TECHNICAL SKILLS

• EDI 837,834, 835, 270/271
• Response files 277CA 999, TA1, 270/271, MAO - 001, MAO-002, MAO-004
• SQL, ( QNXT and EDM) applications
• Transaction Manager
• TFS (Defect database)
• MedTrac
• CERRS
• SharePoint
• TSO
• ANSI X-12 270/271 software, 4010 and 5010
• GAP Analysis
• MHS
• IDX
• Kronos payroll program
• Kenexa Recruitment Application
• PeopleSoft
• Excel
• EHDL
• WEBMD
• Medical Manager
• Medi-solutions
• HBO-C software experience
• Vista Microsoft Office
• Medicare/Medicaid Billing
• Hospital Rev codes knowledge
• Basic CPT- ICD-10 Codes
• Collections
• Basic medical terminology

PROFESSIONAL EXPERIENCE

Confidential

Systems Analyst Advisor

Responsibilities:

• Managing client expectations and eliciting requirements from end user
• Analyze business requirements/need and translates into functional and or technical specifications.
• Deliver requirements, perform analysis and evaluate downstream system, process and/or organizational impacts
• Plan and assist with oversight of test planning and execution including defect identification and resolution, including BETA testing as needed.
• Provides subject matter expert support to internal business partners by quickly triaging and responding to business partner inquiries.
• Work closely with Business Partners, Developers and Quality Assurance Analysts to ensure requirements and design are completely understood
• Communicate design to all stakeholders and varying levels of the organization
• Act as the liaison between Business Partners, Developers and project management groups
• Work closely with business teams to strategize solutions that support long term business objectives
• Ensure IT deliverables align with business requirements with measurable results
• Collaborate with QA team to ensure testing efforts align with system deliveries and business processes
• Lead and mentor other Systems Analysts.
• In depth knowledge of tools utilized.
• Develop estimates for application functionality enhancements.

Confidential

EDI Systems Analyst II

Responsibilities:

• Responsible for supporting encounter submission environment (specifically Medicare and Medicaid - CMS & AHCA)
• Analyze EDI files from Carriers and Vendors and identify the root cause for EDI file rejections.
• Review and assess the quality and accuracy of SHP’s current HIPAA Companion Guides for healthcare x12 transaction sets to include 834, 837, 835 and 999, 270/271, 276/277
• Manage current EDM application to ensure EDI files are scrubbed of errors
• Add Edits as necessary in Stored Procedure DataBase
• Test files in QA and Production environment
• Recommend and draft specific updates to Companion Guides and submit for review by EDI Manager and key business stakeholders.
• Perform Daily inbound and outbound EDI process workflow and accuracy analyses; ensure processes are completed correctly on time; perform necessary quality assurance; assess and communicate any issues related to these processes with internal/external entities when necessary.
• Identify data anomalies and gaps; troubleshoot data in/outbound processing errors and propose solutions.
• Create Reports using SQL to validate Data and track paid, pending or denied encounters.

Confidential

Lead EDI Business Systems Analyst

Responsibilities:

• Work with the Federal Government in regards to the Healthcare Exchange.
• Analyze FFM (Federally-Facilitated Marketplace) records as part of the ER&R(Enrollment Resolution and Reconciliation) project based on 834 transaction files received for Baseline enrollment
• Main liaison between trading partners nationwide as well as state Medicaid organizations on all EDI related issues or conversions.
• Perform root cause analysis
• Perform testing and thoroughly document issues
• Review documented training material for accuracy and assist in end user training and support
• Data Mining and Peer Review of completed cases
• Guide and Mentor Team members on new Processes and Policy updates
• Work with Stake Holders and Project Managers on new initiatives
• Lead EDI projects converting and implementing X12 transactions involving but not limited to 834,835,837, and 277
• Responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges
• Support all phases of the design, development, and implementation of the Enrollment Resolution and Reconciliation Process for health insurance exchanges
• Advised on changes for the system design, methods, procedures, workflows and policies that effected the Medicare/Medicaid claims processing in compliance to government procedures such as HIPAA and EDI formats as well as ANSI.

Confidential, Miramar, FL

Senior EDI Business Systems Analyst

Responsibilities:

• Working knowledge of ANSI X12 healthcare EDI specifically 837 (Professional & Institutional), 277 and 835 file formats
• Technical skills include MS Project, MS Office Tools, MS Visio, UltraEdit, SharePoint, basic SQL query and TFS
• HIPAA Standard Transactions, Implementation Guide, Specifications and HIPAA X12, Changes and Implementation.
• Perform for UAT Testers with Healthcare Claims UAT testing. Understands 835, 837, ICD 9, ICD 10, HCPC, CPT.
• Assist the development team in identifying and correcting errors and issues identified by internal and external customers
• Set up and create Plan file Layout and Mapping documents as part of ACHA/MMA Implementation
• Work closely with the Business Analyst and Development team in creating Encounters for 3rd Party billing to State Agencies (i.e. Medicare/Medicaid)
• Determine error correction based on the encounter rejections and track encounter submission to the payers.
• Interpret Implementation and Companion guide documents such as (837, 835, 834 and 276/277) in order to create processes to resolve rejections and streamline operation
• Also advance knowledge of the EDI Guide and Overview, Claims EDI, Medical EDI and claim related transaction such as EDI 834, EDI 835, EDI 837, EDI 277 CA /EDI 277 U, EDI 997.
• Responsible for individual project management and gap analysis
• Proactively communicate and collaborate with external and internal customers to analyze information needs and functional requirements in identifying (business scope, business requirement documents, process workflows, etc.)
• Test new or revised systems requirements against business requirements and participate in the debugging and implementation of new processes

Confidential, Hollywood, FL

Senior EDI Analyst

Responsibilities:

• Facilitate the 4010A to 5010A conversion process with active Trading Partners and Providers
• Working with 837I, 837P, 997, 997R, 834 Enrollment Files
• Maintain EDI Integrity and maintain EDI Mapping rules for HIPAA Validation software
• Managing all EDI-related activities for the business that include 837 Institutional and Professional claims that comes from all Insurance Carriers, Medicare and Medicaid
• Monitoring the daily receipts and processing of claim files from Medicare contractors along with troubleshooting and resolving data transmission or content problems. Use of EDI data translators and validation support, i.e., Gentran and Faciledi.
• Set up and maintain trading partner profiles and transaction mappings, as well as maintaining the EDI Inquiry Problem database including evaluation of problems or issues through to resolution.
• Conduct regular audits of EDI transactions to determine accuracy and areas for improvement; and maintain EDI maps and business rules for HIPAA validation software.
• Monitor the daily receipt and processing of claim files from Medicare contractors and troubleshoot and resolve data transmission or content problems. Perform analysis based on claim crossover inquiries related to eligibility files and billing.
• Interface with and/or lead management and technical application teams and both internal and external business partners to define project specifications, time-lines, and deliverables. Attend client meetings for ongoing and prospective projects.
• Involved in implementation of Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007
• Train customers and internal employees on the data exchange processes available and the data exchange systems.

Confidential, Sunrise, FL

Risk Reconciliation Supervisor

Responsibilities:

• Oversee daily functions of the Billing Department.
• Responsible for probationary and annual reviews for Department employees.
• Maintain accurate payroll information on department staff
• Develop and implement department policies and procedures.
• Responsible for the reconciling and reporting of membership payments from governmental agencies i.e. Medicare and Medicaid.
• Determine the accuracy of risk data to validate risk scores.
• Run Queries through the use of Sequel and other data base for a comparison of financial information received
• Interact with the internal departments such as Enrollment and IT/IS and Finance for reporting purposes.
• Transmit member information electronically to CMS and maintain accurate log of information sent and received through Argus.

Confidential, Fort Lauderdale, FL

Lead Reimbursement Specialist

Responsibilities:

• Oversee the day-to-day productivity of Intake Coordinators and Reimbursement Specialists.
• Provide guidance and assistance to Intake Coordinators and Reimbursement Specialists.
• Work with management on system reports, accounts payable and insurance issues
• Interact with salesmen, Field Service Representatives, trainers and/ or processors to set up billing system and maintain current patient roster.
• Inform Managers of all Deficiencies and concerns associated with assigned Regions
• Reconciled payment discrepancies
• Resolve Client billing and eligibility issues