TECHNICAL SKILLS

8, HP Quality Center, TPX: Highglass and Non - Highglass Regions QN, QH and RR, Multi Carrier System (MCS). Part B Claims, HP, Encounter Data Systems (EDS), Internet, SQL, Amiss - 3.0 - 11.5, Amisys Advance, WGS ( Confidential Group System), Oracle Customer Claims Billing system (CCB), Trizetto Facet, Medi-Vance, Mainframe, MS Access, MS Word, PLUI, MS PowerPoint, MS Excel, QNXT, Pecos, MCS, PEGA, MS Outlook, Employer Group Wavier Plan (EGW), Validator, Ramp Management Tool, Sales Force, Plan Central, Contractual, Share point, Remedy, Collaborative Application Lifecycle Tool (CALT), zONE, State Exchange Resource Virtual Information System (SERVIS), State Exchange Resource Tracking System (SERTS), TeamMate. Enterprise Identify Management (EIDM), HUB, Qualified Health Plans (QHP), HUB, Financial Management (FM), Small Business Health Option Plans (SHOP), Electronic File Transfer (EFT), Federal Financial Management (FFM), National Provider Number (NPN), Market Learning Network (MLN), Health Insurance Oversight System (HIOS), Five9.

PROFESSIONAL EXPERIENCE

Confidential, Windsor Mills, Md

Lead Software Tester BA

Responsibility:

• All testing was implemented in "Drupal".
• ProductionTest, document and delicate any non-required functionality within the Collaboration and MATS website.
• Create and Document steps for Business owners, Help Desk, Members, Admin (Projects, Teams and Programs).
• Create new Defect process for testers and Developers. implement new processes from verifying defects, documenting includes defect script. screenshots, requirement that applies, upload to SharePoint.
• Document all defects, screenshots, requirement documenting number and steps in order for the developer to re-create in SharePoint for a more structured and consistent process.
• Testing Collaboration in 3 URL's: 1.Test, 2.Development and 3.Production
• Send all found defect to developers, LOE.(Level of Effort) needed to fix each defect. Once information is received, the status (Critical/High, /Med, High/High etc.) Resend defects with to LOE instructing them of the ones needing to be worked based on Status Serverity.
• Test the Collaboration/MATS, website's for information migration, all users functionality and navigation. Create account based on their Roles, Rules or Level of Permissions.
• Experience with 508/ JAWS testing, create and end user manual documentation.
• Assist with creating the test script and resenting during the Demo.
• Experience with FTP File type testing for uploads based on size o Electric Medical Records (EMR), Documents, videos,
• Assists with research and reviews of the projects' scope in order to understand why the project has been initiated. Provide a working knowledge with Agile methodology and processes.
• Experience in creating users profiles for login/password to test Rules and Permissions per their role. Identify and validate business processes and solutions when defects are found.
• Provide weekly communicates, numbers of Critical/High/Medium Defects open, Level of Effort (LOE), Show Stoppers and require.ment clarification pers direction for my team, developers and management.
• Provide support for all testers training, reviews and sign-off on updates/changes.
• Provide assistance to multiple levels of the staff and management. Provide and identify new processes, for tester to developer.
• Facilitate meeting with Testers, Developers and upper management.
• Participates in technical requirements and design of website per requirements.
• Responsible for creating and provide documentation communication with UAT and end-user training for system implementation and navigation.
• Experience and knowledge of waterfall/agile methodologies and best practices.
• Experienced in incorporating successful interviewing, facilitation, and requirements documentation techniques within a project.
• Experienced with writing, executing and reviewing test cases.
• Able to work with minimal direction and guidance from project lead, consultant staff and manager.

Quality Technology Consultant

Confidential, Md

Responsibilities:

• Provide assistance to the System Architects for CMS (Center of Medicaid and Medicare), HHS (Health and Human Services) and the Healthcare.gov website as an Application Specialist Tier 3.
• Assisted EIDM users with resetting passwords, unlocking their accounts and resetting their security questions for numerous accounts, and documenting incidents into Remedy to generate a ticket number.
• Provider support and data discrepancies between the issuer and Federally Facilitated Marketplace records between the State Based Exchange and Centers for Medicare and Medicaid.
• Provided technical and investigative support to entities connecting to the Federal Data Service Hub/DSH regarding processing failures, missing info and other data error.
• Provider resolution of technical issues related to Federal contractors connecting to Federally Facilitated Marketplace systems, including eligibility, completion of certifications for Agents/Brokers.
• Provider assistance in the call center with intake via email or phone, assignment, Security Verification and Approver per CMS SOP for Federal, State, Agents / Brokers, Issuer, CO-OP users.
• Participate in status check of CMS government portal website (The Health Insurance Market Place website and system), responding quickly, clearly, and resourcefully.
• Provider assistance to the SOP architect, Trainers, Project Managers.
• Provided Plan Management (PM) support
• Help desk\SME for HIOS\RBIS, EIDM, FFM Redirect, HUB (CIC and AT) (, CALT, SHOP, E&E, MLN/NPN, EDI 834/820, identify upstream FM, QHP-PM (Qualify Health Plan), QHP - Data Change Related, Agent/Brokers (password reset, CMS Enterprise Portal/EIDM Access non-password related, Market place Learning Market.
• Provider application verification for enrollments, creating login ID, creating passwords, password resets, up-blocking accounts, creating accounts, deleting, adding projects/groups and creating groups and projects for Federal, state, agents\brokers for Remedy, EDIM, CALT, SERTS, SERVIS, zONE, CMS Portal, Market Place, HUB, QHP and TeamMate\CITRIX systems.
• Assisted with requirements management processes for multiple databases, and helped establish a SOP.
• Provider assistance for Agent/Brokers and issuers when updating business requirements and data mapping documents that are imported into the requirement management framework per SOP for EIDM (Federal, State, \Agent / Brokers, Issuers) CALT, E&E.
• Provider the setup for CALT, SERTS, SERVIS, zONE, Teammate/CITRIX, Agent/Broker, HIOS, HUB/DSH, EIDM and QHP, databases, which included states and federal employees, small businesses,
• Provider all clients with a follow-up emails for: creating user names, passwords, SSA info, technical issues whether internally or external, unlocking accounts or resetting a password, walking them throw a process step by step, status updates on a previous issue, give them the remedy ticket number and assisting with getting First approvers.
• Provider data reports from Remedy and Five9 phone.
• Audit all technical support issues logged in Remedy that are Severity 1.
• Provide assistance to Agents/ Brokers trying to acquire their FFM (Federal Financial Management), NPN (National Provider Network), MLN (Market Learning Network) and SHOP (Small Business Health Option Plan) and Training and Certification.
• Provided customer support to clients at times remotely, phone and email.
• Collaborated with Database Architects to create training and update SOP for all data bases.
• Utilizing my healthcare experience in Medicare, PPO, EPO, HMO, PFFS, Indemnity & ASO in the private and government insurance market
• Provided technical support to resolve file failures for Federal, State, Agents / Brokers, Issuer and CO-OP users.
• Experience with EDI transactions, claims formatting, claims extract, claims transfer and load, claims processing 5010, edits, remittance, denials errors.
• X12 - 5010 (834, 835, 837 and 820).
• Provide training material that is created from Remedy KIRK report.
• Test new process with UAT/BETA processes.
• Export daily reports from Remedy report and execute quality analysis of the data created.
• Provided and verified point to point connectivity and EDI data transaction between consumers from multiple data sources.
• Gave tech support to clients in areas such as the correct connectivity {http, https, ftp, ftps} for cms.gov, healthcare.gov, marketplace.com, eidm.cms.gov, regtap.com website.
• Manage projects and delivering results within set time lines.
• Provider excellent interpersonal relational with internal and external clients.
• Verified and created process flows, test cases, user interface and drafts with Direct Capture of Objectives (DCO).

STC MCS BA

Confidential, MD

Responsibilities:

• Performed business process analysis of MCS for modifications, including independent analysis of CMS Change Requests (CR), reoccurring Change Requests, participation in POC review meetings, and analysis of system developer requirements to ensure CMS CR requirements were met.
• Developed test plans and test cases detailing expected results to validate correctness of system modifications, including performing any file maintenance/system set up to allow test cases to execute successfully.
• Tested and monitored participated in the creation of clear, complete, timely business requirements for all systems.
• Tested, and monitored to ensure test cases were executed, documentation was present and accurate, expected results were obtained, and defect reporting and resolution is performed.
• Conducted Independent Verification and Validation (IV&V).
• Implement my project management skills, time management and scheduled meet UAT/BETA deadlines.
• Provide daily status report on all assigned projects.
• Experienced with ensuring all assigned CR (Change Request)) were completely tested by documented before due dates.
• Created and implemented manual testing
• Experience with enrollment scenarios, identifying data requirementbe and different test cases.
• SDLC and Peer reviews
• Verified changes and updates to test cases that did not have a negative impact on productivity and procedures.
• Held Walk through meeting, weekly test status meeting, weekly test release meeting, and change meeting twice a week; coordinating meetings with all lines of business LOBs}
• Experience HP Quality Center, Excel, PowerPoint, SharePoint, Pro-32
• Participated in CMS Readiness Reviews meetings.
• Assist Federal Intermediary Standard System (FISS), CMMI, QA audit compliance processes, policies and procedures during UAT.
• BETA/UAT manual testing with both Waterfall and Agile Methodology.

Medicare Advantage Sales and Enrollment - Consultant

Confidential, Akron, OH

Responsibilities:

• Built and maintained relationships with clients and served as the subject matter expert (SME) in regards to products, program and renewal.
• Served as the point of contact with the client, presenting clear, concise and professionally written communication and verbal communication.
• Communicated verbally with a broad spectrum of audiences in a professional manner.
• Identified issues and coordinated appropriate resources to resolve.
• Provide EDI test cases for 834 (x12), identify upstream and downstream cases.
• Handled inbound calls for customer service, sales, updating of members providers, issuing ID cards, G & A, Dis-enrollment, Pharmacy enrollment, Premium payment, Setting up auto deduction, SEP, LIC, MADP and AEP
• Provided timely internal and external customer service in cooperative, professional, and respectful manner.
• Provided timely internal and external customer service in cooperative, professional, and respectful manner.
• REMOTE project.

EDI Helpdesk / Business Analyst

Confidential, Louisville, KY

Responsibilities:

• Responsible for providing process support to users of client's Electronic Data Interchange transaction processes by direct contact or indirect methods.
• Responded to EDI 834/835 inquiries and/or requests for assistance from customers, clearing houses, providers, faculties peers.
• Identified, investigated and researched questions and problems and also responsible for resolving "on-the-spot", call back or refer to other associates for assistance as needed.
• Performed updates to software in use, changes in electronic file formats, or changes in regulations that impact the exchange of data.
• Participated in design of business cases for testing and in release testing of standard systems.
• Assisted in department initiatives to improve performance, produce reports, and introduce system enhancements.
• May provide guidance and/or training to lower leveled associates or external customers.
• Identified, investigated and researched questions and problems and may resolve "on-the-spot", call back or refer to other associates for assistance as needed.
• QNXT experience.
• Responded to EDI inquiries and/or requests for assistance from customers and peers.
• Experienced creating BRD, Enrollment scenarios, identify upstream/downstream test strategies, data requirements, be able to define different test cases for enrollment, test plans and test cases.
• Performed other duties as assigned to assist trading partner w/ connectivity.
• Responsibilities included Phone support, email, facilitating meetings and written communications.
• Wrote steps and test cases for testing changes, updating to WGS systems.
• Experienced Analyzing and reviewing Data Mapping and updated as applicable.
• Applied Project Management principles to ensure Projects were delivered on time and issues were mitigated.
• Assisted in department initiatives to improve performance, produce reports, and introduce system enhancements.
• May provide guidance and/or training to lower level associates or external customers.
• Performed other duties as assigned to assist trading partner w/ connectivity as SME.
• Maintained focus on details and convey information in a manner that is easily understood.
• Performed with excellent oral and written communication skills.
• EDI 4010/5010 Migration and Connectivity

Cahaba GBA - Consultant

Confidential, Savannah, GA

Responsibilities:

• Workload issued in batches that had to be completed daily and some by weekend.
• Assure the applications were pre-screen, prior to the initial 30 days to allow processing.
• Coordinate with providers when an extended is need for missing information on the applications 855 or if more information was needed for Clearance.
• Coordinate with providers and MAC {Medicare Administrative Contractors that the provider’s applications for Part A, Part B, both paper and electronically was legit and accurate for facilities.
• Initiate contact with provider’s that have a renewal date pass due with an initial 30 days’ notice, which could be extended if information was received in given time frame
• Implement the enrollment from listed providers on an excel sheets, pull the applications paper or electronically), coordinate with my check sheet and completed enrollment using (Pecos, MCS, PTAN and PEGA), systems.
• Experienced creating BRDs and executing effective test strategies, test plans and test cases.
• Applied both Waterfall and Agile Methodology.

CIGNA Healthcare - Consultant

Confidential, Dennison, TX

Responsibilities:

• Assisted providers, policy holders, brokers and others regarding pharmacy benefits, service and general processing on all related inquiries.
• Resolved provider complaints, problems and questions directly or through coordination and follow-up with other CIGNA departments.
• QNXT experience.
• Train members, brokers and providers on enrollment, administration and follow-up educate members, brokers and providers on administrative procedures.
• Provider quality, accurate, prompt and courteous service to provider, agents, customer and
• Experience in reviewing and adjudicating, prior authorization requests telephonically.
• Provide quality and standards for average handle time on a monthly basis.
• Provider report to management any trends or problems that consistently arise.
• Provided timely follow-up and documentation of calls in requiring research or support from other CIGNA areas.
• Utilized all resource materials to provide quality responses to customer inquiries.
• Effectively finalized and closed open calls in a timely manner.
• Processed accurately, enrollments/dis-enrollment, deletions, changes, re activations and contact service forms within the department.
• Experience with coding, approved and denied eligibility potential members.
• Provide audits and error reports.
• Execute daily imported and exported eligible members.
• Communicated and coordinated eligibility issues or questions with external and internal customers in a daily report.
• Experience with navigating the systems, researching, answered and clarified any questions regarding the eligibility of members.
• Continue to meet and maintained set eligibility efficiency and accuracy standards.
• Provide report for all renewal, dis-enrollments, new members and providers.

Confidential

MVP Healthcare/ Business Analyst

Responsibilities:

• Worked on Amisys System 4.21 and 4.41, Medicare claim adjustment, for providers and members
• Made corrections to old billing that paid under the contract rates prior to and after renewals.
• Experienced analyzing data, application and processing architectures.
• Experienced development requirements while evaluating risks associated with development and testing approaches.
• Experienced in specifications; creating and testing programming code for business applications. HIPAA EDI processes, database systems, web page layouts, reports or printed outputs, and interfaces using Amisys system.
• Implemented and created, developed, maintained and integrated all databases and data elements as related to programming processes.
• Applied Project Management principles to ensure Projects were delivered on time and issues were mitigated.
• Performed independently, exercise sound business judgment and discretion
• Experience in coordinating and conducting acceptance testing for Amisys system software revisions and upgrades and analyzing new functionality.
• Performed advanced troubleshooting and research for application programming and data issues, and implemented solutions.
• Experienced creating BRDs and executing effective test strategies, test plans and test cases.
• Performed monitoring performance and traffic of custom designed application solutions after implementation, taking action as required to scale capacity, optimize coding practice and/or database design to meet traffic demands and performance.
• QNXT experience.
• Experienced with Microsoft Office Suite, MS-Access, MS-Project, MS-Visio, Microsoft SharePoint & SQL
• Excellent problem solving and analytical sills, including understanding and analysis of data.
• Experience Analyzing and reviewed Data Mapping Documents and updated them where applicable.
• Performed Loading contract benefits for Groups, individual, Part A, B, C, and D, code to be applied to Ded, OOP, Copays, Coinsurance, Lifetime max., Catastrophic, Inpt and outpt

Confidential, Woodland Hills, CA

Responsibilities:

• Managed healthcare risk management overpayment operations.
• WMS ( Confidential Group System), Facets., QNXT experience
• Experience analyzing data, application and processing architectures.
• Experience developing requirements while evaluating risks associated with development and testing approaches.
• Experience in specifications; creating and testing programming code for business application. HIPAA EDI processes, database systems, web page layouts, reports or printed outputs, and interfaces using Amisys system.
• Implemented, created, developed, maintained and integrated all databases and data elements as related to programming processes.
• Applied Waterfall Methodology principles to ensure Projects were delivered on time and issues were mitigated.
• Experienced in coordinating and conducting acceptance testing for Amisys system software revisions and upgrades, and analyzing new functionality.
• Performed advanced troubleshooting and research for application programming and data issues, and implemented solutions.
• Experienced creating BRDs and executing effective test strategies, test plans and test cases.
• Monitored performance and traffic of custom designed application solutions after implementation, taking action as required to scale capacity, optimize coding practice and/or database design to meet traffic demands and performance.

Peach State Health Plan - Consultant

Confidential, GA

Responsibilities:

• Served as SME for Provider Database Analyst, Auditor and Consultant, claims, Medicare, HMO, PPO, Medicaid, ASO, EPO, PFFS, etc.
• Audited provider, hospitals and members contracts.
• Loaded contracts or enrollment corrections for hospital, physicians and members.
• Facilitated training and meetings on Peach State Health Plan.
• Audited providers, hospitals and Amisys system.
• Experienced analyzing data, application and processing architectures.
• Experienced in development of requirements while evaluating risks associated with development and testing approaches.
• Experienced in specifications, creating and testing programming code for business application.
• HIPAA EDI processes, database systems, web page layouts, reports or printed outputs, and interfaces using Amisys system.
• Implemented, created, developed, maintained and integrated all databases and data elements as related to programming processes.
• Applied Agile and Waterfall methodology to ensure Projects were delivered on time and issues were mitigated.
• Experience in coordinating and conducting UAT for Amisys system software revisions and upgrades and analyzing new functionality.
• Performed advanced troubleshooting and research for application programming and data issues, and implemented solutions.
• Experience creating BRDs and executing effective test strategies, test plans and test cases.
• Monitored performance and traffic of custom designed application solutions after implementation, taking action as required to scale capacity, optimize coding practice and/or database design to meet traffic demands and performance.
• Experience with Microsoft Office Suite, MS-Access, MS-Project, MS-Visio, Microsoft SharePoint.
• Excellent problem solving and analytical sills, including understanding and analysis of data.
• Experience analyzing and reviewing Data Mapping Documents and updating them where applicable.