SUMMARY

• Experienced Business Analyst, User Acceptance Tester, and Health Insurance professional; with over twenty years of progressive expertise in both the Business and IT side of claims for hospitals and physicians from the payer side.
• Detail oriented, with a proven ability to successfully contribute to company objectives and success.

TECHNICAL SKILLS

• SQL Server - Intermediate Level
• Microsoft Access - Advance Level
• Microsoft Word - Advance Level
• Microsoft Power Point - Advance Level
• Microsoft Excel - Advance Level
• Tableau - Intermediate Level

PROFESSIONAL EXPERIENCE

Business Analyst

Confidential, NJ

Responsibilities:

• Conduct analyses of the provider network to ensure “right sizing” of the network and to monitor network performance.
• To ensure effective management of all processes associated with data exchange between Confidential and external business partners.
• Assist and documented processes of contracting physicians, medical groups, and other external business partners.
• Assist in documenting RFPs for new contracted services.
• Coordinate with other departments to ensure contracts are implemented efficiently, accurately, and timely.
• Address provider issues related to contract timing, set up, and payment disputes
• Ensure contracting workflows are followed and document deficiencies with the aim of improving the process.
• Assist leadership in the provider network process.
• Escalate and document provider implementation issues to leadership.
• Conduct and manage a variety of special assignments and projects on provider issues.
• Manage data analysis, review, and reporting in support of provider network management, including:
• Conduct research and data analysis of provider and claims data to assist the company in achieving its goals
• Design and develop database queries appropriate to the question or issue requiring data analysis
• Generate periodic reports on PCP’s and member panel size by network, group, and individual levels
• Perform on going monitoring activities identifying medical loss ratios for contracts
• Generate QA reports to ensure timely and accurate entry of provider data in core systems, including credentialing, claims and member assignment systems.
• Identify trends, issues, and opportunities associated with the provider network based on analysis reports and provide the results to management.
• Develop and implement process improvements to maintain effective management of the function as needed.
• Project Coordinator
• Reviews provider data for accuracy and completeness.
• Reviews provider types, locations, and other data items with special attention for regulatory compliance.
• Prepares files for uploads into the core data systems following data review.
• Communicate with management team on any issues associated with data including network performance and monitoring results.
• Excellent knowledge in Pharma and Healthcare as Business Analyst. Understand payor and PBM system.
• Good to have understanding on Patient assistance program
• Experience in understanding the client business needs and convert them as the business requirements in Pharma & Healthcare.
• Connect & discuss with clients of the client and understand the business need and convert them into business requirements and functional requirements.
• Closely work with Development & Testing teams to clarify the questions on the requirements.
• Work closely with the IT Leads of the client and business colleagues in the design, build and execution of Proof of Concept (PoC) projects across multiple clients and therapy areas, including,
• Designing and leading planning workshops between Client and our external partners
• Clarity of the problem statement and the assumptions to test through the PoC project
• Identification and understanding of the target customer/patient

Business Analyst

Confidential - Optum, NJ

Responsibilities:

• Provided revenue cycle management services in all areas of revenue cycle operations which includes:
• Patient Access / Registrations
• Health Information Management
• Patient Financial Services / Back End.
• Assessed key revenue cycle metricsand performance indicators and provided reporting of operational and financial performance.
• Evaluated and interpreted data to monitor performance identify trends and determine root cause issues.
• Communicated effectively(written and verbal) findings of analyses and audits to support operation and financial decisions.
• Collaborated with other teams and business partners to facilitate resolution of process / procedural issues, implement strategies and initiatives for process re - design.
• Served as a resource for special projects and priority analysis assignments.
• Prioritized and managed multiple tasks and special projects simultaneously.
• Evaluated business processes, identified opportunities for improvement and made recommendations to clients.
• Provided management with statistical findings and conclusions in analyzing interpreting trends and root cause analysis.
• Excellent knowledge in Pharma and Healthcare as Business Analyst. Understand payor and PBM system.
• Good to have understanding on Patient assistance program
• Experience in understanding the client business needs and convert them as the business requirements in Pharma & Healthcare.
• Connect & discuss with clients of the client and understand the business need and convert them into business requirements and functional requirements.
• Closely work with Development & Testing teams to clarify the questions on the requirements.
• Work closely with the IT Leads of the client and business colleagues in the design, build and execution of Proof of Concept (PoC) projects across multiple clients and therapy areas, including,
• Designing and leading planning workshops between Client and our external partners
• Clarity of the problem statement and the assumptions to test through the PoC project
• Identification and understanding of the target customer/patient

Senior Quality Assurance Analyst

Confidential, New York

Responsibilities:

• Performed validation testing for ICD-10 SME.
• Performed test output and validation with client's vendor partners.
• Applied testing validation measures to ensure vendor partners have properly tested ICD-10.
• Conducted and documented business case feasibility analyses.
• Developed and approved business and vendor requirements for stakeholders, user groups and vendors.
• Performed User Acceptance Testing for hospital and medical claims and developed the UAT test.
• Developed cost benefit analyses and risk assessment management plans during business requirements phases.
• Developed and maintained project management documentation for assigned projects.
• Defined work breakdown analyses and schedules.
• Evaluated and recommended technical solutions in support of product, application, and services strategies.
• Developed Plan readiness assessment criteria during User Acceptance Phases.
• Managed day-to-day vendor relationships.
• Developed and submitted project status reports to senior management and customers.
• Ensured all departments impacted met project-team deliverables by coordinated communications.
• Created and delivered presentations at conferences, seminars regarding ICD-10 implementation for healthcare plans and providers.

Business Analyst

Confidential

Responsibilities:

• Developed standardize new group benefit design requests in the Client system.
• Performed multiply functions within the pharmaceutical benefit coder.
• Assisted with complex setups or projects as needed.
• Tracked and reported progress to team to ensure deadlines are met.
• Performed verification/QA and system testing before implementation within contractual time frame agreements.
• Provided consultative support to internal and external clients by researching and assisting with resolution of benefit design and claims issues.
• Excellent knowledge in Pharma and Healthcare as Business Analyst. Understand payor and PBM system.
• Good to have understanding on Patient assistance program
• Experience in understanding the client business needs and convert them as the business requirements in Pharma & Healthcare.
• Connect & discuss with clients of the client and understand the business need and convert them into business requirements and functional requirements.
• Closely work with Development & Testing teams to clarify the questions on the requirements.
• Work closely with the IT Leads of the client and business colleagues in the design, build and execution of Proof of Concept (PoC) projects across multiple clients and therapy areas, including,
• Designing and leading planning workshops between Client and our external partners
• Clarity of the problem statement and the assumptions to test through the PoC project
• Identification and understanding of the target customer/patient

Business Analyst

Confidential

Responsibilities:

• Responsible for using operational and functional systems knowledge to develop business requirements.
• Conducted and documented business case feasibility analyses.
• Developed and approved business and vendor requirements for stakeholders, user groups and vendors.
• Performed User Acceptance Testing for hospital claims, developed the UAT test grid - The claims were paper UB92 format as well as electronic. Extracted the following data:
• Procedure code - if the procedure code is given as a description, convert the service description into a CPT4 code.
• Revenue codes - familiar with all hospital related revenue codes, ICD10 and ICD9 diagnosis codes
• Patient control number, medical record number, Admission/discharge date, DRG# Patient's name and information, Patient's Identification number, Provider number
• Type of bill, Total Charges, etc.
• Reviewed the group's benefits to determine the processing of the claim, including:
• Deductible amount taken
• Copay and Coinsurance amount
• Maximum number of units for a service
• Documented the expected results
• Developed cost benefit analyses and risk assessment management plans during business requirements phases.
• Developed and maintained project management documentation for assigned projects.
• Defined work breakdown analyses and schedules.
• Created and tracked project budgets.
• Evaluated and recommended technical solutions in support of product, application, and services strategies.
• Verified environmental readiness for client server and integrated multiple vendors between National Processing System modules.
• Evaluated technical log issues during Construction Phases.
• Managed stakeholders in testing, implementation, and issue resolution.
• Provided functional interpretation of product, application and services.
• Developed Plan readiness assessment criteria during User Acceptance Phases.
• Managed day-to-day vendor relationships.
• Developed and submitted project status reports to the Director and customers.
• Conducted informal coaching activities with less experienced NASCO associates.
• Performed Benefact Testing and Test Grid preparations.
• Performed EDI 835I and 835P transmissions.
• Documented and received requests using ClearQuest.
• Excellent knowledge in Pharma and Healthcare as Business Analyst. Understand payor and PBM system.
• Good to have understanding on Patient assistance program
• Experience in understanding the client business needs and convert them as the business requirements in Pharma & Healthcare.
• Connect & discuss with clients of the client and understand the business need and convert them into business requirements and functional requirements.
• Closely work with Development & Testing teams to clarify the questions on the requirements.
• Work closely with the IT Leads of the client and business colleagues in the design, build and execution of Proof of Concept (PoC) projects across multiple clients and therapy areas, including,
• Designing and leading planning workshops between Client and our external partners
• Clarity of the problem statement and the assumptions to test through the PoC project
• Identification and understanding of the target customer/patient