PROFESSIONAL PROFILE

Seasoned healthcare business analyst with expertise in the payor space

• Gap and Interface Analysis
• Business Requirements
• Integrations/Implementations
• Testing
• End user training
• SME in the areas of: claims processing, hospital/ medical, case management/utilization, clinical editing criteria, TOS, SEDF
• Technical skills: Facets4.51, CAE 4.41, POS 2.5, MBP 2.0, TCN 1.5,RX-UM, NCCI Edits, CMS, Clinical Editing Processing Actions, BI Query,Sanovia-PA Logic, MeDecision, Reflection, Macess Service Module 2.71, Healthcare, UM Interface, HIPAA, and Microsoft Word, Excel, Access.

PROFESSIONAL EXPERIENCE

Confidential Consulting 07/09- 10/09
Clinical Project Lead/Systems Analyst
Project: NJ and OHIO Facets Conversion (4.51)
Location: Confidential, Virginia Beach, VA

• Configured Merge Fields for Disease and Case Management letters to be imported into Macess Corro Service Module
• Conducted UAT testing of NJ and OH Health Plans letters (Appeals, CM, UM, Grievances) in Mercury QC
• Conducted UAT testing of NJ and OH Health Plans Security Profiles composed of Permissions and Restrictions(Read, Read/Write, and No Access)
• Conducted Regression testing under Facets 451 for the following application areas: Appeals,Grievances,Prospective UM, UM Inquiry, Letters, Operational Reports, and Warning Messages
• Developed Test scenarios using business knowledge,requirements,and design documents
• Created test plans in Mercury QC from test development scenarios
• Identified and reported Quality Assurance, Testing issues, and Test Defects using Mercury QC Defect resolution functionality
• Analyze and troubleshoot the UMI error report for the Amisys to Facets mock authorization conversion which includes the conversion of a 3rd party vendors auth conversion (NIA-National Imaging Associates) authorizations
• Mapping of Health Plans Regulatory Reports to the appropriate Facets crosswalk(Customer Service/Appeals) Application
• Configured User defined codes for Regulatory Report

Confidential- Union, NJ 01/09 - 07/09
Senior QA Analyst
Project/Location: End to End Testing/Development Business Unit- Union, NJ

• Demonstrates excellent verbal, written, and interpersonal communication skills. Demonstrates the ability to work in a fast paced and dynamic environment
• Demonstrates a strong knowledge and understanding of Trizetto's product family functionality and internal business processes.
• An experienced QA Test Analyst with working knowledge(creating, maintaining, and executing)tests using Mercury Quality Center 9.2
• Developed a series of (3) Quick Test Pro (QTP) test scripts based on Business Components being used in the Point of Service automation. Each script (Professional/Outpatient/and Inpatient claims) contained data ranging from the database the test should be run through the member and provider selection and includes all the claim elements supported in the POS 2.0 solution. The initial testing demonstrated a marked improvement in the End to End testing efficiency. Previously, automation consisting of only Business Process Testing (BPT) test cases was able to run, on average, 24 test scenarios per machine per night. Using the new QTP scripts, under the same conditions, the End to End (E2E) team was able to execute, on average, 450 test scenarios per machine per night, representing an 1875% increase in test execution capacity. Used together, the combination of QTP, BPT, and manual testing improved the E2E test coverage dramatically.
• Experienced in participating in quality assurance and testing activities throughout the entire SDLC.
• Experienced with web based, Citrix, and ODBC applications.

Roles / Responsibilities

• Responsible for developing the design and implementation of test plans and the execution of tests for all Trizetto's products/solutions during project engagements.
• Develops test scenarios for Trizetto's software products/Constituent Web solutions(Facets 4.51, CAE 4.41, POS 2.5, MBP 2.0, TCN 1.5,RX-UM) using business knowledge, requirements, and design documents.
• Creates test plans from scenarios; this may include conceptualizing and developing functionality requirements.
• Participates in reviews and audits of product requirements, specifications, designs,code,and test plans related to the SDLC.
• Identifies and reports quality assurance, testing issues, and defects.

Confidential - Newtown Square, PA 4/07 - 10/08
Applications Consultant
Project/Location: FICO, King of Prussia, PA

• Created and tested business processes (UAT and Integration testing) and supported end users in execution of test scripts.
• Tested Functional, Transactional, and Master Data and identified and resolved Test Defects as well as Mapping/Configuration of Cost Centers.
• Successfully accomplished UAT and Wave 1 (Integration) Testing in the following Business Processes:
• Sales and Distribution:
• Order Incompletion Procedures
• Emergency Order
• Review Held Orders Blocked for Credit Check
• Quotations
• Release Orders
• Return Orders
• Standard Orders
• Debit and Credit Memos
• Sales Order Blocks
• AR/AP:
• Credit Analysis
• Customer Dunning for Open Items
• Month End Closing
• Auto Clearing of Open Items
• Test Posting Tolerance for the AR Analyst
• MM
• Create Purchase Orders
• Worked with Quality center to document test results and validate test scripts. Used Quality Center in routing defects, defect resolution and assigning business cases to business users.

Project/Location: Confidential, Risk and Compliance, Franklin Lakes, NJ

• Consolidations of divergent Rule Sets.
• Installation and setting up the initial plan for CC5.3.
• Understanding of the authorization concept utilized in early R3 (4.0b) which is shared between structural and object oriented security.
• Data Mapping of SAP 4.6b to CC 5.2.
• Initial Configuration and Installation of Cc 5.2 to clients SLD.

Project/Location: Confidential, Risk and Compliance, Lancaster, PA

• Initial Installation and Configuration of Access Enforcer v5.2.
• Upon completion, have successfully provisioned the approval process by combining roles and permissions with workflow to the client's SLD.

Project/Location: Confidential, Risk and Compliance, Hightstown, NJ

• Initial Installation and Configuration of Compliance Calibrator v5.2.
• Successful upload of text files from clients legacy system into CC 5.2
• Knowledge transfer and documentation provided to the client on how to upload the text files for future imports.
• Overview of CC functionality and Configuration processes.

Confidential - Germantown, MD 7/06 - 4/07
Consultant/Sr Business Analyst
Project/Client: PacifiCare/UHC Behavioral Health

• Met with business units and project stakeholders to gather and develop business requirements for operations related restructuring programs for Facets 4.31v upgrade
• Created high level use case diagrams, process composition diagrams and data modeling
• Determined appropriateness of mapping for initiatives; mapped deliverables
• Participated in user acceptance testing and identified improvement opportunities for product and workflow
• Wrote test plans, coordinated and executed testing
• Assisted in the design and preparation of reports, correspondence and presentations to document and communicate findings
• Administers the change control process for zero defect software development
• Served as a liaison and SME between internal end users and the technical team regarding claims, case management/utilization, clinical editing criteria, TOS, SEDF
• Ensured quality goals were achieved

Confidential - Denver, CO 2/06 - 4/06
Contract Consultant/Configuration Business Analyst, Facets Utilization Management
Project/Client: Confidential

• Supported the Medical Management Dept by entering Medical Authorizations utilizing UM Service Groups into Prospective UM.
• Converted Business Rules into test development scenarios
• Reviewed, analyzed, and evaluated business system and end user needs.
• Configured and generated letters of correspondence
• Reviewed claims for appropriateness and Medical Necessity of Services

Confidential - Philadelphia, PA 12/98 - 2/06
Configuration Business Analyst I, Facets Administration and Development (6/01-2/06)

• Facilitated the implementation of Facets to several Lines of Business (AMHP/KMHP/ Passport/Select Health) which resulted in limited rework resulting in a high satisfaction rate among the Business Owners
• An active participant in system Regression, Integration, UAT and Implementation Testing
• Supported the Stabilization of the new Lines of Business after Go-Live
• Verified the Migration of Clinical Editing and Prospective UM tables into the established database
• Verified Facets Upgrades under version 2.96 for the Utilization / Case Management Applications
• Verified Facets Fixes under version 2.961b for Utilization Management and Criteria Maintenance Applications
• Conducted Regression Testing of the CLUM and Prospective UM functionality under Facets version2.961
• Claim/UM match parameters configured for Business Owners review / decisions
• Research Clinical Edits and re-evaluated the edits / warning messages and processing actions so as to limit pends and work queues
• Provided analysis / recommendation for the customization of the Clinical Editing Administrative Rules
• Trained Nurses on the manual entry of Authorizations and Referrals into the Prospective UM application of Facets
• Supported the Patient Care Management (PCM) department with special projects and resolving issues pertaining to the UM interface error extract report.

Medical Claims Review Coordinator, Operations (12/98-6/01)

• Reviewed claims and medical records for appropriateness of bill and services
• Researched authorization and takes appropriate measures to resolve
• Analyzed and resolves issues pertaining to Code Review
• Calculated DRG's utilizing the appropriate Grouper Version
• Calculated NDC's utilizing the online or Red Book index

Confidential - Blue Bell, PA 9/97 - 12/98
Case Manager - Workers Compensation

• Provided Disability Assessments with focus on Return to Work Issues
• Monitored Medical Care and Appropriateness, schedule medical and diagnostic appointments within WCA Network
• Communicated Red Flag issues that Prevent Closure
• Maintained Open Communication with Provide, Client and Employee

Confidential - Mt. Laurel, NJ 8/95 - 9/97
Staff LPN

Education

• Liberal Arts curriculum:
• Licensed Practical Nurse