SUMMARY

• A goal - driven healthcare services professional with thirty years experience in the Health Plan and Health Insurance Industry is seeking a position that offers opportunities to master new concepts, skills and practices while providing me the opportunity to utilize my extensive knowledge of Contract Configuration
• Facets implementation, building and testing products, Medicare, Medicare Advantage, Medicare Appeals and Grievances, Medicaid, Product Builder, HMO, PPO, POS, EPO, ASO, Medi-Medi, CMS, Employee Benefits, Medicare Compliance and Capitation Provider Contracts background. I have extensive knowledge of Traditional, Managed PFFS and Medicaid plans.
• Expertise in Medicare, Medicare Part D, Pharmacy, Medicaid Policy Management and Retention. Proficient in Web-Based Applications, Diamond 725, Diamond 950, Facets Qual & Prod 4.11, 4.21 & 4.41, 4.61, 4.71, 5.01, 5.20, 5.3, 5.4, Workflow, CTM 1.9 (Configuration and Management System) (HealthyNet) Tiger 3.0, SQL, Queries, ODBC, Demand 32 NetworX, Webstrat, Winstrat, Lotus Notes, Trailblazer, Quick Test Pro, Team Track, ClearQuest, CRITRIX, Resource Enterprise Testing, Legacy, McKesson Claim Check Knowledge, Work Tracking Tool, Service Now, Software Development Life Cycle and Testing Methodologies, QNXT, MS Word, MS Access, PowerPoint, PowerMHS 2.0 Legacy, MCS, Proclaim systems, MS Windows, Excel, Salesforce, PECOS, OnBase, Filenet, iFile, PSUP, UPIN Registry, NPPES, PMDB, Metavance, CMS Portal, Claimfacts, Cosmos, NDB, Diamonds, Xcelys, HealthEdge/HealthRules, TXEN, RIMS, NASCO, ITS, ASA, CHARTS, IMASIS, ULTERA, CITRIX, ICD-9, ICD-10, Sharepoint Solutions, Zephyr,Team Track, UAT, QTP 9.2, Mercury Quality Center 9.2, Encoder Pro, MDE, PLUTO, WMDS, WGS, Filenet, MARX system, Ultera, UNET, MACESS, ACCESS, TOPPS, MGB, NexGen, GBAS, Erisco, Eldarodo, QMAS, Amisys and MCO.

PROFESSIONAL EXPERIENCE

Confidential

Sr. Configuration Analyst

Responsibilities:

• Configuration Analyst for Professional and Institutional Claims Projects. Provider Configuration, UA Pricing Builds on dual products Medicare/Medicaid and Commercial Products. (DRG, rate based) Building contacts in Xcelys.

Confidential

Sr. Business Analyst

Responsibilities:

• Provided Expert Knowledge and implementations for global business area. Conducted gap analysis based on business requirements relative to NetworX’s functionality and incorporated into project plan.
• Provided Claims Flow on the Facets System. Evaluated operating policies, procedures, job aides and training materials to take on paying Medicare Host Claims. Evaluated the Configuration of the Benefit BRD’s, payment methodology of the Fee Schedules and Provider contracts Medical/UM policies.
• Evaluated the Enrollment segment BRD’s and Configuration such as Pricing used, editing software. EDI Software and additions to the regular pricing.

Confidential

Sr. Business System Analyst

Responsibilities:

• Provided Expert Knowledge and Implementations for global business area. Attended daily Scrum. Created Training Materials and Peer Reviews. Conducted Training Sessions on Facets. Created Test cases and Test Beds. Trained, answer questions and configure Networx’s Pricing and Calculations. Trained offshore on HealthRules/HealthEdge system and benefits.
• Conducted gap analysis based on business requirements relative to Facets functionality and incorporated into project plan. Built and maintained provider contract and pricing records for capitated, Fee for Service and other negotiated provider payment methodologies. (Core/Networx) Configure in the Application Support, Medical Plan, Agreement Medical, Pricing and Claims Application Groups to accomplish task.

Confidential

Sr. Business Analyst/Benefits Configuration Analyst

Responsibilities:

• Provided Expert Application Knowledge and Implementations for global business area. These applications support core business processes such as Facets Benefit Configuration, Claims, Provider and Enrollment.
• Mentor Junior Facets Business Analyst
• Attended daily Scrum meetings and gathered business requirements.
• Tested configuration of Facets for Commercial and Medicare/Medicaid Products
• Tested and configure Networx Pricing.

Confidential

TriZetto Facets 5.30 Benefits Configuration Analyst

Responsibilities:

• Provided Expert Application Knowledge and Implementations for global business area. These applications support core business processes such as Facets Benefit Configuration, Claims Processing and Enrollment
• Attended daily Scrum meetings and gathered business requirements.
• Tested configuration of Facets for Deemed Products
• Updated design documents, updated Supplemental Tables, service rules, service payments, SERL, Accumulator’s, Products, Limits and Deductibles
• Handled Claims Processing issues and resolved the fixes
• Review analysis and mapping of existing contract configuration to FACETS. Analyze existing contracts for FACETS configuration, advising the client of revision/clarifications of contractual language and rates. Configuring/building provider (specialist, in and out of network, hospital) contracts/agreements and related pricing prefixes for appropriate lines of business
• Design custom reports utilizing MS Access of Facets data, for myself and team members that assist in evaluating the impact of configuration changes on existing and future claims and provider records.
• Built and maintained provider contract and pricing records for capitated, Fee for Service and other negotiated provider payment methodologies. (Core/Networx)