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Hipaa 5010 Subject Matter Expert Resume Profile

Summary of Qualifications

  • Certified Ret professional medical code with significant experience with several California State departments, including DMH, DDS, DHCS, ADP, and MRMIB. In addition she has experience with Iowa and Rhode Island Medicaid. Her most recent experience is in a support roll for Sutter Health Information Services, EDI Revenue Cycle in the implementation of the Epic Electronic Health Record system Hospital Billing module - Resolute.
  • Subject Matter Expert SME for Department of Health Care Services MMIS 5010 , Iowa Medicaid Enterprise HIPPA 5010 and ICD-10 , CHHS, and Medical Board of CA
  • Strong understanding of HIPAA business and technical requirements and has experience with the American National Standards Institute ANSI ASC X12 and EDI, as well as with EDI mapping HIPAA transactions notably, 270/271, 276/277, 837 and 835. She has particular expertise in HIPAA EDI transactions, code sets, identifiers, privacy and security rules.
  • Technical background encompasses application design, and she has worked extensively with health insurance company data, formats and coding, such as CPT-4, HCPCS, ICD-9, ICD-10, CMS 1500 and UB04.
  • Familiar with HL7 Standards and LOINC and SNMED nomenclature.
  • Developed strategies and alternative analyses for numerous projects, and served as privacy liaison to federal, state and county agencies, national workgroups and private companies. I have performed policy analysis for California state and county government agencies, and conducted detailed transaction mapping for various EDI transactions. In my assignments, I adhere to the project management methodologies established by the Project Management Institute PMI .
  • I also have familiarity with both the Title IV - Health Information Technology for Economic and Clinical Health Act HITECH and Patient Protection and Affordable Care Act PPACA and how these two Acts impact the health care industry.

Professional Experience

Confidential

Application Analyst III, EDI-Revenue Cycle

  • Providing application and technical support and testing of the Cirius Group, Inc. Hospital Revenue Cycle Solutions PreBill and Remit Manager with regards to implementation of the Epic Resolute Hospital Billing module.
  • Provided triage and troubleshooting to the product customers.
  • Monitored the systems for data quality, efficiency, operation, and data integrity and appropriately escalates issues/problems.
  • Provided system analysis and documentation.
  • Provided standardization direction for the product aligning the application and workflow with current standards.
  • Test planning activities, including creation of test cases and execution.
  • Monitoring the application for data quality, efficiency, operation, and data integrity and appropriately escalating issues/problems.

Confidential

HIPAA 5010 Documentation and Testing Support overlapped with previous project

  • Primary responsibilities included two tasks: 1 generation of HIPAA documentation and 2 Testing.
  • The HIPAA documentation is in the form of Companion Guides for the various HIPAA transactions specified below. The testing effort consists of developing internal test plans, conducting internal testing with MAXIMUS staff and providing support for external testing.
  • Create Companion Guides for the HIPAA 5010 upgrade that must be implemented no later than January 1, 2012. Also, create mapping documentation from the Healthy Families and PCIP MAXe2 systems to the transactions.
  • Work with MAXIMUS staff to develop and execute test plans for internal testing of the following map changes:
  • Healthy Families Health, Dental, Vision 834 Enrollment transactions
  • Plan Response 999 Acknowledgement
  • Encounters for Health and Dental 837 transactions
  • Upon completion of internal testing, provide support for external testing with Health Plan Partners

Confidential

HIPAA 5010 Subject Matter Expert

  • Requirements Evaluation: review all project initiation and planning documents, requirements documents, and the project environment to evaluate completeness and accuracy of business, system and software requirements from a technical perspective, and to determine whether the needs of all internal and external stakeholders are incorporated into the system development process.
  • Requirements Tracking: perform traceability analysis to track requirements through all phases of the project to evaluate that the products correctly reflect all of these requirements from a technical perspective.
  • Design evaluation: determine if the design is appropriate and efficient, if the total system design is reasonable and appropriate to the solution, whether connectivity, security and confidentiality issues have been addressed thoroughly, the proposed solution conforms to the DHCS standards, etc.
  • Code evaluation determine if the development team has established appropriate coding standards, if coding is being done within those standards by all development staff, whether the coding is correct and efficient, etc.
  • Quality assurance evaluation: validate the adequacy and results of the Quality Assurance process, etc.
  • Validation testing evaluation: determine whether Validation testing is adequately planned and conducted, whether test scripts address all functionality, may perform independent testing, etc.
  • Configuration management evaluation: determine the adequacy and completeness of configuration management for system documentation and coding, version control, etc.
  • Deployment evaluation: determine if the planning for the deployment and implementation of the system is appropriate and complete from a technical perspective.
  • Maintenance planning evaluation: determine whether maintenance planning is appropriate and complete from a technical perspective.
  • Technical risk assessment: identify and evaluate technical project risks and will coordinate with the IPO staff and the Project Managers to ensure that technical risks are incorporated into the overall project risk management process.

Confidential

HIPAA 5010 Subject Matter Expert

  • Primary responsibility was to perform an assessment gap analysis for HIPAA Version 5010 impacts on the Iowa Medicaid systems, including but not limited to the MMIS. Her tasks included:
  • Interviews with appropriate staff to determine impacts on systems.
  • Identifying specific impacts of HIPAA 5010 and ICD-10 to systems at the code level.
  • Identifying gaps within systems relative to HIPAA 5010 and ICD-10.
  • Creating a report on all impacts and gaps.
  • Conducted data mapping for existing X12 4010A1 transactions within the MMIS environment, identifying gaps by creating side-by-side comparisons of X12 4010A1 and 5010/A1/A2 and identifying the gaps within existing MMIS business rules.
  • Upon completion of the above tasks, I took on a lead roll during Iowa Medicaid's implementation effort. I provided support and guidance to Medicaid staff not only on HIPAA 5010 issues, but on upcoming initiatives such as the Patient Protection and Affordable Care Act H.R. 3590 , Medicaid Information Technology Architecture MITA , and Health Information Technology HIT .
  • Later in the project, I was assigned as the lead ICD-10 Subject Matter Expert to assist Iowa Medicaid with their implementation efforts, with regards to policy, business process and technical remediation.

Confidential

MITA Assessment Team Analyst

  • Identifying and documenting state Medicaid business processes, systems and technology platforms, stakeholders and exchange partners, current and future initiatives
  • Creating a 5-year and 10-year view of the maturation of Rhode Island's Medicaid program
  • Evaluating each business process against the MITA Framework Business Capability Matrices to establish the current maturity of Rhode Island's Medicaid program
  • Interviewing and surveying representatives of the business processes covered to gather information as necessary to complete the deliverable document
  • Conducting interviews to inventory each business process and map to the MITA Framework Business Process Models
  • Identifying and confirming organizational inventory and contacts, allocating business processes, building preliminary and future views, interviewing state business owners and subject matter experts, and documenting key planning influences
  • Developing and utilizing a State Self-Assessment tool, using the MITA Framework provided by US Centers for Medicare and Medicaid Services CMS , to evaluate the maturity of Rhode Island's Medicaid program
  • Mapping Rhode Island Medicaid business processes to the MITA framework, determining current MITA maturity levels

Confidential

Business Process Analyst / Subject Matter Expert

  • Provided assistance in the design and development of a privacy and security standards framework for California's implementation of electronic health information exchange or HIE. Additionally she is assisting in the analysis of major risks and other issues/concerns as they are identified by CalOHII and developing scope sheets and /or issue papers. This may include issues such as federal actions, court cases or issues raised by advocates or constituent groups. My responsibilities include:
  • Research and analyze national and state privacy and security policy issues and trends
  • Preparing issue papers and briefings on privacy and security policy issues
  • Track and monitor the progress of California's HIE efforts
  • Research and analysis of HIE operations and issues
  • Preparing recommendations for the CalOHII and CHHS
  • Providing subject matter expertise
  • Prepare scope sheets
  • Prepare issue papers
  • Analyze proposed HIPAA rules and prepare issue papers
  • Provide assistance with outreach activities including preparation of handouts, PowerPoint presentation and conference arrangements
  • Review and provide written analysis of issue papers, tools and templates prepared by CalOHII and work groups.

Confidential

Business Process Reengineering Study

Business Process Analyst / Subject Matter Expert

  • Worked in collaboration with the Executive Director and Chief of the Licensing Program in evaluating the currently used physician and surgeon licensing processes efficiencies, effectiveness, strengths, and weaknesses. Her responsibilities include:
  • Researching and reviewing of information relating to the current MBC physician and surgeon licensing application and renewal processes and Web Center applications
  • Researching and reviewing statistical data collected from 2002 to present including Source Material and analyzing the data for number of incoming and reviewed applications, renewal applications, applications for Senior Staff review and outcome, and issued and denied licenses
  • Meeting with the MBC Management team to review the draft Policies and Procedures Manual, make recommendations to modify the document and then complete as input to the Business Plan
  • Mapping licensing and renewal processes in collaboration with Chief of Licensing Program to present to the Executive Director and modifying the same as appropriate based on that review
  • Defining the reports needed to effectively manage the Licensing Program and flow of applications including reports generated from Webcenter, ATS and CAS and other sources and developing a Scope of Work and timetable to accomplish producing these reports
  • Researching and reviewing all staff members' roles and responsibilities for the various licensing and renewal tasks and Web Center functions and analyzing and recommending appropriate staffing levels, seniority, and roles and responsibilities
  • Developing a draft Business Plan to improve efficiencies and performance timeliness, quality and management reports of the MBC licensing and renewal processes and Web Center functions and the staffing required to implement the Business Plan
  • Meeting with the MBC Management team to review the draft Business Plan with proposed workflow, determining appropriate modifications, and revising the Business Plan
  • Defining any organizational changes, and staff roles and responsibilities and identifying any possible budget effects
  • Developing Implementation, Communication and Training Plans and
  • Performing a follow-up audit after the final report is issued and revising the recommendations as appropriate.

Confidential

CD-MMIS National Provider Identifier NPI Compliance Project

  • Independent Verification and Validation IV V Consultant / Business Process Analyst
  • Provided oversight and business process analysis consulting services for the CD-MMIS National Provider Identifier NPI Compliance Project being completed by the Fiscal Intermediary FI Contractor, Delta Dental. This project is focused on advancing CD-MMIS to process claims with the HIPAA compliant NPI and the existing Denti-Cal provider identifier.
  • This project affected the business process for stakeholders across the State, including dental providers, claims processers, clearing houses, dental associations, as well as the State Denti-Cal organization. This complex project required the management of eleven 11 Systems Development Notices SDN and two 2 Miscellaneous Projects. Two 2 MDSB staff and approximately 10 FI-contract staff have been assigned to this project. This project includes application of methods based on IEEE Standards 829, 830, and 1016.
  • This new Provider ID represented a paradigm shift for the organization. In the old model, health plans or States issued provider IDs, and the providers used those ID's in communications with the plan. With the advent of the National Provider ID NPI , providers were responsible for obtaining their own ID, then telling the plan, or State, what ID they would be using in submitting claims. Joey assessed the organizational requirements that would be necessary to support the implementation of this new Provider ID. She identified the new processes that would support this new paradigm, and ensure the accurate and timely payment of claims.
  • My responsibilities include:
  • Ensuring accuracy of the operations/systems remediation and implementation due to HIPAA NPI and Medical Code Set Requirements
  • Assuring MDSB that the Delta Dental HIPAA NPI and CDT-4 Projects will be completed within project constraints and will deliver a functional, quality product that meets standards for certification
  • Determining if CD-MMIS deliverables, procedures and processes met contract requirements
  • Reviewing and verifying test cases and test results as well as logging and reporting the results and status of the testing efforts
  • Continuously working with multiple levels of State and Delta Dental users to ensure reviews are completed, issues are documented and resolved
  • Becoming acquainted with the Provider and Claims subsystems of CD-MMIS, Enterprise Output Solution EOS and Document Image Management Systems DIMS in order to monitor day-to-day operations post implementation and
  • Identifying issues, such as increases in claim denials due to lack of provider NPI registration.

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