SUMMARY:

• Senior consultant with over 20 years of experience in the healthcare industry
• Over 15 years of Trizetto Facets configuration experience with expertise in Medical Plan applications
• Team member for multiple Facets conversions
• Proficient in translating business requirement into technical requirements and providing innovative solutions for complex benefits
• Proven ability to work multiple projects concurrently and meet deadlines
• Proficiencies include trouble - shooting Medical Claims processing errors as well as processing claims and creating realistic test scenarios

PROFESSIONAL EXPERIENCE:

Technical Consultant

Confidential

Responsibilities:

• Determined requirements for Medicaid claims processing products from state provider manuals
• Configured Medicaid products
• Audited configuration of more
• Updated tables Medical Utilization Edits, Supplemental Tables, Automatic Payment Level Overrides
• Configured healthcare reform updates to ASO products
• Audited product build of less experienced analysts

Confidential, Rhode Island

Responsibilities:

• Analyze requirements and build health care reform and products offered on the Healthcare Exchange.
• Analyze source benefit documents and determine whether new Product Components are required.
• Build new Product Components including Service Rules, Service Payment Prefixes, Medical Utilization Edits, Limits, and Deductibles
• Use SQL and MS Access queries to create Excel workbooks to document product build
• Audit Products before migration to production.
• Update Supplemental Revenue and Procedure Tables
• Created Test Subscribers and enter Unit Test Cases.
• Evaluate and corrected Unit Test Cases.
• Resolved claim defects.
• Provide recommendations for new configuration.
• Trained users in Facets Configuration and test claims entry.
• Documented configuration processes.
• Audited configuration of more than 200 products by running MS- Access queries of Facets tables to obtain cost sharing information and comparing benefits to configuration
• Documented and reviewed differences in configuration with client
• Prepared documentation to recommend updates to configuration after validating the updates by claims testing
• Audited configuration of a line of business being converted from Amisys to Facets to increase claims pass rate
• Audited and made recommendations for revision of Processing Control Agent
• Audited products by creating queries to compare Facets Benefit Summaries to Service Payments and created update files
• Worked Tracers to correct various problems and implement Facets changes
• Updated tables Medical Utilization Edits, Supplemental Tables, Automatic Payment Level Overrides
• Acted as SME to assist Customer Service and Claims processors with day-to-day claims problems
• Configured all products and components for implementation of new offering of Medicare Supplemental product line for health plan
• Defined EDI requirements to load Medicare Crossover information to new applications
• Advised health plan on use of Medical Utilization Edits, Medicare Supplemental Rules, and Claims Pay Hold
• Documented procedures to create additional products
• Created procedures for Enrollment including Billing Entity, Electronic Funds Transfer (EFT), Claims Pay Hold, and Premium Rate Tables

Confidential

Facets Configuration Analyst

Responsibilities:

• Created base PPO and HMO products from source documents
• Audited product matrices used to build variations of the base products, for accuracy
• Used MS-Access and Excel to analyze supplemental and various other tables
• Created tables to be loaded through Facets “back-end” also loaded components by keying directly into Facets
• Audited product build variations, using MS-Access, to assure that they were configured according to specifications

Confidential

Facets Configuration Analyst

Responsibilities:

• Created HMO and PPO products in version 4.41 Facets to support Facets implementation
• Defined and developed testing requirements
• Provided clear and supportable findings on test results and conclusions
• Reviewed, performed analysis, and interpreted data relating to policies, procedures, organization, managerial and operational practices, to define and make recommendations for configuration
• Created Medicare and Medicaid products during conversion of data from Amisys to Facets
• Participated in projects mapping Medical Plan tables to meet UM requirements
• Provided innovative solutions to configure benefits previously designated for hands-on processing
• Performed product configuration to support Facets implementations of HMO, PPO, ASO, Medicare (Medigap) and Medicaid Products
• Defined and developed testing requirements

Confidential

Facets Configuration Analyst

Responsibilities:

• Team member in implementation of Facets claims processing system
• Worked with IT developers to map accumulators, during conversions and member enrollments, while maintaining controls to keep Facets in-sync with the system being retired
• Managed multiple projects to implement Medicare, Medicaid products, HMO, PPO, EPO and POS products
• Led projects to implement ASO groups that required innovative solutions to achieve desired claim adjudication
• Trained Product Consultants and new team members in Medical Plan configuration and MS Access
• Provided comprehensive solutions for complex problems to resolve Trouble Tickets (pricing, enrollment and benefit) and Change Requests expediently
• Attained proficiency in running ad hoc reports

Business System Analyst

Confidential

Responsibilities:

• Gained broad healthcare contract knowledge as team member on a project to rework benefit matrices and assured that they followed contracts filed with government agencies and met expectations of internal users
• Demonstrated ability to work independently to meet multiple deadlines
• Accomplishments included resourceful resolution for processing claims without manual intervention
• Configured Provider Agreements as well as all Medical Plan applications
• Managed multiple projects concurrently to implement pricing and benefit changes

Technical Analyst

Confidential

Responsibilities:

• Acquired in-depth knowledge of Facets configuration as a team member during conversion of legacy system to Facets
• Revised and implemented Accounts Receivable System including admissions, electronic billing, rate negotiations, and collections
• Coordinated functions of multiple departments to resolve reimbursement problems while maintaining compliance with several regulatory agencies

Computer System Specialist/AR Specialist/Team Lead

Confidential

Responsibilities:

• Designed and implemented system to collect billing information
• Became expert in Medicare regulations related to home health billing and medical documentation
• Educated professional staff in medical documentation related to Medicare reimbursement
• Responsible for invoicing process incorporating: input of billing information, electronic invoicing
• Reduced monthly processing time to report financial and statistical data by 10 days
• Maintained controls and documentation necessary for audits by regulatory agencies
• Trained computer operators in multiple duties that included file maintenance that included “back-up” and “restore” processes