SUMMARY

• A well - organized, detail - oriented professional with over 30 years diverse experience in the Benefits Administration and Health Care Industry with emphasis in Information Technology. My experience has developed into a strong, progressive background working in goal-oriented projects dealing with deadlines and a proven track record of increased responsibility as well as outstanding results. I work well individually and as part of a team.

TECHNICAL SKILLS

Management: Programs, Projects, Database and Web - Based Application Administration, Telephony, Technical / non-Technical personnel.

Platforms: Mac, Windows 9x, XP Professional, Windows 7 / 8, AS/400 clients (powerSTEPP, GBAS, Amisys, LuminX, Eldorado HealthPac)

Database: MS Access, OracleSQLDev

EDI file layout: ANSI 270, 271, 834, 835, 837 (professional, institutional, dental), NACHA,997,999

Miscellaneous Business Software: Microsoft Excel, Word, Outlook, Visio, PowerPoint, Access; SQLDeveloper, NAV, Quickbooks Enterprise, Active-Sync, Call Center Suite, Adobe Acrobat, WordPerfect, Lotus, Thomson Creative Solutions-Payroll, Taxworks, GoToMeeting, NetMeeting, GoToPC, Skype, Zimbra email, various claim system and emulation packages, 8x8 Configuration Manager

PROFESSIONAL EXPERIENCE

Confidential

Senior EDI & Systems Analyst

Responsibilities:

• Perform in-depth, on site analysis of multiple systems and organizational workflow; including existing claim payment systems each utilizing a variety of manual workflows and system platforms, including legacy and GUI based technologies.
• Determine enhancements for transaction standards, coordinate testing and implementation of new automation for partners.
• Develop and maintain relationships with project stakeholders and clients ranging from executive management to operations personnel to define, change, train and deploy new automated workflows, generating additional time and material revenues for Confidential .
• Provide day-to day support to resolve client issues in a timely fashion as well as provide audit of current automation processes with recommendation for areas of improvement.
• Serve as the resource to java developers and operation teams relative to EDI standards, claim system functionality including mapping document creation and overall business rule assignment related to health care industry payment standards.
• Serve as support to Systems Administration relative to user setup and maintenance well as 8x8 phone system configuration maintenance.
• Architected the Vesta-ACH project workflow which is an end to end solution that minimizes payment distribution expenses for Payor Clients by maximizing electronic payment delivery to providers as well as the paper remit delivery via secure email. This included an accompanying web portal to allow providers to register, retrieve/ view EOBs and EDI files. Once architecture was determined worked closely with the development team as the business workflow liaison as well as handled project oversight.
• Performed analytics and project oversight for automation enhancements required to support the introduction of ANSI 5010 migration and ICD9 to ICD10 conversion.
• Oversee organization education and understanding regarding ERISA and HIPAA rules.

Confidential

Reporting / Database Development Specialist

Responsibilities:

• Selected to lead the Regional Operations Center of 27 employees in addition to maintaining the functions of the Information Systems, Technology & Support Management. Development and execution of plans to meet and exceed industry standard claim adjudication and customer services through effective workflow organization, technology integration and employee motivation.
• Ensured progress towards objectives by recruiting qualified people, setting rules of performance & results to be attained, forecasting workloads, tracking performance & using the results for reward or improvement opportunities. Reviewed weekly productivity goals with departmental managers.
• Partnered with Account Management to resolve escalated issues. Maintained relationships with Human Resource representatives to answer employee claims/benefit questions, and provide client-specific reports. Participated in new group implementations.
• Performed Human Resource duties for the Operations Center including payroll record keeping, employee counseling, hiring & termination.
• Managed all corporate Information Systems, Infrastructure, Databases. Developed corporate Access databases with customized reports.
• Developed and maintained corporate policies and procedures relative to the technology initiatives
• Assisted in and supervised the development and setup of the EDI process used in the AS/400 claims system.
• Created custom programs Foxpro, InfoSTEPP, & AS/400 client- IBM query for data extraction, manipulation and client reporting. Also produced standard reports from the AS/400 system.
• Developed plan cost analysis reports used to determine renewal rates for employer groups in Excel. Website administrator of an ASP model self-service Internet tool provided to our clients. Managed, developed and maintained client set up, user authentication, and customized components. Served as the trainer and helpdesk support to both internal and external customers.
• Developed, managed and participated in a multi-layered help desk support structure for all internal hardware and software issues.
• Provided informational and statistical responses to requests for self funded health coverage or administrative service proposals by obtaining and securing group quotes for reinsurance coverage, life and AD & D coverage, network usage, and utilization review (UR)/ pre-certification services.
• Lead responsibility in coordination of employer/vendor contract initiation with networks, pharmacy benefit administrators, UR/ Pre-certification companies, and Confidential . Interacted with employer groups, brokers and vendors on various issues.