OBJECTIVE:

EDI Tester Six Sigma, EDI project specifications X12, HIPAA, NCPDP , Business Requirements, Use Cases, Confidential, EDI Trouble Shooting

SKILLS:

• HIPAA 5010 EDI Tester: Serve as an EDI expert on ALL HIPAA 5010 EDI transactions. Work on Test Plan and Test / Use Cases, Validation . Also serve as an EDI problem solver, to identify problems in EDI files. Design and document Business Requirements by using HIPAA EDI guides and reviewing or interviewing business process owners and companion guides. Produce Test or Use Case requirements and produce HIPAA 5010 EDI Test data as well. Skill level includes: 270/271, 276/277, 278/278, 820, 271U, 834, 835, 837ip d, 275, 824.
• ICD-10 Testing: Lead Testing for ICD-10 projects, SIT, UAT, Regression test script building and Test Plan development. Other, higher-level projects included Project Costing models for Project Resources.
• EDI Test Management: Skilled a building Test Plans from stakeholder interviews, including scope, deliverables, validation criteria, test data development, test cycle definition and schedule.
• Six Sigma: Utilize Six Sigma's DMAIC approach to data-driven project analysis. Recognize, Define, Measure, Analyze, Improve, Control, Realize . Apply six sigma principals to project, including analysis, reporting and performance matrix.
• EDI Validation: Personally responsible for attaining HIPAA EDI validation from Medicare, Medicaid, and other payers or government carriers. Developed HIPAA EDI Transmissions for both government carriers and commercial entities. Work includes complete business cycle management and hands-on production as well ETL methodologies for data mining and testing. Create EDI Testing process, documentation, and performance matrices.
• HIPAA Resource: Completed several HIPAA Projects, leading a number of HIPAA projects for Medicaid Plans, large insurance companies, clearinghouses, and healthcare providers. Companion Guides, legacy system integration, HIPAA code set resolution and payment posting projects, including Claims, Eligibility, Claim Status, Remittance, COB, Explanation Of Benefits EOB or EOP , Enrollment and other healthcare IT projects. Work with government carriers and payers to support the provider community, including Institutional, Professional, Dental, and specialty work such as Encounter transmissions, Secondary Payers, and Cross-Over billing. Includes Medicaid MCC / MCO and Medicaid Management Information System MMIS work: 837 and 824 system design.
• EDIFECS, Spec Builder: Knowledgeable in use of EDIFECS tools, including EDI analysis and Companion Guide tools. This includes EDIFECS Spec Builder and HIPAA 5010 EDI raw data analysis all HIPAA Transactions.
• EDI Department Designs. Skills utilized: Project Scope determination corporate interviews to determine the scope of project. Work Flow, WBS Work Break-Down Structure Trading Partner Selection: Hardware, software, and vendor services are determined after appropriate interviews. Development of Job descriptions, documented in detail, including skills needs, desired experience, and a general description of costs. Production phases are documented as well as a test plan for deployment.
• Trading Partner / Vendor Management: Manage the requirements and selection for Trading Partners and Vendors. Schedule conferences, JAD sessions, participate in negotiations, set/create/resolve EDI TP issues and create legal draft points for corporate attorneys.
• Gap analysis and Market Research: Trading partner assessment as well as corporate readiness for EDI production. Industry knowledge sharing to assist in long-term goals. Gap analysis skills developed from several EDI healthcare projects, spanning many years. DMAIC processes used to identify changes as-is and to-be status for six sigma , which was kept projects within the corp. objectives both financially and objectively.
• Technical Specification Creation for EDI. Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 278/278, 820, 834, 271U, 835, 837- I,P, D , 835 Remittances and others. Resource for UB04 and CMS1500 billing formats, transaction sets requirements, EDI development and Design, X12 protocols through Version 5010 and Errata conversion needs and understanding of legacy EDI formats.
• Unix, DOS and Windows Operating Systems: End User Knowledge of OS navigation for Unix, DOS and Windows platforms.
• Communications and Security knowledge: Work with vendors to set up electronic communications and clearinghouse communications, including protocols such as Frame Relay, FTP, Dial-up, Web Solutions, and others. Encryption software was also selected and tested, including SSL, PGP, and encryption keys, both public and private.
• Use cases, test plan creation and Companion Guide development: Development or oversee others in developing EDI Specifications, Test plans and/or companion guides for the 837 Institutional, 837 Professional, 837 Dental, Confidential, others. Test plan design, from stage to production, including both internal and external requirements. Companion guides and crosswalks were developed using Excel. Insurance and clearinghouse entities were consulted to insure proper integration and compliance, research done on segments and elements and composites. Mapping staff were instructed on EDI issues and management was made aware of systems issues, status, and progress.
• Research and Reporting for upper-level management : Interview stakeholders, create and maintain reporting and milestones for upper management. Work on MS Project to create Project Plans, Participate in corporate meetings to resolve issues and present solutions. Identify resources needed for special projects.
• RUP, Rational Unified Process: Inception phase-define scope elaboration phase-analyze needs construction phase-create product/source code transition phase-delivery, installation and user sign offs.
• DMAIC / Six Sigma: Six Sigma practices are used as they related to business analyst and project documentation and project development. Other similar processes, such as SDLC are incorporated into project documentation and development practices.
• Disaster recovery plans. Experienced in creating Disaster Recovery plans, including hot and cold off-site Recovery Procedures and validation processes. Design problem escalation parameters. Work with third party vendors to arrange appropriate communication and data transfer for operation set-up in the event of a disaster.

Management Tools / Skills:

• Microsoft Project, Microsoft Office, MS Word, MS Excel, Power Point, Visio, Access, custom Project Management tools, Test Management tools, such as Test Director, Validation Testing tools such as CLAREDI, SOAP XML tool, SOAPUI, Disaster Recovery Planning and trouble ticket software, SAP version 4.6, meetings and conferences speaker , client and employee training.
• Use of the following management methodologies: PMM: Project Management Methodologies, Six Sigma methodologies DMAIC . Work with Sarbanes-Oxley requirements SOX to resolve regulatory requirements. Registered with PMI, preparing to take the newest PMBOK PMP Certification test.
• Project Management has been a regular requirement of resent and past projects.
• Database work: Microsoft Access, Table File Design, Data importing for Databases, SQL commands to access the databases.

Project work performed in conjunction with EDI tools:

• EDIFECS SpecBuilder 6.1, Mercator Event Server, Mercator Message Manager, Sterling Software Gentran, custom EDI transmission development in Visual Basic, EDI testing with CLAREDI, St. Paul's Software, Advantis and other VANs.
• Certifications: Validated State and Federal HIPAA EDI Vendor, personally. I ran my own HIPAA EDI software shop from 1997 to 2006. I am published in Medical Billing Manuals See Author s from Alfred State, included in a number of healthcare and billing publications. I own UB04-to-5010837i and CMS1500-to-5010-837p software XML-to-835 software EDI viewers and other HIPAA EDI tools and advanced project processes, to reduce project time lines while increasing project accuracy at the same time I also train on HIPAA EDI transactions.

EXPERIENCE:

Confidential

ICD-10 Project: Test Manager.

• Develop Test Plan for ICD-10 Project
• Establish milestones and timelines for ICD-10 Testing Phases SIT, UAT, Regression
• Review and implement ETL Extraction, Transformation and Loading process for data preparation
• Identify HIPAA EDI Transaction elements impacted by the ICD-10 mandate
• Work with Trading Partners, both Clearinghouses and Providers, to set up testing
• Serve as SME for project documentation: Project Plans, Business Requirements, Functional Requirements, Test Plan, Test Cases / Scripts.
• Maintain Requirements traceability matrix database and status reporting
• Train other BA's and Testers on the requirements building and testing processes

Confidential

ACA Enrollment / HIPAA 834: Technical and Business Analyst.

• Create and validate business rules for Enrollment.
• Provider leadership for team as an EDI SME
• Create flow diagrams and other Business project documents, typically using MS word, Excel and Visio
• Automate Testing. Create auto-validation processes.
• Work with trading partners to resolve issues. Assume lead when necessary.
• Create HIPAA 5010 EDI files
• Validate 5010 834 Transaction
• Validate 5010 999 Transaction
• Create SOAPUI / XML files

Confidential

• RFP and EFT/ERA - HIPAA 5010 EDI PM and EDI SME Provider Remittance and Web Portal RFP
• Create RFP for Vendors to bid on HIPAA 5010 EFT/ERA Remittance and Web Portal Application
• Serve as PM for EFT/ERA HIPAA 5010 835 RFP
• CAQH CORE and Meaningful Use Requirements were defined, outlined and implemented.
• Serve as SME for BRD and UAT for both IT and Business areas
• Develop UAT Test Plan and create initial UAT Test cases and structure
• Hold Team Meetings, SME meetings, Stakeholder Meetings, Vendor Meetings
• Serve as the team guide and functional project owner

Confidential

Senior HIPAA 5010 EDI PM 834 Enrollment

• Build Requirements documents for 5010 EDI transactions: 834 - Enrollment
• Serve as 5010 EDI SME
• Develop 5010 834 Requirements and enrollment and application conversion
• Mentor State Team on Best Practices for Project Documentation and HIPAA 5010 EDI standards

Confidential

Senior HIPAA 5010 EDI BA / SME 278 Prior Authorization / Review

• Build Requirements documents for 5010 EDI transactions: 278 Health Care Services Review
• Serve as 5010 EDI SME
• Develop 5010 278 Requirements
• Build Test Cases for the On-Line Web Portal Application for Prior Authorization HIPAA 278
• Interface with Programmers, during build / test phase

Confidential

Senior HIPAA 5010 EDI BA / ICD-10 Resource Assessment/Financial Analysis

• Build Requirements documents for 5010 EDI transactions: 837i, 837p, 834, 820.
• Serve as 5010 EDI SME
• Develop ICD-10 documentation for ICD-10 related resource requirements.

Confidential

Program Manager

• Oversee Requirements and Gap review for ICD-10
• Review Project Progresses of Project Managers working around the ICD-10 project
• Responsible for auditing off-shore team selection
• Build job descriptions, financials, and ramp-up/ramp-down models for multi-million dollar ICD-10 project
• Work with Integration Teams on related projects such as EHR and HIPAA 5010 projects
• Review Testing Approach for ICD-9 to ICD-10, including mapping rules and issues

Confidential

Senior HIPAA 5010 EDI Business Analyst for HIPAA 5010 Project.

• Note: Sept. 2011 Dec. 2011 was part time/off hours as I had moved to a 5010/ICD-10 project in FL.
• Develop Business Requirements for all 5010 EDI transactions: 270, 270, 276, 277, 278, 820, 834, 835, 837i, 837p, and 837d and unsolicited transactions 271U, 277U .
• NCPDP, D.0 upgrade project work.
• ICD-10 assessment: Work on ICD-10 issues as they relate to the 5010 project. Prepare assessments and overview of ICD-10 requirements.
• Develop Gap and Impact documentation for all HIPAA EDI transactions.
• Work with Sharepoint, existing legacy documentation and WPC Implementation Documents and Client Companion Guides to complete a set of Business Requirement and System Requirement Specification documents, in preparation for HIPAA 5010 Peer Reviews.
• Create PMO documentation from scratch.
• Organize the 5010 project, including timelines, project plans, BRD, FRD, SRS and other templates.
• Work with Fiscal agent and stake holders to resolve interface issues.
• Setup reoccurring HIPAA 5010 and/or JAD sessions to review both physical and logical models for business processes and data transaction processing and adjudication processes.
• Serve as a lead and information source for HIPAA 5010 details and related tools and best business practices.

Confidential

Senior EDI Business Analyst for HIPAA 5010 Software Project.

• Develop Business and Technical Requirements for HIPAA 5010 EDI software, including the HIPAA 5010 837 Institutional and the HIPAA 5010 837 professional transmissions.
• Develop Use Cases for the UB04-to-5010-837i transaction.
• Develop Use Cases for the CMS1500-to-837P transaction.
• Utilize Claredi web validation tool to validate software product to all 7 levels of HIPAA compliance.
• Design logical and physical documentation for the XML-to-5010-835 conversion and web clearinghouse.
• Complete testing and bring software product to live status.

Confidential

Senior EDI Business Analyst for HIPAA 5010 Project.

• Develop Business Requirements for all 5010 EDI transactions: 270, 270, 276, 277, 278, 820, 834, 835, 837i, 837p, and 837d.
• Work with WPC Gap documents, WPC Implementation Documents and Client Companion Guides to provide a map and crosswalk for ALL 4010A1 to 5010 and Errata EDI projects.
• Oversee a team of Business Analysts and work with technical teams to produce business and technical requirements.
• Serve as a lead SME for all EDI-related projects.
• Automate the WPC to BRD documentation process by converting PDF's to MS Word documents. Provide documentation standards. This saved months of labor while enhancing document accuracies.
• Meet with management regarding EDI issues.
• Produce 837 test data. As a validated Federal EDI Vendor, I also have UB04 to 5010 and CMS1500 to 5010 software for test or live production. Type claim data into claim-form screens and output 5010 837 transactions.
• Work on Test/Use Case designs.

Confidential

HIPAA EDI Business Analyst and DB Consultant for NPI Project.

• Work Description: Design and create NPI de-duping process. Responsible for MCC/MCO flat file validation and testing. Define 837 I/P/D errors for all MCC / MCO entities.
• Create compliant HIPAA 837 EDI Transactions for Technical Vendor Testing Purposes:
• Encounter transmissions, 837 institutional and professional.
• COBA transmissions, 837 institutional and professional.
• Standard 837 transactions for professional and institutional EDI validation.
• Develop data importing processes for EDI files.
• Create reporting and custom applications for analyzing flat files as well as HIPAA EDI files.
• Maintain NPI and NPPES database.
• Work on NCPDP files and compliance requirements.
• Produce EDI Testing environments for HIPAA EDI transactions.
• Business Analyst Functions: Produce and maintain all vendor performance matrices and reporting, including details numerical analysis. Create project documentation. Define and suggest needed improvements to management.

Confidential

EDI PM / BA Consultant

• BA work for HIPAA TCS: Develop Mapping rules, Design specifications, and Test Case / Use Cases for the HIPAA 837i/p/d 270/271, 276/277, 835, 824, 275 and others. Worked on multiple 837s and multiple Eligibility 270/271 and healthcare claim status 276/277 . Create EOB systems 835 . While in-house , help with development. While on-site, work as a business analyst. These projects span several Insurance Payers, Carriers, and providers, working with and for each of these, typically in an EDI Business Analyst roll.
• MMIS work for Medicaid Carrier: Created the complete 824 to 837 indexing system for ACS in Hawaii. Worked as an EDI Coordinator, working with Trading Partners / Providers. Worked on and initiated changes to Medicaid EDI rules, specifically the Coordination of Benefits processes. Worked on the MMIS system, doing EDI claim testing and EDI processing functions.
• SAP 4.6, Inventory and Disaster Recovery for ROCHE SAP EDI work for Merisel Confidential .
• Business Designs for EDI Departments: Consulting work included corporate interviews to determine the scope of project. Existing legacy systems were examined and personnel with ownership responsibilities were interviewed. A design of how the newly created EDI department would function was put together in Visio type flow charting. Job description and skills needed were documented separately. Launch plan created with appropriate stage and production plans was documented. Reviews and corporate meetings were held to discuss issues.
• Responsibility/accountability: On consulting projects, generally manage or lead 3-8 technical or business personnel. On in-house projects, responsible for HIPAA EDI from start to finish. Participate in both pre and post client interface to insure projects roll out smoothly. Serve as a representative and contact person.
• Technical Tools: EDI and Billing Systems were created with Visual Basic, Sterling Software, Microsoft C. Some Gentran and Mercator work. Windows and user-level Unix operating systems. SQL commands were used to manipulate databases. Used EDISM while working 6-month contract with Magellan, for specifications only.
• Accreditations: HIPAA-approved by carrier status was attained for proprietary Medical EDI systems. Received letters of validation from both Medicare and Medicaid. Listed on the Federal Government's list of approved validated Medicare Vendors list. Sat on the Blue Cross Blue Shield Association's committee for launching the 837 while working for BCBS/ Confidential .
• Common EDI work performed: X12 specifications were developed, issues were addressed EDI, security, HIPAA, NPI , X12 version design. Some automation tools and/or scripts were created. EDI systems were evaluated. EDI setup work was performed for Client site, administrative tasks, including personnel and cost estimates were created. Transaction sets included UB92 Versions 4, 5 and 6 X12 270/271, 276/277, 278, 837 I,P D , 810's, 850's, 864's, and 997's. More recent work includes UB04 and review of upcoming 5010 EDI versions.
• Internet work: Internet Domains and HTML and Java Script were developed. Internet software included Microsoft's Front Page. Communication protocols were suggested, including FTP, modem, Frame Relay, Virtual Private Networks, Internet. Encryption options were also evaluated and/or setup, including PGP, SSL, and others.
• Security work: Create processes to protect PHI Protected Health Information for HIPAA compliance. NPP Notice of Privacy Practices was researched and protocols were created for sending NPP's to patients and users of PHI.
• Outbound and Vendor work: Remittance automation has also been performed. Multiple Trading Partners were set up as well. Vendors were assisted in EDI interfaces.
• Project Scopes: EDI systems were created for both large and small critical medical and/or insurance corporations. Projects also have included Billers, Payers, and both institutional and professional providers.
• Roles: HIPAA EDI specialist, HIPAA EDI Business Analyst, EDI Project Leader, systems designer and developer, Client Representative, Conference Speaker, corp. technical trainer.
• Data Conversions and Computer Interfacing: Legacy System integration conversions were created. Imports were created to take data from existing systems and convert import data to new systems.
• Visual Basis work: Custom reports were done in Visual Basic. Visual Basic functions used included data grids, VB modules for customized functions, and direct file I/O for custom VB functions.
• Database and file format work: Database systems were developed using Visual Basic and Access with SQL commands to access the Tables in the database. XML software was created to produce XML documents for information distribution. XML standards were defined. Clients have used a wide variety of databases, including Oracle, SQL Server, Access and others.
• Classes taken: 2001: IBM classes were taken in UNIX basics and Korn Shell scripting. Mercator Event Server and Message Manager Classes were taken in 2001 as well.

Confidential

Project leader.

EDI transmissions were created in both Microsoft C and other EDI transmissions were created in Sterling Software's Gentran product. Both were used in production and maintained. Worked with Trading Partners and flew out to site for installation. Determined parameters for best up-time for the EDI for this home-infusion health company.

Confidential

DP manager

• Note: Nationwide Care went through a buy-out or merger process that laid off technical personnel J.F. Malloy was an interim solution until re-employment with the same Vice President that had moved from Nationwide Care to Quantum Health Resources, who tendered the offer.
• Conversion programs and hardware work. Set up telecommunication software and hardware for telecommuting work at home employees. Worked with virus control software to protect systems. Ordered hardware systems and updates to maintain corporate systems. Helped to resolve Windows issues.

Confidential

Software Engineer

Cross-Platform Conversion programs for Multi-platform software. This company was a Nationwide Nursing Home acquisition company. Systems conversions were written in C to convert and or automate the production flow of data.

Confidential

Software professor

Taught the Macintosh operating system for students In Michigan Public School system - this was a Special short-term interim course. Daily projects and assignments as well as course objectives were set. Students were assisted in various stages of their work assignments.

Confidential

Lead Programmer

• Paperless billing software was created and maintained. C programming, Supervising, Research and Development were performed.
• Key problem resolution for Data Importing from all platforms for the EDI Medical Billing products and services.
• Hardware included mainly micro computers also used were Xenix, and RISC 6000. Files were interfaced from Mainframes, Mini's, and Micro computers.
• Communication scripts were written in ProComm Plus and PC anywhere.
• Mainframe upload software was also written.
• Medical paperless billing software was the main focus.
• This involved all client hospitals and physicians and their UB92 and HCFA1500 billing forms.

Confidential

Programmer Analyst

• C programming and training was done for staff and 12 other client Blue Cross and Blue Shield plans.
• Work orders were created for the programming staff. Cost estimates were created.
• Quality control, check lists, and manuals were created and maintained.
• Software research, process automation, and documentation were created. Data Importing was programmed for these EDI Healthcare Billing Systems.
• Computer programming for hospital billing was performed using Microsoft C.
• Hardware used included IBM compatibles and LAN networks such as Novell and Corvus.
• Database used: Rbase. Utilities: Norton Utilities, Brief.
• Job cost estimates and purchase orders were coordinated for billing.
• Technical support was maintained. Production was coordinated with Blue Cross plans throughout the Confidential.