SUMMARY:

• My bio includes Healthcare IT project management, support, and facilitator within the Payer System sector. I have over 25 years of hands on experience in Project Management and Lead experience in system analysis, and requirement elicitations to support a system design. I am hands on at a Senior Level in Configuration Analyst for front end work, and backend table update and maintenance based on a data model. My direction and support involves full SDLC Implementations, data migration and integration exercises with ongoing system support. I have over 25 years’ experience in the Facets world but also other claims payers systems as well.
• I have a passion in mentoring to provide knowledge transfer to Jr. Analysts and other support staff to include documentation for training in support of Configuration, and Quality Assurance metrics. The projects that I provide support involve Government, Commercial, and Managed Care large scale operation efforts. In leading efforts to support necessary conversion and integration of Medical and Vision products to streamline the efforts in the initiation of a product build, down to a benefit and pricing level, allows a payer system to be fully utilized and optimized for maximum performance for auto adjudication of claims. The support teams involve onshore and offshore resources working with functional and non - functional requirements for the ability and proficiency to engage successfully.
• My leadership skills are solid based on years in the healthcare industry, quality standards and state vs federal mandates during a full SDLC from an system analysis, optimization, and design perspective. I am an acting business owner, and the liaison between operations and the business. My support includes Leadership role in driving the design sessions in a cross functional team capacity to obtain a strategy and flush out, and mitigate cross team dependencies to identify, and bridge GAPs in determining what’s in scope and out of scope based on an iteration or phased approach. Based on current state an approach I use is to determine root cause based on analysis and implement as appropriate a business process workflow. My job as a SME is to articulate, document, and provide visual proof of concept(s) based on the culture and pulse of the business with expert knowledge of the Health Insurance Industry, Finance, and Claims Administration guidelines for state and federal regulatory compliance. Output of each phase or iteration creates standards for operations to include lessons learned, and exposing myself and others to compliance regulations consistent with the laws and mandates applicable to CMS guidelines from a business perspective with MMIS requirements for Medicaid, Medicare, and MCO business for 837 claim files via GUI interfaces for successful transmission across vendors, HIPAA gateway, and service provider lines.
• The tools I use to perform my daily responsibilities are: SQL, Oracle, and Sybase to interrogate data, Flow Charting, Microsoft suite, Microsoft Project, Power point presentations, Visio, Clear Quest, and JIRA.

TECHNICAL SKILLS:

Software/ Applications/ Databases: MS Office Suite, Visio, MS Project, Lytec, Medi-soft, HSS Winstrat, Ingenix formerly Encoder Pro,APC Grouper, Rate Manager, EZ Group, ICS, CPSI, Sharepoint, Siemens 3M products, Tapestry (EPIC),HBOC, SMS, Care Systems, Envisions, Facets V5.3X, Ulticare, CICS, SSI, Meditech, HMS, Optum 360,McKesson clinical editing, MHS, TDH, Premis, Southware, NASCO, Diamond 950, Paradigm, RIMS, FoxPro, Oracle, Sybase, Amisys, Misys, CAPPS, TOPPS, FISS, Cisco, HPQuality Center, and Load Runner

Operating Systems: UNIX, AS400, Windows based, HP/Unix, Linux

Networking: Novell, Citrix

PROFESSIONAL EXPERIENCE:

Confidential

Sr. Consultant

• Sr. Consultant for system optimization in support of payer integrity for a customized solution based on current and future business on a Facets v5.4X.platform
• Responsible for creating Governance document for Facets designs based off current state for future modeling of ACA, Individual, and Transitional business for Large, Individual, and Small Group lines of business.
• Hands on SQL query validations for data analysis, validation, and file comparisons in support of Facets optimization for plan structures.
• Responsible for documenting Configuration Design documents (CDD) for configuration traceability, and requirement traceability based on TFS service requests and incident tickets.
• Initiate preliminary Use Cases based on test cases for the administration of Medical Plans for claims, benefits, and provider contracting agreements to support financials, and reporting.
• Implement naming conventions for product, and product component prefixes based on smart coding for customized BCBSNC business.

Confidential, Santa Ana, CA

Product Owner

• Product Owner and Team Lead for FACETS implementation efforts for the state of Nebraska.
• Project Lead for MMIS development efforts for coding in FACETS to support Nebraska Medicaid.
• Managed configuration efforts to implement a design for development, configuration, and UAT testing based off benefit categories for business optimization and payer integrity.
• Orchestrated set up and configuration rules for clinical editing based on benefits, services, and state/federal guidelines and rules working with Optum 360.
• Support dual eligibility 834 transaction configuration for Medical plans.
• SME for Product build, Benefits, and Pricing in FACETS.

Technologies: Optum 360 coding guidelines, ICES, Toad.

Confidential,TX

Sr. Systems Analyst

• Lead Systems Analyst for full data migration from Legacy system to Facets V5.01.
• Created the Benefit Grids for the State of TX and IN that shows the breakdown of all applicable benefits in support of an MMIS system implementation; similar to a benefit summary for group insurance but formatted and customized specifically for Texas Medicaid.
• Performed product build for Medicare Advantage, and Medicaid/ Medicare secondary plan products.
• The implemented grids included all benefits, coinsurance based on FPL (Family Poverty Level), exclusions, benefit codes, and product variables for panel approval from HCSC prior to a handoff to configuration.
• Facilitate team and departmental meetings to ensure all requirements are supported by FACETS design and configuration efforts for: Financials, Clinical Editing using McKesson Claims Xten, and Claims Administration in support of Health Care Service Corporations (HCSC) governance for TX Medicaid benefits involving: Duals for Medicare/ Medicaid, Chip, Chip Perinatal, and Star lines of business.
• Performed Level V configuration based on the architectural design for standard and non-standard products/ plans. Performed table modifications, and updates in the ODBC using Facets data models for:
• Participated in creation of an ICD-9 crosswalk for ICD-10 coding based on Optum coding guidelines for Medical claims, Medical coding, benefits, and pricing.
• Worked with IT for the technical design and infrastructure to optimize Facets functionality prior to making recommendations for extensions.
• Responsible for Facets Configuration efforts based on a plan document or benefit summary to define and structure all components of a product for claims administration and auto adjudication of claims based on:
• Product type
• Member and Family Accumulators (MEAC/ FAAC)
• Subscriber/ Member Eligibility - includes dual, and conditional
• Limit accumulators, and Cost shares
• Benefits, to include Supplemental and BPA modeling for SPQG and SRQG tables.
• Pricing, and Provider Agreements
• Worked special projects with the EDI team in the migration of data and conversion of the 834 enrollment files as received from the State. Performed mapping exercises to format data for the file to be ingested within Facets via the HIPAA gateway.

Technologies: Optum 360 coding, McKesson, SQL, Access, Excel, 834 Companion Guide.

Confidential

Lead Systems Analyst

• Lead Systems Analyst for a full SDLC project to integrate data from an AS400 legacy system into FACETS V5.20
• Performed data modeling to analyze potential payer system optimization for a customized solution on a FACETS platform in preparation to migrate data from an AS400 system as the source of truth to promote business into FACETS.
• Gather requirements from stakeholders to create a business requirement document (BRD) for to have traceability in document form as current to establish gaps, make recommendations to support utilization of the new system (FACETS) for future state and new business.
• Provided knowledge transfer in a team effort for FACETS configuration.
• Facilitate requirement sessions with the business, stakeholders, and operations to gain buy in and ultimate approval.
• Identify and document requirement items considered in scope utilizing an AGILE methodology approach to maintain project timelines.
• Leveraged current processes to be recognized and adopted into a new system.
• Implemented best practice logic for system optimization for internal and external clients for data migration and integration.
• Create high level benefit structure approach templates for product builds based on current and future state for all lines of business.
• Perform initial integration testing prior to transitioning to the Quality Assurance team.

Technologies: Excel, SQL Developer, and Sybase.

Confidential

Project Team Lead/ SME, Facets Project

• Sr. Technical Analyst Lead for 18 Configuration Analysts, and offshore Developers.
• Provide support in working with project managers, business analysts and lead programmers to define technical solutions for implementing business requirements and see them through to completion.
• Work with the business team to define, analyze and document requirements.
• Document functional specifications and work directly with development and QA to ensure successful delivery in testing efforts for configuration, and batch processing using requirement metrics.
• Provide input into system design to help development of batch processing, flat file layouts for integration, and batch job scheduling for development work and efforts.
• Develop a strong partnership with the delivery team to ensure on time, scalable and high quality business solutions.
• Act as an escalation point person for support issues that require detailed analysis and management. Provide management status reports for overall team efforts to benchmark.
• Assist in on-boarding Configuration Analysts on an Excellus project based on line of business for Commercial Managed Care HMO and PPO products.
• Provide leadership and guidance in configuration of Core Facets and Networks V5.01
• Create template structure for product builds to assist with the Quality Assurance process.
• Create training material for configuration of Product builds, Medical Plan Applications, and Variable Components for: Claims, Benefits, Pricing, Provider Agreements, and Member out of Pocket (MOOP), to resolve triaged service requests from the business, any change requests for groups based on changes identified in Sales and Marketing for new and/or existing business.
• Perform peer review and table set validation prior to data being CMU’d into production from UAT pre-production environments.
• Use of Agile methodology to engage in phased standards for: SIT (system integration testing), regression testing after defects resolved, and user acceptance testing for business rules.
• Triage defects to Analyst and provide direction for a resolve based on best practices in determining root cause for configuration to ensure positive results in regression testing.
• Create update, unmatched, and append SQL queries in ACCESS, Oracle, or Sybase for FACETS backend tables.
• Prepare Analyst for transition into Core BCBS Excellus team.

Technologies: Access, Excel, SQL, ODBC, and Sybase.

Confidential

Sr. Business System Analyst

• Lead Business Engineering Analyst for Managed Care/ ASO products based on state and federal guidelines involving Health Care Reform laws, and Dual eligibility, for Commercial and Government business (grandfathered and non-grandfathered products) in Facets V5.01.
• Senior Systems Analyst in providing guidance to mentor Jr. Analysts in configuration of a system design for development projects using Facets Medical Application modules.
• Document functional and non-functional requirements based on the Business.
• Host JAD sessions involving Operation teams for cross dependencies and GAP analysis strategies.
• Working knowledge of setup & configuration for various Facets modules for product coding and administration of claim, benefits for claims, pricing, and provider agreements within Facets prior to a production load. Trained in utilization of FACETS BPA module to streamline supplemental qualifier groups for various benefits.
• Assist in data mapping exercises for xml & flat file layouts for integration of data for provider, pricing, benefits, membership, and eligibility files for 837P/ 837I data push via the HIPAA gateway.
• Support implementations for ICD- 9/10 initiatives based on claim administration and EDI transactions.
• Facilitate Team meetings to review and mitigate system impacts and cross dependencies for iterations of a software development life cycle.
• Working with technical on various Facet extensions for provider, member eligibility, and claim table uploads.
• Triage defects based on configuration and/or programming issues.
• Create SQL queries using Access, Oracle, and Sybase.
• Create detailed Configuration Design Documents for all modules in creating Medical Products, that includes but is not limited to:
• Create workflow for job aids as policies and procedures are established for handling of claims during adjudication.
• Facilitate cross functional team meetings to resolve and triage defects based on coding issues, system changes, or configuration issues as identified in quality reviews, change requests, or contract renewals.
• Work with management to ensure high standards for a high 90 percentile in auto adjudication with minimal manual intervention.
• Part of team to establish quality assurance metrics with putting metrics in place to ensure high standards for testing, and tight configuration for overall accuracy and timeliness of claims administration and code delivery.

Technologies: Access, Excel, SQL, ODBC, HP Quality Center, and Sybase.