SUMMARY:

• Working in the HealthCare Industry for 15 years.
• Software professional with more than 8 years of experience in the analysis and testing of business requirements.
• Extensive experience in the insurance domain.
• Well versed in various stages of Software Development Life Cycle (SDLC) - analysis of requirements and testing those requirements.

TECHNICAL SKILLS:

Languages: PL/SQL

Other Tools: Encounter Pro, EDM for Exchanges, Hewlett Packard Agile Manger, Market Prominence, Banner Impact, Center of Excellence (COE), Test Director (TD)QCare

PROFESSIONAL EXPERIENCE:

Confidential, Phoenix, AZ

IT Quality Analyst

Responsibilities:

• Evaluate pertinent data and facts in order to test business requirements specific to the Enrollment, Medical Confidential, Pharmacy Confidential, DME Confidential, Supplemental Diagnoses, and Reporting modules.
• Interpret Business Requirements Document (BRD), Centers for Medicare and Medicaid Services (CMS) regulations and mapping documents in order to identify requirements
• Write and revise test cases for each requirement to ensure that the quality of the new functionality is of the highest standard
• Write SQL scripts for each requirement
• Modify appropriate data to ensure records are either selected or bypassed
• Modify appropriate data to ensure that new functionality meets requirements
• Conduct the test execution for both positive and negative scenarios for each requirement
• Conduct regression testing to ensure that existing functionality is not affected by enhancements
• Analyze test results
• Identify and track defects
• Document the outcome of all test execution, including defects
• Review and approve test cases of fellow QA Analyst
• Review and approve test results of fellow QA Analyst
• Review and approve defects raised by fellow QA Analyst
• Analyze and identify underlying system errors that cause defects
• Analyze and determine the correct course of action
• Identify areas that can be improved to ensure efficiency and accuracy
• Create and implement changes in procedures to ensure efficiency and compliance
• Conduct audits to ensure compliance with said procedures
• Prioritize and organize workload to meet deadlines
• Analyze and Interpret CMS regulations to ensure compliance
• Analyze and identify inconsistencies between CMS regulations and system processes
• Analyze encounter data to ensure compliance with CMS regulations
• Provide recommendations for encounter processing when regulations conflict and/or are vague
• Interface with Clients, Project Managers, Developers, and other departments to ensure the successful completion of implementations and requirements
• Interpret communication from clients in order to identify opportunities
• Provide system to clients
• Provide system to fellow colleagues within the organization
• Provide system to fellow colleagues outside the organization

Confidential, Phoenix, AZ

IT Quality Analyst

Responsibilities:

• Evaluate pertinent data and facts in order to test business requirements specific to Confidential and Provider functional areas.
• Interpret Business Requirements Document (BRD), Detail Specification (SRS), and mapping documents in order to identify requirements
• Write and revise test cases for each requirement to ensure that the quality of the new functionality is of the highest standard
• Write SQL scripts for each requirement
• Modify appropriate data to ensure that records are either selected or bypassed
• Conduct the test execution for both positive and negative scenarios for each requirement
• Analyze test results
• Conduct regression testing to ensure that the existing functionality is not affected by the enhancements
• Identify and track defects
• Analyze and determine the correct course of action
• Document the outcome of all test execution, including defects
• Interface with Business Analysts, Project Managers, and Developers to ensure the successful completion of each package
• Prioritize and organize work to meet deadlines
• Identify areas that can be improved to ensure efficiency and accuracy

Confidential, Mesa, AZ

Lead Confidential & Reimbursement Analyst

Responsibilities:

• Provide leadership for the Confidential and MedCare lines of business
• Approve all claim payments over $10,000
• Analyze and identify inconsistencies between the Evidence of Coverage (EOC) and the benefit plan filed with CMS
• Analyze and identify trends in claim processing error
• Analyze and identify underlying system errors that cause claim issues
• Interface with system analysts to ensure the system is updated
• Configure Banner’s Impact system for the MedCare line of business
• Maintain the system logic for the MedCare line of business
• Identify areas that can be improved to ensure efficiency and accuracy
• Create and implement changes in procedures to ensure efficiency and compliance
• Ensure Confidential are processed according to provider contracts, i.e. CPT combinations, per diem rates, prior authorization requirements, etc.
• Process UB 1500s and UB04s according to the policies and procedures established by CMS and the State of Arizona
• Research claim issues related to CMS’ DRG, APC, ASC, Home Health, SNF, Inpatient, Outpatient, Medical necessity, Lab rules, etc.
• Provide recommendations for claim processing when Confidential and/or adjustments do not follow established guidelines
• Research and conduct claim adjustment requests according to established policies
• Distribute all claim processing on a daily basis to claim examiners
• Provide all claim processing to claim examiners
• Provide to employees outside the Reimbursement Services Department
• Perform daily claim audits
• Post provider refund checks
• Void and reissue checks
• Answer and resolve provider complaints

Reimbursement Analyst

Confidential

Responsibilities:

• Analyze and identify trends in claim processing error
• Analyze and identify underlying system errors that cause claim issues
• Interface with system analysts to ensure the system is updated
• Identify areas that can be improved to ensure efficiency and accuracy
• Create and implement changes in procedures to ensure efficiency and compliance
• Configure the system with the new benefits and premium rates for the MedCare line of business on an annual basis
• Maintain the system logic for the MedCare line of business
• Ensure Confidential are processed according to provider contracts, i.e. CPT combinations, per diem rates, prior authorization requirements, etc.
• Process UB 1500s and UB04s according to the policies and procedures established by CMS and the State of Arizona
• Research claim issues related to CMS’ DRG, APC, ASC, Home Health, SNF, Inpatient, Outpatient, Medical necessity, Lab rules, etc.
• Research and conduct claim adjustment requests according to established policies
• Provide claim processing to claim examiners when requested
• Provide to employees outside the Reimbursement Services Department
• Perform weekly claim audits
• Answer and resolve provider complaints
• Track claim issues to ensure Confidential are processed timely and accurately
• Provide world-class customer service via ACD line
• Received the most verbal and written recognitions from employees and customers
• Answer phone calls regarding eligibility, claim status, authorizations etc.
• Solve customer complaints
• Interpret and provided feedback on all correspondence sent to members to ensure accuracy
• Translate the Sales Department presentations into Spanish
• Provide Bilingual Customer Service to ALL Spanish-speaking members
• Translate and Interpret the English member booklet into Spanish to provide excellent Customer Service

Confidential, Phoenix, AZ

Acting MSSP Enrollment Coordinator

• Interpret CMS Rules & Regulations to ensure enrollment/disenrollment compliance
• Create and implement new desktop procedures
• Prepare and submit documents to CMS
• Process and submit applications, disenrollments, and other information to CMS
• Verify all records are kept appropriately
• Conduct audits
• Research and correct any enrollment discrepancies
• Assist Department with processing reports and applications
• Answer ACD line
• Provide Bilingual Customer Service to ALL Spanish-speaking members
• Answer phone calls in the Customer Service Department, switchboard and Provider Services Department

Customer Service Representative

Confidential

Responsibilities:

• Answer multi-phone lines
• Provide Bilingual Customer Service to ALL Spanish-speaking members
• Answer phone calls regarding eligibility, claim status, authorizations etc.
• Solve customer complaints
• Set-up and coordinate transportation for customers enrolled in 3 different health plans
• Interpret and provide feedback on correspondence sent to members
• Assist Grievance and Appeals with research for plan changes
• Assist Provider Services with answering phone calls
• Periodically assist switchboard
• Responsible for copying and other duties assigned