Objective

T gain a position in a professional growth oriented organization t which I can apply my Business Solution Analysis skills, Technical knowledge, and/or Healthcare work experience.

Skills Abilities

• Experience in dealing with the general public, diverse multi-level work structures.
• Patient with exceptional performance under trying conditions.
• Capable of establishing a positive and productive example.
• Excellent verbal and written communication skills with the ability t recognize and satisfy customer needs.

Summary

My Healthcare background includes 3 years as a Business Consultant, 5 years as a QA Product Testing Analyst as well as 10 years in Healthcare Claims Processing Configuration providing me with exceptional attention t detail, problem solving, communication written verbal , and multitasking. Over the span of 18 years I have been involved in 2 implementations as a Health Plan employee, 5 implementations 10 upgrades as a Consultant of the Core Product and tested 5 new developed products, 20 enhancements and numerous change packs CP /and hot fixes HF for at least 8 different products giving me a strong understanding of Quality Assurance strategies and methodologies on all stages of the Software Deployment Life Cycle SDLC and/or Agile process. My experience als includes participating in collaborative efforts of multi-level skill sets with clientele and third party consultants t achieve company goals while ensuring Client's business requirements are met.

Experience

Business Consultant Lead

Confidential

• Delivered onsite and remote support as subject matter expert SME t Client s during Implementation or Upgrade of QNXT as it applies t the client's business requirements with a strong understanding of core functionality in various business areas, such as benefits, members, provider, contracts, claims, etc
• Implemented QNXT versions 4.6 5.0 and Upgraded QNXT Versions 3.4 t 4.6 and 5.0
• Scheduled and Managed my Travel Arrangements and Expenses Flight, Hotel, Car Rental, Car Service and Daily Meal Per Diem t be onsite with client 25-75 , as required by Client.
• Provided transfer of knowledge regarding functionality in TriZett products QNXT, MBP, VBB, CWS by conducting Q A Sessions, Presentations/Demonstrations either onsite or remote via GoToMeeting or Conference Call.
• Analyzed, Interpreted, Configured and Tested Client Business Requirements based upon Q A Sessions with the Client while using the above application knowledge and experience t identify alternative solutions, if necessary.
• Documented and Created meeting notes, business solutions and transition plans for next stage of project t Project Managers prior t rolling off, ensuring that all application design and oriented issues relating t the implementation or upgrade projects are appropriately addressed.
• Assisted in interviews of new hires t the Consulting Service Department.
• Mentored and documented for new hires the basic knowledge for building a model plan in QNXT, submitting defects, troubleshooting submitted defects, understanding the process for resolving defects and developing workarounds.

Confidential

• Mentored and Established QA Standard Processes for WebService testing through the SoapUI Pr application and assisted in Establishing QA Standard Processes for Core Enhancement PDR workload.
• Participant in SDLC Review meetings in addition t conducting Test Plan Review meetings for DCS Development Customer Support team of assigned PDR tasks.
• Create and Execute manual test plans based on Customer Requirements, Company business processes and application requirements within Quality Center.
• Experienced in troubleshooting issues found in Core application by using SQL Server Query statements.
• Log and Monitor Defects found during testing of multiple Applications Core, WebService and Constituent Solution systems using Team Track application.
• Manage multiple tasks for different applications and releases with proficiency in prioritization, reporting status and estimates without Direct Supervision.
• A Key knowledgebase of the Healthcare Business for the HealthWeb project Creator of Test Plan Suite and Liaison for defect resolution t off-shore development resources.
• Acquired the Lead role in managing the content of High-risk modifications reported by client t be delivered in Change Packs and Hot Fixes for Member Benefit Profile MBP and Personal Health Record PHR .
• Designed test suite for functional and regression testing, including assisting in the development of Descriptive Programming scripts that validated FACETS and QNXT products against its databases.
• Completed Technical and Foundational Training in multiple versions of QNXT Core Applications up t QNXT 4.7 including completion of Technical Training and FACETS Overview Training for version 4.6.

Confidential

• Construct and execute Analytical designs of facility contracts through configuration via the Diamond Perot System integrating Medicare and Medicaid lines of Business requirements as specified by State compliancy regulations.
• Structured a standardized testing template during the implementation of the Nebraska Health Plan in order t coordinate the configuration of Facility Contract's detailed tables with Member Benefit requirements.
• Generate quality assurance reports using PL/SQL Queries.
• Responsible of critical t minor tasks using Mercury TestDirector in accordance with our Business Service Level Standards SLS .
• Trained and advised on configuration functions regarding Pends resolution, Contract configuration for all Facility specialty types, and basic contract analysis.
• Planner and designer of user viable policy, reports, instructions and testing grids for Configuration Team's functions in coordination with immediate Supervisor.
• Interacting with internal staff and Plan Contacts t expedite resolutions of outstanding issues.
• Troubleshooting complex adjudicated claims pended t our Department for resolution.
• Liaison for Standard Sysgens and Pdters useful in coordination of New Contract's configuration and Benefits t ensure Claims payment accuracy in Diamond Perot systems.

Confidential

• Research complex appeals by correlating contract specification's compatibility t the claims processing system Rumba or Diamond Perot System for Institutional provided services.
• Substantiate adjustments of duplicate or incorrect payments with Comprehension and use of Rumba-INC, Diamond Perot System, and HSS Winstrat Optimizer Products in connection with ACPA Medicaid Policy Procedures including Payment, Denial and Pend codes Various Provider Fee Schedules, HCPC, CPT, ICD-9, and ADA/CDT Coding Schemes.
• Generate cover letters with clarification of payment, denial, or pend status upheld per ACPA Medicaid Policy Procedure Guidelines.
• Update UB Policy Procedures for processor usage in Diamond Perot systems.
• Demonstration of institutional claims processing in Diamond for the ACPA Plan associates through the use of Web cast.
• Trained Claims Examiners, Adjusters, and Team Leads on Institutional processing per ACPA's UB Policy Procedures.

Confidential

• Adjudication of all types of Medical, COB, Dental, and Institutional Claims.
• Research validity of duplicate or incorrect payments t be sent for an adjustment.
• Review and resolve pended documents meant for Team Lead's immediate response.
• Comprehension and use of Rumba-INC, Diamond Perot System, and HSS Winstrat Optimizer Products in correlation t ACPA Medicaid Policy Procedures integrating Payment, Denial and Pend codes with comprehension of various Provider Fee Schedules, HCPC, CPT, ICD-9, and ADA/CDT Coding Schemes.
• Enter any content that you want t repeat, including other content controls. You can als insert this control around table rows in order t repeat parts of a table.

Computer Skills

• Documentation: Microsoft Word, Excel, Microsoft Access, PowerPoint, Visio, and Outlook , SharePoint, and GoToMeeting.
• Testing Tools: Mercury TestDirector/HP Quality Center, TeamTrack/Serena Business Mashups, Onyx, HSS Winstrat/Optimizer, SoapUI Pro, PL/SQL, SQLServer/Sybase, Oracle and Visual Studi Beyond Compare.
• Web/Core/Third-Party Systems: QNXT, QMAC, Diamond, MyHealthView, HealthWeb/eService/CWS, MBP, PHR, FACETS and ClaimCheck.