OBJECTIVE:

To secure a position with an organization that will provide me the potential for growth while utilizing my vast experience, education, interpersonal, analytical and organizational skills.

SUMMARY:

• Business savvy leader who interprets and applies company core competencies to everyday business needs.
• Time management and training skills to promote speed, production and agility despite sudden deadlines and changes.
• Detailed oriented individual with proven ability to analyze, identify, resolve and trend problems.
• Motivated individual that accepts every task as a challenge with the ability to determine root cause and justify results.

SKILLS:

Confidential and Q - Blue(SME), ISET application, PPMO(PPM Optics) UCSW, SDLC Agile and Waterfall methodologies, Planview, Citrix, Cisco, Salesforce, Cognos reporting, Data Warehouse, ClearQuest, BlueExchange, EDI 27X and 834 transactions, ISM, TOAD, CPL, SharePoint and MQ Visual Edit. Microsoft Office Suite and Outlook, Extensive Knowledge in the Managed and Traditional Networks, Commercial, ASO/Fully Insured, all Network LOB’s HMO, Direct Access, POS, SHBP, CDH, PPO, FEP, EHB and EPO. CMS Medicare Regulations, Medicaid, HIPAA, HealthCare Reform, Medicare Advantage Plans and Federal and State Mandates.

PROFESSIONAL EXPERIENCE:

Confidential, Basking Ridge, New Jersey

Senior IT System Analyst

Responsibilities:

• Translate d business needs into system/technical requirements (Solutions Summary Documents) .
• Ensured system solution options were thoroughly researched, analyzed and documented and reviewed business requirements documents (BRDs, VFQs/PRDs.).
• Create d /contribute d to project estimates (e.g., Budget Guidance Estimate and Solutions Analysis Estimate .
• Perform ed system walk - throughs (developers, testers, customers, stakeholders) and i dentif ied changes in project scope.
• Appl ied software development lifecycle methodology (SDLC) to evaluate current system processes.
• Identif ied possible solution options for new functionality or modifications to existing functionality.
• Provide d support to Quality Assurance and User Acceptance Team s on development of test approaches and test plans.
• Communicate d to the business teams and stakeholders of deployment and/or migration status.

Confidential, Englewood Cliffs, New Jersey

Business System Analyst

Responsibilities:

• Gathered, developed and maintained business and technical requirements for various projects and system migrations.
• Determined and discussed with Plan volume details to be migrated and provided resource availability.
• Evaluated and resolved EDI transaction issues and provided resolution and/or workaround to the client.
• Created and monitored CSR’s and ensured all documentation was listed in the appropriate status.
• Coordinated Mock Model Office test runs and ensured checklist reflected documented task performed end results.
• Facilitated and reviewed migration meeting details which included updating and providing finalized ownership task.
• Created system workflows, diagrams and functional specifications to provide direction to business and developers.
• Performed user case acceptance testing (UAT), validated test output and accepted final test results based on new logic.

Confidential, New Jersey

Customer Delivery Lead

Responsibilities:

• Educated and Trained clients on Medicare Advantage products and services and performed plan assessments.
• Performed root cause analysis on impending client issues and provided daily response to internal clients and vendors.
• Scheduled and created application fixes related to CMS guidelines and discussed CMS Guidelines issues with client.
• Provided data management analysis, proposed a solution and recorded results. Lead Business Analyst on Special Projects.
• Developed new System workflows and Procedures to assist Business Teams in System changes implemented to production.

Confidential, Newark, NJ

Business System Analyst

Responsibilities:

• Translated and wrote CSRs/Technical Design Requirements as documented in the Business Requirements.
• Updated Confidential as it related to Business Requirement Document which included removal of code/Plan General Exclusions.
• Created Solution Designs and CSR’s in order for coding to be configured in Confidential Processing System.
• Prepared Detailed Test Plans Test Scenarios and Deployment Plans as related to CSR.
• Developed and Reviewed and output and updated all claim scenarios.
• Submitted completed Solution, CSR and Test Matrix to the Business Owner.

Contract Analyst

Confidential

Responsibilities:

• Educated and Monitored weekly reports provided by contract and ensured all goals/metrics are being met.
• Interacted with Vendors daily regarding claims distribution and purpose and created processes and workflows for contracts.
• Facilitated weekly and bi-weekly meetings pertaining to Operational issues and update all spreadsheets.
• Presented contract stats at annual DVOD meetings and served as a liaison between internal and external vendors
• Managed daily operations, identified process deficiencies, documented improvements and solved operational issues.
• Investigated and responded to outstanding Operation, MTM and Compliance Audit Points .

Business Analyst

Confidential

Responsibilities:

• Identified and analyzed system problems/limitations and recommended viable solutions or workarounds.
• Validated processes after a defined period and made necessary changes to workflows/procedures.
• Coordinated and developed system specifications and provided test output to the client.
• Performed root cause analysis on problem logs and provided a detailed solution or workaround.
• Developed new system workflows and procedures and ensured logic were adapted to Business Unit needs.
• Provided technical support, which included file maintenance and systemic feeds.
• Educated the provider community on Horizon’s contracts policies/procedures and ensured SLAs were met.
• Analyzed complex claims issues and followed-up with the provider until issue was completed.
• Ensured providers were compliant with Federal and State mandates pertaining to network adequacy.
• Coordinated with various areas to troubleshoot contractual issues and responded to executive inquires.
• Evaluated and identified opportunities for various electronic initiatives and provided network input.
• Negotiated and managed rate negotiations and special contractual arrangements and maintained provider files.
• Registered and provided tutorials for web based provider portal. Built and sustained relationships with Providers Groups.