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Operations Business Analyst (ba) Resume

Virginia Beach, VA

SUMMARY

Healthcare Professional with more than ten (10) years experience in Healthcare Delivery Systems and Operations, Managed Care and the Healthcare Revenue Cycle. Goal and results - oriented leader who has served on several State Government MMIS and ICD-10 project implementations.

PROFESSIONAL EXPERIENCE

Confidential, Atlanta, GA

ICD-10 Implementation Analyst (Consultant)

  • Analyst with the State of Georgia DCH client and HP vendor in the conversion of the federally mandated ICD-9 to ICD-10 code sets;
  • Assist in Policy enhancements for Georgia Medicaid edits and audits for ICD-10;
  • Maintain the Requirements Traceability Claims Edits/Audits, Ancillary and Testing matrices;
  • Maintain business requirements documentation for utilization by the fiscal agent; and
  • Manage the testing effort for functional areas to ensure Requirements and Change Orders are successfully implemented;
  • Develop and execute testing strategies, plans, scenarios and test cases for UAT.

Confidential, Virginia Beach, VA

Operations Business Analyst (BA)

  • Principal BA for requirements gathering, analysis and process data flow for assigned Medicare markets and corporate projects;
  • Responsible for the Medicare Advantage Plan (MAP) covering seven (7) markets and the Provider Data Management department;
  • Liaison for Medicare Operations and Health Plan and other cross functional resources and departments;
  • Drafted and maintained Plan Benefit, Pricing, Claims and Enrollment requirements documents for all MAP markets;
  • Created and maintained the CMS annual Benefit Summaries in the Trizetto Facets system for Health Plan and call center utilization and scripting;
  • Initiated, tracked and completed Requirements Change Documents (RCD) for requirements and configuration updates;
  • Utilized Citrix ClearQuest system software for querying, benefit and Amerigroup configuration change requests (ACCRs);
  • Facilitated weekly CMS Medicare Learning Network (MLN) learning sessions, as well as, project status meetings; and
  • Monitor all CMS Medicare Compliance regulatory alerts for Health Plan Services (HPS) benefit and configuration updates.

Confidential, Tallahassee, FL

Business Services Analyst, Operations

  • Managed the daily operations of the Medicare Dual Eligibles department;
  • Audited program operations to ensure compliance of CMS and State policy and regulations;
  • Reviewed Medicare & Medicaid dual eligibility policy for claims adjudication;
  • Consulting liaison between the State and external clients including CMS, SSA, and the RRB;
  • Developed and implemented the Quality Assurance initiative to ensure the integrity of the State program and financials;
  • Defined and implemented strategic plans and process improvement strategies;
  • Facilitated program training and development to staff, internal and external clients; and
  • Consultant with the Georgia MMIS implementation project.

Business Services Analyst, Systems Implementation

  • Served as a Business Analyst during the Medicaid SDLC implementation;
  • Subject matter expert for Medicare Buy-In;
  • Conducted client meetings to gather and implement system requirements and recommendations;
  • Effectively collaborated with client and TFAL to document and implement system specifications;
  • Performed testing and UAT for the HP InterChange system testing and production environments;
  • Initiated system changes and tasks utilizing the Florida Interactive Portal (FIP), Information Tracking Repository Portal (iTrace) and SharePoint application tools; and
  • Streamlined position into operational role.

Confidential, Thomasville, GA

Billing/Collections Specialist - Revenue Management

  • Audited claims and billing accounts and performed collections from commercial insurance agencies;
  • Worked denial Management claims to identify trends and process improvement areas;
  • Reviewed managed care contracts for claims adjudication and coordinated collections activities;
  • Trained registration and billing staff on billing policy initiatives;
  • Developed financial data reports for RMD and corporate reporting; and
  • Credentialed 800-bed hospital network system for Georgia Medicaid CMO contracts.

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