EXPERIENCE:

Confidential

• Participated in the Business Requirements gathering process for the Blue Cross BlueShield Blue Chip and ITS Claim Adjudication Systems for the ICD-10/ ANSI 5010 Projects.
• Analyze, define and document Business Requirements for Business Stakeholders and Development for ICD-10 Remediation and Conversion.
• Defined and analyzed system impacts and gaps related to government mandates such as ACA, ICD-10 and Healthcare Reform initiatives.
• Involved in testing activities and analysis of Medicaid Fee for Service, reimbursement payments and electronic billing for ICD-10 and integration with MMIS.
• Analysis of Benefit Administration for Medicaid, Medicare and , Managed Care products against contractual requirements.

• Analyzed 4010/5010 side by side document and 5010 changes and impacts to Blue Chip Application, ITS and NASCO Claims Functionality.
• Reviewed 837 P/I and 835 Implementation/TR3 Guides for electronic claims submissions during the analysis phase
• Created User Acceptance Claims and Billing Test and Use Cases based on Business Requirements
• Participating in testing support for ICD-10/ ANSI 5010 implementation and ICD-10 Pilot Testing.

• Cross functionally coordination with various Corporate departments including BlueCross Blue Shield, EFE, HCM, EPPO and ITG to mitigate risks and issues
• Help define and design future state processes for ICD-10/5010 transaction processing for 837 , 835 and NCPDP electronic transactions.
• Participated in analysis of ICD-9 TO ICD-10 conversion to determine impacts on Claim Adjudication and electronic billing Systems.
• Participated in Requirements Test Cases Walkthroughs with Development, Business and QA Staff members for 5010 and ICD-10 projects.
• Assisted QA team during the testing effort and to make sure coverage for the Requirements were captured in the Test Cases.
• Participated in the ICD-9 TO ICD-10 and ANSI 4010 to 5010 ICD-9 Gap Analysis studies.
• Utilized Edifecs and Claredi compliance checker tools to verify 837 ICD10/ANSI 5010 compliancy.
• Significant Exposure to 837I/837P Claims Submission Processing and 835 Remittance Advice electronic processing and structure.
• Participated in troubleshooting and analysis of ICD-10 defects found during testing.
• Familiarity with ICD-9/ICD-10 Diagnosis and Procedure Code Sets and mapping.
• Develop Test Strategy and Approach documentation and workflows.
• Participated in Requirements gathering implementation activities for BlueCross BlueShield Health Care Exchange and ACA initiatives.
• Familiar with Healthcare mandates, CMS guidelines and ACA.
• Participated in Requirements gathering activities for Healthcare Exchange initiatives.

Confidential

• Participated in the Implementation process for the Installation of Epic Software at three Network hospital sites.
• Collaborated with various departments to create process and system workflows.
• Gathered Business Requirements from various departments.
• Participate in re-engineering and validation sessions with users and SME's.
• Participated in System Build of new application in be installed.
• Participated in software conversion activities.
• Provided Application support and served as liaison between IT and user community.
• Completed Epic training at Epic University in Wisconsin in Inpatient Modules.

Confidential

• Responsible for creating and developing test plans and scripts and executing test scenarios on-line and in Batch for Claims System Enhancements, software bug fixes and updates.
• Analyzed User Requirements and Functional Specifications for ITS Claims Processing and PTS applications to indentify and evaluate Test Scripts and data needed and gaps.
• Participated in UAT User Acceptance Testing and coordination.
• Assisted with creation of Test Beds and created own test data and perform data manipulation through File-Aid.
• Utilized Rational Tools and in-house testing utilities for high volume data loads and testing.
• Assisted Automation Group with automating tests scripts for enhancements and Regression purposes.
• Identified, documented, reported and tracked software defects for Development Team through ClearQuest.
• Investigate and troubleshoot Production application problems. Participate in all phases of the Test Life Cycle including Integration, Regression, Conversion and Automation. Create Test Strategy documents.
• Participate in Development, Design meetings and workgroups for Enhancements and software releases.
• Interact closely with Business Analysts and User groups to resolve functionality discrepancies.
• Projects include those related to claim pricing, billing, Healthcare compliance, HIPAA, Medicare Advantage, Blues Plan Network changes and reporting.
• Utilized Cognos for querying and reporting off of large claim and provider databases and performed SQL queries.
• Assisted with the gathering, determination and update of Functional Requirements and Specifications.
• Created statistical and metrics reports related to performance indicators and utilization for Plan Data.
• Participated in multiple testing projects including testing enhancements, re-creating and investigating production defects/bugs and taking ad-hoc requests simultaneously.
• Used Quality Center to load test cases, link defects, reporting and test planning activities.
• Mentor junior staff and create training documentation.

Confidential

• Principal responsibilities include the creation of Test Plans against Requirements and execution of Life and Health Insurance Products test scripts.
• System functionality tested includes Claims Processing, Billing, and Carrier Administration.
• Responsible for analyzing application specifications, gathering business requirements from users and UAT.
• Issue tracking and use of Reporting tools such as AS400 Query for querying were other tasks.
• Confidential
• Responsible for compiling, analyzing and validating the accuracy of provider data in BCBSIL networks.
• Extracts data from several large databases and use various report development and analytical techniques to perform statistical data comparisons and tracking.
• Perform routine monthly and quarterly processes for quality checks and to ensure organizational compliance to set guidelines.
• Maintained, created databases and queried with use of MS Access.
• Participate in audit preparation activities and table maintenance.

Confidential

• Responsible for providing application support to end-users of McKesson HBOC proprietary and third party Healthcare Managed Care software at Hospitals, Clinics, Medical Groups and TPA's.
• Troubleshoot application errors on multiple platforms including client server and IBM mainframe environments.
• Assisted in User Acceptance UAT , Regression and Performance testing.
• Participated in Managed Care software implementations, upgrades and conversions.
• Responsibilities include system testing, training, and analyzing claim payment errors.
• Required development of procedural documentation. Involved table maintenance, plan/provider contract load setup and custom reports development.
• Heavy exposure to diverse applications utilized in a hospital, managed care and physician practice settings with exposure to claims, EDI batch processes, patient care, physician billing, eligibility and credentialing software.
• Performed system maintenance and application issue tracking. Maintain communications with vendors and administrative personnel within user groups on projects and system or software related concerns.
• Served as lead Analyst in requirements gathering and testing EDI claims conversion project.
• Coordinated hardware and equipment upgrades and performed software application installations.
• Participated in Performance and Stress testing.
• Responsible for database reporting utilizing Crystal Reports.

Confidential

• Processed UHC/Chicago HMO claims in a high volume production environment for TPA.
• Perform claim auditing and processed adjustments.
• Involved analysis of hospital and provider contracts, fee schedules and member medical history for calculation, coordination of benefits and determination of liability.
• Responsibilities included follow-up research, projects resolution via phone with providers regarding payment discrepancies, denial and contract issues.

Confidential

• Developed data and created test plans for testing of insurance claims application software and products on the mainframe.
• During execution of test plans, analyzed results, identified software defects and recommended modifications or enhancements.
• Reviewed and analyzed system requirements Major project tested was claims system for BlueCross Blue Shield of Massachusetts.
• Assisted in User Acceptance Testing UAT and documentation of systems issues identified.

Confidential

• Adjudication and extensive investigation of group LTD claims for risk management.
• Coordination of eligible benefits with social security workers compensation, State Disability and pension plans.
• Involved pre existing condition and evidence of insurability investigation and review of tax/earning data to calculate benefit amounts.
• Handled Policyholder and benefit administrator servicing via phone, in-person or letter.

Confidential

• Analysis and processing of contestable health and bodily injury indemnity and disability claims for benefit and liability determination.
• Involved evaluation and review of medical records, police and Equifax reports for possible pre-existing conditions or policy misrepresentation.
• Heavy phone contact and composition of own letters for correspondence with doctors, lawyers and members.