PROFESSIONAL OBJECTIVE:

To secure a lead role in an innovative and thriving company that rewards over 21 years of diverse experience in the Healthcare Insurance industry

PROFESSIONAL SUMMARY:

Over 21+ years of experience in claims and customer service, experience in information technology across several healthcare companies, having played key roles in business analysis, testing software design, software development, training, implementation of online systems, organizational assessments and support of business solutions, self - starter with solid multi-faceted experience on QNXT/Facets online Systems. Effective in analyzing root cause issues, such as Project Management Office, Sr. Business Analyst, Business Analyst/Testing Lead Provider Configuration Analyst System Configuration Analyst, Quality Assurance Analyst Service Consultant/Claims Benefit Specialist, Benefit Specialist and Claim Examiner III, in the growing healthcare industry of the United States.

SYSTEMS/TOOLS:

• Facets4.6
• ACAS
• Xcelys
• QNXT
• P2
• IKAclaims
• QMACS
• XCELYS
• IDX
• RIMS
• REVA
• MS OFC
• ICES
• MDE
• Trailblazer iCRM
• HSS
• ATU iFile
• Citrix
• CCA
• MHC iCRM
• Blue Chip
• Macess
• Outlook
• Webstrat
• Winstrat
• CTP
• Bugzero
• Red Gate
• Sharepoint
• Ingenix
• Encoder Plus
• CMS
• Sprinter
• Windows OS
• Lotus Notes
• Claimcheck
• Concur
• Team Track
• NNPES
• Noridian
• Access
• Excel
• Micro-Dyn
• Office Ally
• Health eConnex
• 3M Core Pricer

PROFESSIONAL EMPLOYMENT HISTORY:

Configuration Analyst

Confidential, Des Plaines, IL

Responsibilities:

• Responsible for Customization of Mckesson/Claimcheck
• Resolved ServiceNow SLA tickets regarding Configuration issues such as Benefit Restriction Group Validation Failed edits
• Responsible for Benefit and Provider Contract Configurations
• Responsible for validating Service Groups coding within Benefit Plan
• Maintained Benefit Crosswalk with new Employer Group/Plans
• Write test scenarios and executed for new plans, contracts, benefits, changes in DOFR.
• Updated CMS fee schedules for 2017
• Responsible for configuring Program Rules to satisfy business practices
• Responsible for pulling daily reports for Aging Claims

Tools: Optum360, ServiceNow, Citrix Application, Confidential Portals, Webex Facilitate, train and created Templates for Authorization

Confidential

Configuration Analyst

Responsibilities:

• Assessment of Confidential System following up with Trizetto service request where needed
• Configuration Module Assessments using Collapse the table of content
• Expand the table of content
• This documentation is archived and is not being maintained.
• This documentation is archived and is not being maintained.
• Image Configuration Editor (ICE) User Review the user interface of Image Configuration Editor (ICE).
• Advisor of configuration
• EDI Provider Reject Assessments (837I and 837P)
• Provider Set-up
• Contract Term Validation
• Benefit Set-up Validation
• Member/Eligibility/ Setup Processes
• Utilization Management (CCA) Authorizations
• Sponsor/OrgPolicy Processes
• Claims Reimbursement (UCR, RBRVS, CSR, MODIFIERS)
• Plan Relationships set-up (Products/LOB)

Confidential, CA

Configuration Analyst

Responsibilities:

• Member Eligibility Module configuration of information regarding member's eligibility organization, health plan, rider, and restriction history, date sensitive enrollment segments.
• Manage member changes, eligibility organizations, health plans, rate codes, or coverage types, existing enrollment segment Termination and new enrollment segment
• Enter Rate Codes into Policy Administrator Module
• Review requirements, specifications, testing plans, support documents
• Train team to ensure business’ objectives.

Confidential, CA

Senior Business Analyst/Consultant

Responsibilities:

• Create BRD for Claims Department
• Facilitate meeting with stakeholders to review BRD
• Gather Roles and Responsibilities from HR to build queues to distribute work via Security Level
• Work closely with IT Project Manager to develop CSP+ Golden Book of procedures

Confidential, CA

Project Management Office/ Consultant

Responsibilities:

• Test Cases have been created based on High Dollar and High Frequency codes identified during the historical data analysis
• Efficient using CTP Tool (Claim Test Pro), Encoder Plus, 3M Core Pricer and CMS Pricers, GEMS Mapping, iCRM
• Testing the conversion from ICD 9 to ICD 10 along with the validation that all LOB’s Benefit
• Processes and in-depth working knowledge of healthcare diagnosis and procedure codes, ICD9 and knowledge of ICD-10 coding, creating claim within CCA (Utilization Management Module) to validate the functionality
• Knowledge of healthcare reimbursement guidelines, policies and procedures.
• Creating ICD 9 CM to ICD 10 CMS/PCS and CPT/HCPCS coding procedures test scripts and test plans per LOBs.
• Train and prepare UAT Team for testing Confidential functional and non-functional processes
• Maintains knowledge of and compliance with established policies and procedures governed through Medicare and Medicaid
• Benefit Requirement Documents (BRD) for Institutional, Professional gathering and documenting requirements and artifacts -facilitating meetings
• Validate Adjustment Claims processes

Confidential, Plano, TX

Sr. Business Analyst/Configuration

Responsibilities:

• Use Case modeling, Word, Excel, VISIO
• Strong skills in Business Analyst Planning and Monitoring
• Reports status, tasks and issue tracking, closure of resolutions of issues found
• Understanding of Regulatory and Regulation of Medicare, Medicare Advantage and Medicaid
• Ability to create test plans and test scripts per the Objectives and Scope of the organization
• Provider/Benefits Configuration Analyst (Ikaclaims)
• Fully trained and Lead Business Analyst, team of 15, on executing and understanding Benefit Summaries and Provider Contracts in Ikaclaims
• Full understanding of Modules within Ikaclaims
• Understand Division of Financial Responsibility
• Understanding Coordination of Benefits

Confidential, Tucson, AZ

Provider Configuration Analyst (Consultant)

Responsibilities:

• Provider Configuration for Medicare and Medicaid in Xcelys (System Implementation)
• SME in Claims/QA/Automated/Manual Testing of Provider Contracts/Benefits

Confidential, Kansas City, KS

Facets Business Analyst/Testing Lead

Responsibilities:

• SME in Claims/QA/Automated/Manual Testing of Provider Contracts/Benefits
• Certified NetworX Integrated Pricer, NetworX Standalone Pricer and NetworX Modeler.
• System Implementation
• Provider Contract Configurations
• Build fee schedules and transfer the data to NetworX Pricer.
• Build rate sheets with code groups and calculations according to hospital, ACS (Alternate Care Services), physician, medical group, ambulance, and behavioral service’s contracts in NetworX Pricer based on the hierarchy rules and process.
• Perform audit on rate sheets that have been built for accuracy.
• Knowledgeable of Medicare and Medicaid Guidelines
• Documenting Agreements in Clear Quest. Configure and create detail test scripts and perform detail unit testing on complex configuration changes. Formulate and define configuration requirements and objectives based on professional and facilities contracts.
• Provide feedback of findings to enhance productivity, to management and perform regression testing to correct templates.
• Benefit Product - VBB testing to ensure accuracy to better serve members with ongoing illness.
• Clear understanding of Medicare and Medicaid, Creating and executing test scripts to validate benefits and Coordination of Benefits
• Configuration Decision Documents

Confidential, Denver, Colorado

Quality Assurance/Tester

Responsibilities:

• System Implementation
• Prepare for Hawaii Implementation of Xcelys
• Created test scripts for Provider contract and Benefits implementation using Maccess.
• Formulate and define configuration requirements and objectives based on professional and facilities contracts and benefit plans.

Confidential, Houston, TX

Quality Assurance/Tester

Responsibilities:

• System Implementation
• Provider Contract and Benefit Requirement Document testing to ensure accuracy in provider configuration reimbursement and benefits configurations concerns in Facets.
• Creating test scripts and executing and providing feedback documentation to verify the Configurator, NetworX and Benefit Configurations
• Documented details of test plans and maintained record.
• Apply benefits from the benefit grid, co-pay, deductible and/or coinsurance and benefit limits per network physicians and facilities, service area, OPP, PCP etc.
• Ability to interpret plan documents (COC, SPD, Schedules, and Riders etc.) to identify configuration requirements
• Ability to provide input on product/benefit design to ensure operational efficiency
• Ability to validate systems administration products/benefits as designed
• Manually applied CPT/HCPCS code pricing logic to verify correct provider reimbursements including validation that iCES configurations.
• Implemented manual tests to ensured quality measures taken for system and applications.
• Documenting defects in ClearQuest
• Assisting in policies and procedure documentation to educate examiners

Confidential, Manhattan, NY

Quality Assurance/Tester

Responsibilities:

• System Implementation of Qcare
• Payer/Risk Adjustment. Performs claims systems testing and/or system analysis to ensure accuracy of the system’s benefit configuration and provider reimbursement and validating Coordination of Benefits. Conducts research and root cause analysis on various claims issues to identify and resolve problem payment and configuration concerns.
• Excellent research and auditing skills with emphasis in healthcare claims; understanding cost containment measures, adjudication processes, ERISA, HIPPA, state mandates and contractual structures
• Knowledgeable of RBRVS, CPT, DRG and HCPCS coding utilized on UB04 and HCFA 1500, Health Care Reform Enhancements, Winstrat, also Webstrat, and the migrating from ICD-9 based HIPAA 4010 to ICD-10 based HIPAA 5010