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