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Sr. Business Analyst Resume

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

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