Sr. Business Analyst Resume
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Franklin Lakes, NJ
SUMMARY
- Over 10+ Years of experience as a Sr. Business Analyst in Medicaid.
TECHNICAL SKILLS
- Business Analysis
- Managed Care
- Translation
- Financial Analysis
- Insurance Verification
- Financial Report Writing
- Medical Terminology
- HIPAA
- Epic
- Interpretation
- Medical Billing
- Microsoft Excel
- Microsoft Word
- Accounting
PROFESSIONAL EXPERIENCE
Sr. Business Analyst
Confidential - Franklin Lakes, NJ
Responsibilities:
- Provided operational support for assigned client markets (Commercial, Medicare, Health Plans) undergoing plans changes, new implementations and renewal activities
- Reviewed, analyzed and verified intent of assigned benefit set-ups as they relate to products
- Updated account structure grids following Medicare Part D requirements in terms of poverty levels (POV), drug tiers and medication copays configurations
- Performed Emergency Access to Benefits, Manual Copay Set-up, Account Structure Automation activities
- Gained valuable cross-functional communication skills while updating CBM Matrix and SOPs internal files
- Identified and communicated need for customization to support client benefit requirements
- Utilized WebEx to schedule and attend client and internal account team/management meetings
- Adhered to all organizational processes and compliance standards; provided subject matter input relating to checklists and internal processes
- Conducted training and mentoring for new team members, off-shore and contingent employees
Sr. Business Analyst
Confidential - Ridgewood, NJ
Responsibilities:
- Obtained pre-certification for 3700+ high tech diagnostic procedures to ensure coverage and hospital reimbursement
- Reviewed medical requisition orders to ensure diagnosis meets medical necessity for exam requested
- Registered and pre-registered patients for various modalities according to department guidelines
- Adhered to all hospital and departmental policies and procedures ( corporate compliance, confidentiality, HIPPA, safety, security)
- Initiated MRI safety checklist to identify possible contraindications
- Monitored exam and surgery day registration needs for each patient such that all incomplete pre- registration procedures are completed on the date of service
- Scheduled patients for diagnostic and preventative radiological procedures
- Followed up on all outstanding errors, incomplete work and medical records issues
- Provided patient/legally responsible individual with information on financial assistance
Sr. Business Analyst
Confidential - New York, NY
Responsibilities:
- Serviced 45000+ members and providers of Elderplan, HomeFirst, Medicare/Medicaid/EPIC recipients following HIPPA regulations and CMS guidelines
- Worked closely with CMS, NY Medicaid Choice, NYC DOH, SSA, providers of medical and recreational services
- Managed members financial statements: Explanation of Benefits (calculating and applying Part B, deductibles, co-payments and co-insurance amounts)
- Managed Part D (Prescription Drugs coverage) Invoices and EOC rider statements
- Processed invoices for DME supplies, PCW services, located PAR-providers, managed transportation claims
- Authorization's follow-up within Member 's Operations, Enrollment and Finance Departments
- Assessed needs for claim and service appeals, filed internal appeals, advised on external appeal process
- Identified, filed, coded, investigated and resolved grievances (Standard/Expedited/Same Day)
- Provided members- and PAR-providers-education on billing process and claims denial reasons
- Confirmed hospitals/ nursing homes/rehabilitation centers/ADC 's admission/discharge authorizations
- Managed OTC (Over-The-Counter) financial records, processed OTC PAR-vendors claims, identified OTC cases for claim reimbursements
- Issued and distributed informational materials (triggering ID/OTC cards; evidence of coverage, benefits and eligibility packages, PAR providers directories)
- Detected and reported files and statements with discrepancies of sensitive information
- Identified and classified suspicious/fraudulent activities, reported cases to Fraud Investigation Unit Department
Sr. Business Analyst
Confidential- New York, NY
Responsibilities:
- Acknowledged and processed 250+ member's, provider' action appeals, grievances and correspondence
- Conducted an investigated members' (active and inactive) and provider's (PAR and NON-PAR) Medicare and Medicaid grievances
- Provided adequate grievance resolution (substantiated, partially substantiated, unsubstantiated, inconclusive, withdrawn) within time-sensitive CMS guidelines
- Filed and processed action appeals, requiring clinical review and medical determination
- Defined eligibility for all claim-appeal reconsiderations and requests for financial reimbursements
- Processed pre-service requests for authorizations of medically necessary services (standard/expedited)
- Prepared upheld appeal cases for Maximus (NY Medicaid Choice) review and determination
- Composed Fair Hearing and External Appeal documentation for cases with the final adverse determination outcome
- Referred qualified cases to Quality Management, Compliance and Fraud Investigation Unit Departments
- Provided adequate information to all QIO requests
- Maintained thorough electronic and paper case's loads and records
Business Analyst
Confidential - Brooklyn, NY
Responsibilities:
- Accurately and impartially transmitted information without altering the content or intent
- Facilitated effective communication between the patient and the healthcare provider
- Conducting operation of the neurofeedback instruments and computer software
- Registering new patients and updating medical record
- Monitoring equipment, keeping adequate medical offices supply inventory