configuration team on applications and best practices for both Medicare and Medicaid products.
• Assist internal infrastructure team with QNXT schema questions/solutions.
• Meet with client SMEs to develop new or update current business practice.
• Developed new letter generation process utilizing current QNXT configuration for utilization management team.
• Analyze and resolve production claims issues for Medicaid product when client's claim team is unable to resolve issues.
• Assist with the implementation and integration of EAM membership system into QNXT 4.7.
• Lead on project to clean up corrupt provider records within QNXT affecting claims payment.
• Analyze and resolve all payment manager issues within QNXT.

Confidential

Senior Business Analyst

• Configure payer, health plans and benefit service groups aka benefits for new North Carolina MMIS proprietary system NCTracks.
• Conduct information gathering JAD sessions with client.
• Supervise and train Benefit Service Group configuration team on new or changing configuration practices.
• Meet with client SMEs to develop new or update current business practices that meet MITA certification requirements.
• Assist internal CSC infrastructure team with development of benefit and claims system functionality.
• Assist with data mapping of legacy edits and audits and benefits to NCTracks.
• Testing of benefit services group, and claims functionality.

Confidential

Senior Systems Analyst / Configuration Manager

• Health Information Management Division responsible for the implementation and support of state Medicaid systems.
• Supervise QNXT Configuration and Test Teams.
• Configure QNXT and McKesson Claim Check applications for state Medicaid contracts.
• Assist in development of unit and system test case database.
• Assist with training of on-site QNXT configuration team on applications and best practices.
• Assist internal infrastructure team with QNXT schema questions/solutions.
• Meet with client SMEs to develop new or update current business practices that meet MITA certification requirements.
• Assist larger northeast client in achieving MITA certification.
• Conduct requirement gathering JAD sessions and review sessions with clients.
• Test and report on QNXT application functionality and defects.
• Assist configuration analysts with QNXT application functionality and testing.
• Manage QNXT User Security.
• Identify areas of improvement within QNXT and write and submit PDRs to TriZetto.
• Analyze and develop gap and custom solutions when QNXT system cannot meet required business need.
• Assist conversion team with data mapping from Legacy systems to QNXT.
• Conduct provider training seminars on changes to claims submission for new MMIS system.
• Create provider handbooks and user guides for new MMIS system.

Confidential

Senior Business Analyst / Requirements Manager / Consultant

• Conduct requirement JAD sessions with client for all business areas for New York Facets implementation.
• Develop and document new requirements gathering process.
• Train Business Analyst team on best practices and new requirements gathering process.
• Responsible for development and loading of requirements in to Rational Clear Quest.
• Assist executive management team with presentations of project timelines, milestones, and system functionality to client.
• Knowledge transfer of Facets configuration and system functionality to project team members.

Confidential

Business Analyst / Consultant

• Gather business requirements and develop business requirement documents for any new or existing UHG business.
• Assist developers in translating and documenting Facts, DIAMOND and Cosmos business requirements into system requirements for new or existing UHG business.
• Analyze, maintain, and configure Facets, DIAMOND, and Cosmos claim and provider data utilizing PL/SQL.
• Advise on business process improvement methods considering business implications of technology on current and future business environments.

Confidential

Healthcare Consultant

• Conduct requirement JAD sessions with client for all business areas for large New Jersey Blues MMIS conversion.
• Identify and resolve business or system gaps between NMS, QBlue, and Latron health management systems for New Jersey Blues client.
• Assistant Project Manager for MMIS conversion project.
• Assist with EDI mapping of ANSI 4010 837I, 837P, 834, 835, 270 and 271 formats for various clients.
• Successfully market and acquire Facets dental gap analysis project for large Utah payer.
• Managed and executed system gap analysis project between Facets dental and various dental and health management systems.
• Directed and monitor successful MCO NCQA and Washington State TeaMonitor audit for Medicaid and Medicare Advantage programs.
• Develop and document workflows and procedures for QNXT in all functional areas for Medicare Advantage program for large Washington State implementation.
• Responsible for validating and documenting of QNXT configuration issues for Washington State implementation.
• Develop material and execute training of 'train the trainers' for several system implementations.
• Develop RFP and SOW documents for various payers.
• Configure QNXT 3.2 interface with ICES 2.5 large health payer in Hawaii.
• Developed and implemented beta test case scenarios for QNXT and ICES 2.5 claims editing.

Confidential

Business Analyst

• Development and documentation of claims functionality for new web based Havalina product.
• Gather claims business and system requirements and develop business and system requirement documents.

Confidential

Business Application Analyst

• Evaluation of business requirements for enhancements to QMACS and QNXT systems.
• Configure applications QMACS, QNXT for the processing of medical claims.
• Research claim processing issues to determine if problem exists with system configuration in the areas of contracts, benefits, claim finance codes, fee tables, provider and member modules.
• Testing and implementation of solutions for claim processing issues, which include creating test scripts and input of test claims.
• Participate in system implementations and maintenance activities including design, configuration and documentation of all system files and options.
• Coordinate with business application users to evaluate, test and implement new business application system releases.
• Perform quality control on production builds for lower level analysts.
• Identify areas for process improvement.
• Develop and run basic SQL queries to identify claims for reprocessing after resolving issues.

Confidential

Health Systems/Business Configuration Manager

• Played integral part in conversion project from Legacy claim system to PowerSTEPP Health Management System intgrated with PowerrQueue claims routing system for commercial lines of business.
• Responsible all configuration of PowerSTEPP and PowerQueue.
• Created and implemented process for documenting and executing test scripts for new or updated configuration changes.
• Developed and managed Modle Office and Benefit Plan Building teams.
• Responsible for business and technical development and maintenance PowerSTEPP and PowerQueue.
• Increased claims auto-adjudication rate by 15 within in one month exceeding corporates projections by 10 .
• Updated and implemented more effective and user friendly desktop procedures for all departments.