Summary

• My professional experience has given me the skills and exposure to communicate with business and technical members, researching and interpreting information for business and IT projects.
• My analytical skills allow me to see the big picture and break it down into action steps while skills in client relationship management, leadership and aptitude for technology allow me to make my business analysis role more cohesive and portable into different industries.
• Following is a brief summary of skills and knowledge that will allow me to contribute greatly for your organization:
• About 4 years experience with Medicaid Managed care organization: Analysis of CMS regulations, its impact on payment policies, claims reimbursement and provider contracts.
• Participated in implementation of CommonwealthCare plan - a plan set up to include members eligible in MA Healthcare Reform Act of 2006
• Role of Claims SME during implementation of MMIS - Medicaid Management Information systems for Executive office of Health and Human Services of State of Massachusetts. Understanding and experience with Software Development Life Cycle, SDLC.
• Consultant for Revenue Management project: Analysis of regulatory compliance, infrastructure and revenue management of Local Health Departments LHDs of New York State.
• Analysis of patient data for market expansion, financial reporting and patient and service analytics for Partners Healthcare.
• The common denominator throughout my career is my success in connecting the dots to put together the big picture from fragmented details. My experience proves that I have a natural ability to analyze and correct inefficiencies in processes and systems to save money and time while achieving the set goals.
• The attached resume summarizes my experience and demonstrates my successful advancement I look forward to meeting with you so we may further discuss how my extensive skills and experiences can benefit your organization. Please contact me at your earliest convenience so this meeting can be scheduled.

Profile

• Healthcare Industry MMIS implementation State of MA
• Managed Care industry QA / UAT testing Manual
• Requirements Analysis Medicaid Managed Care
• Business Analysis Process Flow Analysis
• Healthcare Claims Systems Medicaid payment methodologies
• Healthcare Claims Adjudication Medicaid Payment policy analysis
• Provider Contract Configuration Patient data and payment trends
• Revenue Cycle Analysis SDLC methodology
• Claims systems implementation Infrastructure analysis - LHCs
• Operational Analysis - LHCs Government Regulations Compliance
• Documentation SWOT reports, Requirements Reports, Test plans, Medicaid Payment policies,
• User guides for internal tasks
• Building, implementing and enhancing processes, procedures and work flow for a new system
• Medicaid regulations and compliance CMS, DHCFP, State of MA healthcare reform of 2006

Experience

Confidential

Business Analyst / Revenue Cycle Analyst

• Consultant role analyzing infrastructure and revenue cycle management of Local Health Clinics - LHCs of New York State Health Department. Gained knowledge and applied federal healthcare regulations, statues which impact health care revenue operations.
• Prepared business requirements narrative report for client New York State health Department.
• Analyzed business processes, state and federal regulations compliance, healthcare claims and revenue cycle and overall infrastructure of six local health departments of New York State.
• Provided gap analysis between as-is and to-be processes and made recommendations.
• Created a sample workflow based on requirements, best practices and recommendations.
• Compiled reports summarizing findings and recommendations for each of sample counties. This allowed them to make immediate changes and use it as a benchmark for all LHCs.

Confidential

Business Analyst/ MMIS Analyst

• Claims SME role for implementation of a web-based, SOA , claims processing system, MMIS - Medicaid Management Information system for State of MA Executive Office of Health Human Services.
• Applied knowledge of medical codes and terminology, provider benefit rules, provider reimbursement methodologies, service limitations, member eligibility of different plans and government regulations compliance to analyze Claims Adjudication system for State of MA.
• Utilized knowledge and researched federal and state regulations to ensure accurate Claims adjudication and TPP reimbursement.

Confidential

Business Analyst / Provider Contract Analyst

• Key role in configuring provider contracts into claims processing system for Medicaid MCO. Key role in configuring member benefit plans, business rules, payment rules and service limitations into implementation of new Claims adjudication system, HealthTrio. Applied knowledge of medical coding and terminology to process third party payments and overall claims adjudication.
• Reviewed contract agreement terms and configured benefits plans, fee schedules and processes into claims processing system to ensure accurate provider payments.
• Implemented tools and strategies to reconcile reimbursement methodologies and healthcare claims processing systems.
• Researched, communicated information to align federal health care regulations that impact health care revenue operations.
• Managed Payment Policy Project plan to ensure compliance with governmental regulations CMS, DHCFP - and aligned provider billing practices with Network Health's payment policies.
• This communication resulted in increased efficiency and accuracy of claims billing and payments and improved provider relationships.
• Analyzed and manipulated health care data to improve insurance adjudication processes to ensure accurate TPP Third Party Payments.

Confidential

Business Analyst, International Operations

• Managed and analyzed patient demographic and financial information for Partners International Program. Partners Healthcare is a integrated healthcare system founded by Brigham and Women's hospital and Massachusetts General Hospital.
• Analyzed patient data and payment trends for profit and market analysis resulting in expansion of new markets and increased revenue.
• Demonstrated ability to learn and apply medical coding, medical terminology and TPP reimbursement to analyze and manipulate data for senior management.

Confidential

Team Lead Product Implementation

• Led new product implementation that reconciled and recovered capitation non-payments or partial payments to various medical groups. Audited Claims activity of several clients for capitation overpayments and recovered 60,000.
• Conducted on-going monitoring of contracted and non-contracted Third Party Payment TPP trends.
• Identified and assisted with software enhancements resulting in increased efficiencies of analytics reporting by 30 .Managed automation of data processing and reduced system run times by 90

Confidential

Business Systems Analyst

• Analyzed business requirements for GUI application development for efficient monitoring licensing and registration of associates.
• Created and executed test cases for LARS Licensing and Registration based on functionality analysis and business requirements resulting in reduced errors and improved functionality.

Confidential

Project Coordinator

• Managed internal projects for senior management.
• Created an office management infrastructure to monitor profitability and develop income projection matrixes by analyzing and performing data and workflow analysis.

Confidential

Business Analyst / Team Leader

• Led new products/functions from inception to maintenance stage: defined processes, analyzed their applicability, and enhanced them to meet anticipated needs, resulting in time and money savings.
• Redesigned a provider database after extensive data analysis, data mapping, process mapping and work flow analysis. Increased report accuracy rate by 50 , decreased annual costs by 60,000.
• Key role in the implementation of a new product / new business, GIS application, GeoAccess.