SUMMARY:

• Serve as an EDI expert on ALL HIPAA 5010 EDI transactions. Work on project management documentation (Charters, BRD, FRD, TDD, TRD, 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.
• Project Management of EDI staff and business processes, responsibility for formal project specifications and project status reporting, personnel work assignments. Assist with system design overview and database requirements. Work with and between trading partners, clients, management, technical and non - technical personnel to define issues and identify solutions. HIPAA EDI resource person (segments, elements, loops, etc.), negotiate with Trading Partners, work on legal issues with corp. attorneys, perform vendor selection.
• 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.
• 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. Create EDI Testing process, documentation, and performance matrices.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.

TECHNICAL SKILLS:

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, Disaster Recovery Planning and trouble ticket software, SAP version 4.6, meetings and conferences (speaker), client and employee training.

Programming Languages: Visual Basic, C.

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.

EXPERIENCE:

Confidential, Phoenix

Senior HIPAA 5010 EDI BA

• Build Requirements documents for 5010 EDI transactions: 278 Prior Authorization.
• Serve as 5010 EDI SME
• Work with programming staff to resolve any requirements issues
• Participate in JAD/Scrum meetings with client and United Health Care, to identify and/or resolve EDI questions, concerns or opportunities, around the web-based 278 PA application.

Confidential, Melbourne, FL\

Senior HIPAA 5010 EDI BA / ICD-10

• 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, Phoenix, AZ

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, Oklahoma City, OK

Senior HIPAA 5010 EDI Business Analyst

• 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 Reivews.
• 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, Providence, RI

Senior EDI Business Analyst

• 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, Phoenix, AZ

HIPAA EDI Business Analyst and DB Consultant

• 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. Fillmore, IN

EDI PM / BA Consultant

• 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.
• 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.
• Inventory and Disaster Recovery for ROCHE; SAP EDI work for Merisel (CA).
• 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.
• 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.
• 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.
• 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 Confidential Association’s committee for launching the 837 (while working for BCBS/GA).
• 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 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.
• 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.
• Remittance automation has also been performed. Multiple Trading Partners were set up as well. Vendors were assisted in EDI interfaces.
• 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.
• HIPAA EDI specialist, HIPAA EDI Business Analyst, EDI Project Leader, systems designer and developer, Client Representative, Conference Speaker, corp. technical trainer.
• Legacy System integration conversions were created. Imports were created to take data from existing systems and convert & import data to new systems.
• 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 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.
• 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, Indianapolis, IN

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, Indianapolis, IN

DP manager

• Note: Confidential went through a buy-out or merger process that laid off technical personnel; Confidential was an interim solution until re-employment with the same Vice President that had moved from Confidential to Confidential, 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

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, Indianapolis, IN

Programmer Analyst

• C programming and training was done for staff and 12 other client Confidential 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 United States.