SUMMARY:

• Over fifteen years of EDI analysis, EZ - CAP, Project coordination experience with demonstrated proficiency in the following key areas:
• Deliver exceptional results as business analysis, production support, project management, and account management.
• Technically proficient with proven track record of leading projects and team members to exceed expectations.
• Clarify business requirements, perform root cause analysis and gap analysis; create process and system improvements to increase productivity and decrease cost.
• Known as patient and motivated an out-of-the-box critical thinker who inspires team members to achieve peak performance.
• Create long lasting relationships with internal and external customers.

EXPERTISE IN:

• Production Support and Issue Resolution
• Account / Vendor Management
• Business Requirements: Info Gathering and Writing
• Research and Root Cause Analysis
• HIPAA ANSI 837 (P, I, and E) and other transactions
• Process Improvement Initiatives
• User Acceptance Testing (lead and contributor)
• Project Management HIPAA Expert
• ANSI 5010 HIPAA Expert
• 837P, 837I, 834, 835, 270,271,276, 277, 277U, 997, 999 EDI Specialist (Electronic Data Interchange)
• EZ-EDI mapping Specialist ICD -9 and ICD -10
• Business Processes/Needs Analysis
• Ability to work well with people from different disciplines with varying degrees of technical

PROFESSIONAL EXPERIENCE:

Confidential

Lead EDI Analyst / Project Manager

Environment: MS Access, MS Excel, MS Project, HIPAA, FTP pro, Ultra edit, Claredi, SQL scripts / queries/testing

Responsibilities:

• Created maps for each Health Plan and LOB
• Test 837 files with Health plans so we can do direct submissions Used Confidential create profiles for each TP
• Extracted monthly files for submissions of 5010 files Automate extractions for monthly submissions
• Communicate with X12, WEDI and Confidential for new information on 5010 and all standards Resolve client issues with mapping and X12 education
• Used MS Excel to track submissions
• Worked with MS Access for error, and other tracking SQL scripts / queries/testing
• Managed several projects, same time In charge of training
• Responsible for implementation of Confidential 5x to 6X

Confidential

EDI / HIPAA ANALYST

Environment: MS Access, MS Excel, MS Project, HIPAA, FTP pro, Ultra edit, Claredi

Responsibilities:

• Verified and corrected files formats 837 P I 835 Restored ERA files
• Helpdesk hotline
• Reprocess EDI 837 files, test using Claredi
• QAD ERP system for handling EDI interactions

Confidential

EDI / HIPAA ANALYST / Test coordinator

Environment: MS Access, MS Excel, MS Project, HIPAA, FTP pro, Ultra edit, Claredi

Responsibilities:

• Facilitation of IT based solutions through extensive collaboration with business clients.
• Provided subject matter expertise and project support thru the entire project development life cycle.
• Assigned to 5010 /DO project Assigned to the ICD-10 project Scrum, Agile

Confidential

EZ-EDI/HIPAA/QA

Environment: MS Access, MS Excel, MS Project, HIPAA, FTP pro, Ultra edit, Claredi Created 4010/5010 guides for all transactions and performed 5010 Testing of all transactions

Responsibilities:

• Processed files all transactions through Claredi and report errors to clients
• Instructed providers on 837 P & 837I formats and Claredi errors suggest business solutions to satisfy HIPAA requirements
• Project manager on 6-month project for client to get 837P and 837I into production with 8 health plans
• Communicated with X12 and Confidential for new information on 5010 and all standards Resolved client issues with mapping and X12 education
• Created maps for all X12 transactions inbound and outbound formats in accordance with health plan guides
• Created custom maps for Blue Shield, Health net, Cal Optima, Molina, Care1st, EZ-Choice and SCFHP according to their guides
• Ability to work both independently and in team-oriented environment Confidential team member HIPAA task force
• WEDI member
• Kept up on CMS changes and alert the appropriate staff.
• Comprehensive knowledge of professional (1500) and institutional (UB92/ UB04) billing forms, knowledge of CPT, HCPCS and ICD9, ICD-10 codes
• Analyzed information and situations to determine possible future issues and report resolutions and recommendations to the team for solutions.
• Advised development team on issues with maps that need to be changed.
• Led on-site client sessions for EDI/ HIPAA training and resolutions to EDI issues Knowledge of claims processing work flow
• Crystal reports inner outer joins.
• Managed the scope and timelines per the client’s requirements and responsible for delivering projects on time

Confidential, Woodland Hills, CA

EDI ANALYST

Environment: MS Access, MS Excel, MS Project, HIPAA, FTP pro, Ultra edit, Claredi

Responsibilities:

• Verified accuracy of x12 HIPAA transactions
• Processed 837, 834 test files, NPI and accuracy Analyzed 837 test data from providers
• Ran test files through Claredi
• Instructed providers on 837 P & I formats, and Claredi errors
• Gathered user requirements, made recommendations for system changes Demonstrated business solutions to satisfy HIPAA requirements
• Verify HIPAA production files and make corrections to the file to pass Claredi requirements
• Kept up on CMS changes and alert the appropriate staff
• Created maps for 837 format, with all the X12 segments to make sure all the information to our ABS system and MS Access systems were passing
• Assisted providers with claims and x12 formats
• Ability to work both independently and in team-oriented environment Confidential team member HIPAA task force
• Led on Confidential encryption team
• Comprehensive knowledge of professional (1500) and institutional (UB92, UB04) billing forms, knowledge of CPT, HCPS and ICD-9 and ICD-10 codes
• Analyzed information and situations to determine possible future issues and report resolutions and recommendations to the team for solutions

Confidential, Woodland Hills, CA

EDI ANALYST

Environment: MS Access, MS Excel, MS Project, Crystal reports, HIPAA, FTP pro, TSOAIMSP

Responsibilities:

• Verify accuracy of X12 HIPAA transactions
• Verified provider and claim information in WGS 2.0 and Star Used FileNet verify claim information
• Processed 837 test files
• Analyzed 837 test data from providers Ran test files through Claredi
• Instructed providers on 837 P & I formats and Claredi errors
• Gathered user requirements, make recommendations for system changes Came up with business solutions to satisfy HIPAA requirements
• Verified HIPPA production files for providers
• Keep up on CMS changes and alert the appropriate staff Processed enrollments for 837 claims and ERA/EFT
• Validated provider information in the mainframe to process enrollments
• Assisted providers in a helpdesk environment with claims and X12 formats Created monthly encounter report
• Tracked encounter counts
• Managed the scope and timelines per the Client requirement and responsible for delivering projects on time

Confidential

EDI/HIPAA ANALYST

Environment: MHC, Ms excel, HIPAA, MS Access, Claredi, UB92, NSF, EC MAP, FTP Pro

Responsibilities:

• Created HIPAA transaction companion guides and verify accuracy X12 HIPAA transactions
• Processed 837 production files
• Analyzed 837 test data from providers Managed several projects at same time Ran test files through Claredi
• Instructed providers on 837 P & I formats and Claredi errors
• Gathered user requirements, make recommendations for system changes.
• Processed files using EC map to translate into a flat file that I can upload into MHC our billing software
• Analyzed MHC problems and create solutions.
• Came up with business solutions to satisfy HIPAA requirements Processed 834 monthly production files
• Created and processed 837 test data to AHCCCS Created memos to inform staff of HIPAA updates Confidential team member HIPAA task force
• Lead on Confidential encryption team/
• Kept up on CMS changes and alert the appropriate staff
• Comprehensive knowledge of professional (1500) and institutional (UB92) billing forms, knowledge of CPT, HCPCS and ICD9 codes
• Analyzed information and situations to determine possible future issues and report resolutions and recommendations to the team for solutions
• Managed the scope and timelines per the client’s requirements and responsible for delivering projects on time
• Managed several projects at the same time

Confidential, Encino, Ca

EDI ANALYST

Environment: EZ cap, MS Access, MS Excel, MS Project, Crystal reports, HIPAA, FTP pro

Responsibilities:

• Responsible for all encounter submissions to Health Plans and tracking
• Analyzed HIPAA version of EZ Cap and make recommendations to software vendor and test updated recommendations
• Automated the system and data process
• HIPAA testing of all in/outbound transactions
• Communicated with Health plans to get specifications and preferred method of data submission
• Discovered system errors and report them to system programmers to be corrected
• Tracked errors and made sure that departments responsible make correction so that I can resubmit data, including verifying that correct ICD-9 and HPCS and CPT codes are being used
• Constantly checked MEDI-Cal and other sites for currents changes to LOB and inform the appropriate departments so that changes can be made
• Create reports using Crystal and Arpeggio reports
• Used Access and Crystal reports to verify that all data that should be sent is being sent to Health plans
• Extracted data using Crystal reports
• Discovered system errors and correct them
• Communicated with the health plans and clearinghouses to decrease errors and increase volumes
• Tracked encounters, verify error reports and instruct Medical Groups on corrective actions
• Created an organized working area and department
• Attended JOC meetings to discuss compliance issues and other pending items. Used MS Project to better organize my time
• Tested, analyzed and submitted new file formats
• Created queries, reports and researched data using MS Access, MS Excel, and Crystal reports
• Validated membership enrollment for data processing

Confidential, Woodland Hills, CA

Senior Business Operations Analyst

Environment: MS Access, MS Excel, MS Project, Crystal reports, HIPAA, FTP pro, TSOAIMSP

Responsibilities:

• Knowledgeable in X12 all formats and legacy formats
• Responsible for providing updates to system tables related to claims, e.g. Diagnostic code, procedure code, code sets for claim status, (from the Washington publishing site), modifier code, and pricing tables
• Comprehensive knowledge of professional (1500) and institutional (UB92) billing forms, knowledge of CPT, HCPCS and ICD9 codes
• Analyzed information and situations to determine possible future issues and report resolutions and recommendations to the team for solutions
• Processed enrollments for Professional and instructional claims, eligibility, and encounters
• Ability to work both independently and in team-oriented environment
• Tracked claims and encounters, verify error reports and instruct Medical Groups on corrective actions
• Created month end reports and database to track data
• Managed the scope and timelines per the client’s requirements and responsible for delivering projects on time
• Managed several projects at the same time

Confidential, San Juan Capistrano, CA

Senior Business Operations Analyst

Environment: MS Access, MS Excel, MS Project, Crystal reports, HIPAA, FTP pro, TSOA, IMSP

Responsibilities:

• Created Access database to effectively track all claims, contracts and calls. Created reports and queries as requested
• Supported external customers with troubleshooting system problems and applying appropriate solutions. Removed software from provider’s systems using PC Anywhere and Carbon Copy prior to license expiration
• Supported internal employees with installation and configuration of software.
• Ensured department wide operation of MS Outlook, including making necessary configuration using MS exchange server. Added required configurations to Outlook allowing administrative personal access to management’s calendars
• Provided installation and ongoing support of software and hardware, printer configuration, etc. For employees
• Trained employees on various software packages including MS Office, Windows navigation and answered how to questions
• Transmitted claims via modem, helped to setup a FTP server
• Implemented and automated procedures that resulted in 80% increased efficiency in the tracking and processing of all Medi-Cal and Medicare Part B claims and Medi-Cal contracts
• Authored procedures on all desktop duties Managed several projects at the same time