SUMMARY:

• Develop Requirements Approach for handling complex project requirements for multiple health plans(9)
• Manage all project information using Joint Requirements Document.
• Complete complex research and analysis of State legislations to get necessary information for requirements gathering processes
• Create Proof of Concept and Statement of Work documentation for project initiation
• Elicit requirements using documents analysis, conference calls, and onsite meetings including: Health Plan/ Corporate Leadership, SMEs, IT, and Project Managers
• Create applicable visuals for decision making and requirements tracking including: Power Points, Visio workflows, and Excel Documents
• Elicit requirements for large, highly complex, Enterprise - wide project consisting of multiple focus points for teh 9 Molina Health Plans in scope. (File processing, User Interface Application, and Inbound/Outbound Claims and Encounters systemic validations)
• Author and maintain multiple Business Requirement Documents for complex Enterprise-wide project
• Create specifications for reports based on business needs and required or available data elements.
• Create Requirements Traceability Matrix to track requirements for testing and implementation
• Collaborate wif key stakeholders from other Corporate projects to ensure seamless integration across projects
• Add input during all stages of project develop including design, development, testing, and implementation to ensure end product meets teh intended requirements as defined.
• Use LEAN Methodology to analyze Benefit Configuration, Provider Contract Configuration, and Fee schedule processes to create an Enterprise-wide end-to-end Standardized Benefit and Provider Contract Configuration process flow
• Developed SOP to accompany teh Standardized Benefit and Provider Contract Configuration process flow
• Produced applicable project visuals as needed: Power Point Presentations, Visio Workflows, and photos
• Collaborate wif multiple Molina Health Plans in order to implement new process: gap analysis, status meetings, and strategy meetings as needed
• Interact wif all levels of leadership wifin teh organization Present project findings, updates, best practices, and results as needed
• Attended and presented at teh COO Summit - April 2016
• Served as Lead Consulting Business Analyst for Provider Match Logic project

TECHNICAL SKILLS:

SYSTEMS:

Microsoft Office Suite(Excel, Word, Power Point, Visio, Sharepoint, Internet Explorer) / QNXT/ Power MHS / Echo / Medco / Business Objects / Network Provider Management System(McKesson) / Siebel / MaxMC / Legacy System / Rightfax Util / IPD-DocRequest FileNet and workflow / MACESS / AMYSIS / Planview / McKesson Claim Check / NPI Translation System / Mobius / Blue E /Lawson / Provider Contract Management System(Portico) / Blue Squared / Workday

SKILLS:

Meeting facilitation / presentation development and elicitation / Customer Service / call center / training / workflow / administrative work / process development / problem solving / project planning / office and meeting organization / medical claims coding / training course development / team building / fast learner / multi-tasker / leadership skills / effective communicator(all forms) / HIPAA / motivated / takes initiative / decision maker / team player / easily adapts to change / determined

PROFESSIONAL EXPERIENCE:

Provider Information Analyst/Business analyst

Responsibilities:

• Analyze and process provider/hospital/ancillary application data efficiently based on priority and time management for Network participation, claims filing, and directory printing
• Research validity of Provider Credentials (education, license, NPI, Tax ID)
• Data configuration in multiple systems wif high quality and data accuracy
• Quality Analysis Review for internal and external audits
• Analyze user requirements and software requirement specification documents
• Maintain data based on reports/queries for quality control - daily / weekly / monthly
• Medical claims research - denials, hold codes, CPT codes, HCPCS, and ICD-9
• Interact wif claims department using Macess and IPD Suite/FileNet workflow management to correct claim errors
• Contract review and processing for Network Management in DocRequest/FileNet document storage and Portico PCMS
• Carolina Healthcare Systems (CHS) and Duke Health System stakeholder provider and group system management
• Trainer for various courses - class sizes ranging 1 -15+
• Create - presentations for internal and external training/JOC’s SOPs / desktop procedures / user guides / training manual / job aids
• Testing(UAT) for new systems and/or procedures prior to department usage
• SME(Subject Matter Expert) on provider data (enrollment, credentialing, contracting, claims)
• Assist IT Team wif system clean up and data validation
• Business requirements and functional requirements gathering- individual interviews / team meetings
• Translate requirements-process mapping/ workflow diagramming/ LEAN Six Sigma
• Complete Deliverables- update teh business processes and complete system documentation
• Assist on various Business Process Projects including for new procedures and new software

Project Team Projects

• Methodologies: Custom BCBSNC, Waterfall
• Perform existing environment assessments - employee shadowing
• Assist wif stakeholder meetings
• Business requirements gathering
• Complete deliverables - working wif technical testers, writing training documents, creating training course
• Data validation after development
• User Acceptance Testing

Provider Education Team Service Professional:

• Provider Services for all Lines of Business(LOB) ASO / Commercial / Individual / Inter-Plan(Blue Card) / Medicare following HIPAA guidelines
• Call Center wif first contact problem resolution including Third-Party Billers
• Claims Research / Adjustment / Medical Records coding review / Coordination of Benefits
• Inbound Correspondence processing using FileNet Document Storage
• Accounting management - Accounts Payable and Receivable research / EFT enrollment / insurance premiums billing & payments / HSA enrollment / Voucher Deductions in Lawson and DocRequest/ FileNet
• Benefit management and enrollment including Open Enrollment
• Web Support for My Member Services / Blue E / EDI
• Data analysis - system errors / claim denials / error trends
• Onsite state-wide provider visits
• Host workshops at Annual Provider Conferences - average size 20+ provider offices’
• Help Desk for Customer Service Professionals
• Subject Matter Expert(SME) for Accounting Management and Service Professionals