SUMMARY:

• PMBOK knowledge and skills for delivering project documentation in all Knowledge areas (Initiating, Planning, Executing, Monitoring & Control, Closing); Charters, Business Requirement Documentation, Functional Requirements, Test Plans, UAT Test Cases, Performance Matrix Reporting.
• Knowledgeable on Claims Adjudication Processes. Applied knowledge of Clinical and Payer data processes, including but not limited to Enrollment, Prior Authorization, Claims billing for both Institutional and Professional Providers, Claim Status Inquiry, Eligibility and process flow.
• Knowledgeable on PMP/PMBOK methodologies for projects, including Initiating, Planning, Executing, Monitoring and Controlling, and Closing. Six Sigma practices are used as they related to business analyst and project documentation and project development. Other similar processes, such as SDLC are practiced regularly.
• Experienced in participation in various development methodologies, include Agile/Scrum and the related Sprints and Reporting.
• Native English and also comfortable and capable of communicating using Spanish on Spanish - speaking projects.
• Top and applied knowledge of EDI transactions. Experienced on project management documentation (Charters, BRD, FRD, TDD, TRD, Test / Use Cases, Validation). Effective and FAST as an EDI problem solver, to identify problems in EDI files. Companion Guide design and interpretation skills, including reviewing or interviewing business process owners and applying companion guide rules. Teaching-level knowledge and professionalism in creating actual EDI data, from scratch or from data mining processes. Years of experience on all HIPAA transactions: 270/271 Eligibility; 276/277 Claim Status; 837ipd Claim; 835 Remittance; 278/278 Prior Auth; 834 Enrollment; 820 Premium Payment; 810 Invoice; 850 Purchase Order; 850, 855 PO Acknowledgment; 856 ASN/Manifest; 867 Pharmaceutical Product Transfer Report; 999, 277CA and others.
• Solid Payer and Provider/Clinic business knowledge, including all Payers. Very skilled at defining HIPAA and EDI requirements for Claims Processing, Payment / Remittance / EOB; Eligibility, Prior Authorization and other Adjudication Processes. Knowledgeable on mapping the UB04, CMS-1500 and other forms. Able to build Use Cases from a Payer perspective.
• Over 15 years of Confidential experience, including all Payer Functions: Eligibility, Claims, Remittance, Enrollment, Prior Authorization and all related Government mandates.
• Skills includes experience with ICD-10 diagnosis coding and CPT procedure codes, including procedure code modifiers and grouper scenarios.
• Over 15 years of experience as a Business Analyst, including full project methodologies from both a business perspective and from a technical and SDLC perspective. Capable of authoring project documentation for Charters, Business Requirements, Functional Requirements, Project Plans, Test Plans, Use Cases and Project Costing / ramping resource costing. Skilled at bridging the gap between Technical and Business Personnel or between Client and Corporate Personnel.
• Over 15 years of EDI experience, with a focus on healthcare EDI.Serve as an EDI expert on EDI and ACA transactions. EDI resource skills (segments, elements, loops, etc.), Skilled at analyzing raw EDI data for mapping.
• Skilled at validating Data Lake and Data Governance mapping responsibilities. Understanding of process flow and low-level EDI requirements.
• The following are EDI Data Skills:
• Creation of Business Function Scenarios, with a focus on Healthcare: Claims, Encounters, Enrollment, Remittance, Claim Status, Eligibility, Prior Authorization, Acknowledgments.
• Creation EDI data files, to match defined business function test cases
• Creation of volume EDI files
• Creation of Volume Testing Files. Able to produce individual or stress-testing files (transaction volumes by the thousands).
• Able to mentor IT or Business Teams on successful EDI data file builds, for testing and validation. Experience includes teaching both Government and private corporations, on EDI data construction.
• Very skilled at building mapping documentation and requirements to validate and/or define gaps between Requirements, Mandates and Corporate Data Bases, Data Lakes or Data Warehouse storage.

TECHNICAL SKILLS:

• Microsoft Project
• Microsoft Office
• MS Word
• MS Excel
• Power Point
• Visio
• Access
• Custom Project Management tools
• Test Management tools
• Such as TFS
• Test Director
• Validation Testing tools such as CLAREDI/Optum
• PMP / PMBOK Project Management Methodologies
• Six Sigma methodologies (DMAIC). Registered with PMI
• Preparing to take the newest PMBOK PMP Certification test.

PROFESSIONAL EXPERIENCE:

Confidential, Miami, FL

Lead EDI SME, BA, and EDI Testing Analyst

• Mentor group in Healthcare Business Processes:
• Claims
• Enrollment
• Payment / Remittance
• Eligibility
• Acknowledgements
• Develop EDI Test Cases for SIT/UAT
• Develop EDI Data for test cases
• Build Test Plan
• Mentor other co-workers on test plans, test cases, test data, healthcare
• Work on all HIPAA EDI transactions
• Perform Go-Live for 27X processes
• Validate 837 Institutional and Professional systems and files
• Automate testing
• Perform Gap Analysis
• Create Artifacts and design, build and train testing processes, per department
• Build Training Materials

Confidential, Scranton, PA

ACA Business Analyst

• Train Montana State Employees on claims requirements
• Develop ACA Enrollment criteria
• Create Enrollment Maintenance Type Scenarios
• Create Enrollment coverage scenarios
• Perform 834 analysis for matrix reporting
• Define success / failure criteria for 834 Enrollment scenarios
• Create raw 834 data files
• Billing Transactions
• Create secondary billing scenarios
• Create raw data files
• Perform matrix reporting and statistics
• Develop testing for 834 scenarios
• Create testing SOA requirements for Enrollment, Claims and Remittance
• Develop testing scenarios for 837 Claims
• Test Trading partner on-boarding/enrollment transactions and scenarios
• Resolve EDI issues
• Submit and receive files through EDIFECS translator
• Resolve issues outlined in 999 Functional Acknowledgements
• Build requirements for Premium Payments (820)
• Develop validation artifacts
• Work with various groups to resolve EAI (Enterprise Application Integration) issues.
• Train Resources on how to build transactions
• Work directly with both external trading partners

Confidential, Phoenix, AZ

Project Manager

• Multi-State APTC project Deliverables
• Develop Testing Scenarios for EDI processes
• Develop validation artifacts for Tax Subsidies
• Serve as team lead over large testing team
• Develop testing documentation, templates and processes
• Define sub-teams for large-scale testing
• Coordinate sub-team testing efforts to management, including status updates
• Manage artifact production and protocols
• Serve as EDI SME for EDI Transactions
• Work through several EAI issues involving translators, EDI Formats, and VPN processes
• Complete Project Management Documentation

Confidential, Orlando, FL

Lead BA

• Perform SOA Testing, include test scripts and testing plan
• Develop Test Plan for Claims Testing
• Perform Analysis of 834 Enrollment Data
• Establish milestones and timelines for 837 Testing Phases (SIT, UAT, Regression)
• Review and implement ETL (Extraction, Transformation and Loading) process for data preparation
• Identify HIPAA EDI Transaction elements impacted by the ICD-10 mandate
• Work with Trading Partners, both Clearinghouses and Providers, to set up testing
• Serve as SME for project documentation: Project Plans, Business Requirements, Functional Requirements, Test Plan, Test Cases / Scripts.
• Maintain Requirements traceability matrix database and status reporting
• Train other BA’s and Testers on the requirements building and testing processes

Confidential, Portland, OR

EDI Business Analyst.

• Create and validate business rules for ACA Trading Partner Enrollment
• Provide leadership for team as an ACA Enrollment SME
• Lead and define the business processes and related 834 technical details for ACA Enrollment
• Create flow diagrams and other Business project documents, typically using MS word, Excel and Visio
• Automate Testing. Create auto-validation processes.
• Work with trading partners to resolve issues. Assume lead when necessary.
• Create EDI test files
• Validate EDI X12 Transactions
• Validate X12 999 and TA1 Transactions
• Create SOAPUI / XML files

Confidential, Schenectady, NY

RFP and EFT/ERA PM

• Create RFP for Vendors to bid on EDI, EFT (Electronic Funds Transfer) and Web Portal Application
• Serve as PM for EFT RFP
• Serve as SME for BRD and UAT for both IT and Business areas
• Develop UAT Test Plan and create initial UAT Test cases and structure
• Hold Team Meetings, SME meetings, Stakeholder Meetings, Vendor Meetings
• Serve as the team guide and functional project owner

Confidential, Phoenix, AZ

Senior PM and Enrollment BA

• Create PMO templates for claims and enrollment
• Create project plans for 18 different projects
• Build Requirements documents for EDI transactions: 834 Enrollment
• Serve as 5010 EDI SME
• Develop 5010 834 Requirements and enrollment and application conversion
• Mentor State Team on Best Practices for Project Documentation and HIPAA 5010 EDI standards

Confidential, Phoenix, AZ

Senior HIPAA SME

• Build Requirements documents for 5010 EDI transactions: 278 - Health Care Services Review
• Serve as 5010 EDI SME
• Develop 5010 278 Requirements
• Build Test Cases for the On-Line Web Portal Application for Prior Authorization (HIPAA 278)
• Interface with Programmers, during build / test phase

Confidential, Melbourne FL

Senior BA

• Review and define Plan documentation for Government Requirements around claims
• Assess and/or define Medicare and Confidential requirements
• Develop Companion Guides for Claims
• Build Requirements documents for 5010 EDI transactions: 837i, 837p, 834, 820.
• Serve as 5010 EDI SME
• Develop ICD-10 documentation for ICD-10 related resource requirements.

Confidential, Phoenix, AZ

Program Manager

• Drive the QA process for the ICD-10 project
• Developing Project Costing Analysis for million-dollar project
• Perform Vendor Analysis
• Oversee Requirements and Gap review for ICD-10
• Review Project Progresses of Project Managers working around the ICD-10 project
• Responsible for auditing off-shore team selection
• Build job descriptions, financials, and ramp-up/ramp-down models for multi-million dollar ICD-10 project
• Work with Integration Teams on related projects such as EHR and HIPAA 5010 projects
• Review Testing Approach for ICD-9 to ICD-10, including mapping rules and issues

Confidential, Oklahoma

Project Lead / Senior BA

• Develop Business Requirements for all 5010 EDI transactions: 270, 270, 276, 277, 278, 820, 834, 835, 837i, 837p, and 837d and unsolicited transactions (271U, 277U).
• Medicare COB / secondary billing requirements
• NCPDP, D.0 upgrade project work.
• ICD-10 assessment: Work on ICD-10 issues as they relate to the 5010 project. Prepare assessments and overview of ICD-10 requirements.
• Develop Gap and Impact documentation for all HIPAA EDI transactions.
• Work with Sharepoint, existing legacy documentation and WPC Implementation Documents and Client Companion Guides to complete a set of Business Requirement and System Requirement Specification documents, in preparation for HIPAA 5010 Peer Reviews.
• Create PMO documentation from scratch.
• Organize the 5010 project, including timelines, project plans, BRD, FRD, SRS and other templates.
• Work with Fiscal agent and stake holders to resolve interface issues.
• Setup reoccurring HIPAA 5010 and/or JAD sessions to review both physical and logical models for business processes and data transaction processing and adjudication processes.
• Serve as a lead and information source for HIPAA 5010 details and related tools and best business practices.

Confidential, Dallas, TX

Senior EDI Business Analyst

• Develop Business and Technical Requirements for HIPAA 5010 EDI software, including the HIPAA 5010 837 Institutional and the HIPAA 5010 837 professional transmissions.
• Develop Use Cases for the UB04-to-5010-837i transaction.
• Develop Use Cases for the CMS1500-to-837P transaction.
• Utilize Claredi web validation tool to validate software product to all 7 levels of HIPAA compliance.
• Design logical and physical documentation for the XML-to-5010-835 conversion and web clearinghouse.
• Complete testing and bring software product to live status.
• Hold Peer-Review Sessions
• Build Visio flow diagrams
• Build Project Plans for the adjudication process

Confidential, Pinnacle, RI

Senior EDI Business Analyst

• Develop Business Requirements for all 5010 EDI transactions: 270, 270, 276, 277, 278, 820, 834, 835, 837i, 837p, and 837d.
• Work with WPC Gap documents, WPC Implementation Documents and Client Companion Guides to provide a map and crosswalk for ALL 4010A1 to 5010 and Errata EDI projects.
• Oversee a team of Business Analysts and work with technical teams to produce business and technical requirements.
• Serve as a lead SME for all EDI-related projects.
• Automate the WPC to BRD documentation process by converting PDF’s to MS Word documents. Provide documentation standards. This saved months of labor while enhancing document accuracies.
• Meet with management regarding EDI issues.
• Produce 837 test data. As a validated Federal EDI Vendor, I also have UB04 to 5010 and CMS1500 to 5010 software for test or live production. Type claim data into claim-form screens and output 5010 837 transactions.
• Work on Test/Use Case designs.

Confidential, Phoenix, AZ

HIPAA EDI Business Analyst and DB Consultant

• Create compliant HIPAA 837 EDI Transactions for Technical Vendor Testing Purposes:
• Encounter transmissions, 837 institutional and professional.
• COBA transmissions, 837 institutional and professional.
• Standard 837 transactions for professional and institutional EDI validation.
• Develop data importing processes for EDI files.
• Work closely with 18 MCO’s (Managed Care Organizations) to identify problems and solutions.
• Create reporting and custom applications for analyzing flat files as well as HIPAA EDI files.
• Maintain NPI and NPPES database.
• Work on NCPDP files and compliance requirements.
• Produce EDI Testing environments for HIPAA EDI transactions.
• Business Analyst Functions: Produce and maintain all vendor performance matrices and reporting, including details numerical analysis. Create project documentation. Define and suggest needed improvements to management.

Confidential, Fillmore, IN

EDI PM / BA Consultant

• Develop Mapping rules, Design specifications, and Test Case / Use Cases for the HIPAA 837i/p/d; 270/271, 276/277, 835, 824, 275 and others. Worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277). Create EOB systems (835). While “in-house”, help with development; while on-site, work as a business analyst. Projects spanned several Insurance Payers, Carriers, and providers and included work as an EDI Business Analyst roll.
• Created the complete 824 to 837 indexing system for ACS in Hawaii. Worked as an EDI Coordinator, working with Trading Partners and Providers. Worked on and initiated changes to Confidential EDI rules, specifically the Coordination of Benefits processes. Worked on the MMIS system, doing EDI claim testing and EDI processing functions.
• SAP 4.6, Inventory and Disaster Recovery for ROCHE; SAP EDI work for Merisel (CA).
• Consulting work included corporate interviews to determine the scope of project. Existing legacy systems were examined and personnel with ownership responsibilities were interviewed. A design of how the newly created EDI department would function was put together in Visio type flow charting. Job description and skills needed were documented separately. Launch plan created with appropriate stage and production plans was documented. Reviews and corporate meetings were held to discuss issues.
• On consulting projects, generally manage or lead 3-8 technical or business personnel. On in-house projects, responsible for HIPAA EDI from start to finish. Participate in both pre and post client interface to insure projects roll out smoothly. Serve as a representative and contact person.
• EDI and Billing Systems were created with Visual Basic, Sterling Software, Microsoft C. Some Gentran and Mercator work. Windows and user-level Unix operating systems. SQL commands were used to manipulate databases. Used EDISM while working 6-month contract with Magellan, for requirements specifications.
• HIPAA-approved (by carrier) status was attained for proprietary Medical EDI systems. Received letters of validation from both Medicare and Confidential . Listed on the Federal Government’s list of approved & validated Medicare Vendors list. Sat on the Confidential ’s committee for launching the 837 (while working for BCBS/GA).
• X12 specifications were developed, issues were addressed (EDI, security, HIPAA, NPI), X12 version design. Some automation tools and/or scripts were created. EDI systems were evaluated. EDI setup work was performed for Client site, administrative tasks, including personnel and cost estimates were created. Transaction sets included UB92 Versions 4, 5 and 6; X12 270/271, 276/277, 278, 837 (I,P & D), 810's, 850's, 864's, and 997's. More recent work includes UB04 and review of upcoming 5010 EDI versions.
• Internet Domains and HTML and Java Script were developed. Internet software included Microsoft's Front Page. Communication protocols were suggested, including FTP, modem, Frame Relay, Virtual Private Networks, Internet. Encryption options were also evaluated and/or setup, including PGP, SSL, and others.
• Create processes to protect PHI (Protected Health Information) for HIPAA compliance. NPP (Notice of Privacy Practices) was researched and protocols were created for sending NPP’s to patients and users of PHI.
• Remittance automation has also been performed. Multiple Trading Partners were set up as well. Vendors were assisted in EDI interfaces.
• EDI systems were created for both large and small critical medical and/or insurance corporations. Projects also have included Billers, Payers, and both institutional and professional providers.
• HIPAA EDI specialist, HIPAA EDI Business Analyst, EDI Project Leader, systems designer and developer, Client Representative, Conference Speaker, corp. technical trainer.
• Legacy System integration conversions were created. Imports were created to take data from existing systems and convert & import data to new systems.
• Custom reports were done in Visual Basic. Visual Basic functions used included data grids, VB modules for customized functions, and direct file I/O for custom VB functions.
• Database systems were developed using Visual Basic and Access with SQL commands to access the Tables in the database. XML software was created to produce XML documents for information distribution. XML standards were defined. Clients have used a wide variety of databases, including Oracle, SQL Server, Access and others.