QUALIFICATIONS SUMMARY

• QA Engineer/Sr. Business Analyst with over15 years of demonstrated success directing healthcare business operations to achieve corporate goals. Proven success providing strong leadership within both mature and start-up environments. Skilled at leading process improvement programs to enhance operations, increase efficiency, and impact the bottom-line. Highly proficient at developing effective relationships with external business partners, suppliers, clients, and staff at all levels. A respected leader and solution provider dedicated to exceeding objectives. Extremely proficient in software development life cycle within Waterfall and Agile development processes with solid years of experience testing web based software applications, preparing test strategies, test plan development, test case creation, test execution and bug tracking.

PROFESSIONAL EXPERIENCE

Confidential

Sr. QA Engineer

• Served as Sr. Operations Lead for healthcare company responsible for providing leadership to junior business analysts Developed executive status reports for director Developed webinar presentations for training Provided expertise for identifying defects based on UAT testing Developed manual test cases.
• Responsible for interfacing with client and McKesson business and development teams Assisted with sales and product demonstrations.

Confidential

Sr. Healthcare Production Support Analyst

• Served as Sr. Healthcare Production Analyst for healthcare data analytics company Responsible for approving data submitted by audit data service teams Responsible for processing inbound and outbound data files within the agreed upon SLA Responsible for managing data file uploads and return file downloads Developed adhoc reports to report on errors and status reports for director Responsible for overseeing conversion of data from ICD-9 to ICD-10 Performed claims analysis using SAS Created SQL for processing of data and creation of data files.
• Responsible for leading junior support analyst and training of new employees.

Confidential

Sr. Quality Consultant

• Served as Sr. Quality Consultant for leading healthcare company Responsible for detection of Medicaid Fraud and Abuse using claims data Responsible for prioritizing and planning daily work plans for the national test team Developed queries for Oracle databases Performed claims analysis using SAS Supervised the creation and execution of manual/automated test cases and SQL Plus data mapping Identified/Documented issues Recommended improvements as a result of testing efforts.

Confidential

Sr. Systems Business Analyst

• Served as Sr. Systems Business Analyst/Consultant for healthcare company responsible for leading claims payment and financial Analyzed and Documented business requirements Participated in transitioning the requirements and use cases to the designers and ensured a clear and complete understandingof the requirements.
• Consulted with the project manager, architects, sponsors, stakeholders, and other project team members to define metrics and performance goal requirements for the business solution Analyzed and designed new business processes Consulted with the clients and end users to define application functional requirements and use cases needed Functioned as Claims subject matter expert SME for Medicaid Management Information System MMIS Project.

Confidential

Sr.Business Analyst

• Served as Sr. Business Analyst for leading healthcare insurance company Functioned as Kaiser Permanente's subject matter expert in Medicare/Medicaid Developed business processesin accordance with CMS guidelines for enrollment and disenrollment procedures Consulted with internal stakeholder to document business and functional requirements in the development life cycle to produce system enhancements Interfaced with development and architecture teams to clarify and refine requirements as well as generate technical specifications, including process diagrams and report mock-ups Conducted gap analysis, business requirements gathering, and writing functional specifications.
• Maintained effective working relationships with project managers, IT representatives, and other Kaiser Permanente regions and departments by participating in cross-functional daily team meetings to insure quality improvement initiatives through benchmarking practices Successfully managed multiple projects with competing priorities and worked within tight timelines Developedaccess queries to monitor Medicare/Medicaid member's data quality in source and downstream systems, including ESRD and Hospice member's status Tracked business processes through the creation of numerous dashboards captured and communicated specific data points to upper management and concerned personnel within the organization Analyzed membership, claims, and provider data specifically related to fraud and abuse in eligibility and claims coding identify gaps in processes and make recommendations
• Analyzed Membership discrepancies off of data mining report. Investigated potential fraud and abuse
• Download File Transfer Protocol files from main frame systems and export them into Excel spreadsheets to produce possible Medicare Advantage leads for Sales department Generatedadhoc queries and reports against the data warehouse

Confidential

Sr. Healthcare Data Auditor-Analyst/Sr. Project Manager

• Served as Sr Project Manager for consulting firm, overseeing revenue of 100 million, accounts 90 days and over.
• Responsible for cash acceleration and collection of multi-payor revenue cycle projects for hospital and physician groups, e.g., Medicaid, Tricare, HMO, Commercial, Workman Compensation Experienced Business Analyst responsible for accounting analysis of membership, claims, and provider data specifically related to Medicare eligibility and claims coding Experienced Financial Analyst with project based experience preparing budgets and operational procedures, developed executive reports, developed webinar presentations on Medicaid and Medicare cash collections Served as recovery specialist for government programs, including Medicaid, providing expertise in identifying solutions to improve billing accuracy and compliance as well as collection results.
• Provided training and documentation for billing and compliance teams created documentation manuals included billing guidelines, claims corrections, re-billing instructions, and submission of appeals Responsible for identifying and analyzing incorrect billing procedures and non-compliant billing. Responsible for developing corrective measures Medical center accounts payable experience, including direct patient interaction, adjustment processing, payment plan initiation and tracking, and compliance monitoring.

TECHNICAL SKILLS

• Computer Skills/Applications: MS Office Suite SQL2005 -2008 Report Writing Data Warehouse File Transfer Protocol Visio Golden Cognos Oracle Visual Studio 2008 People Soft MySQL
• Testing Experience:SQA Testing Methodologies Test Plans Test Cases Writing/Understanding Functional Requirements Scripting Writing Test Documentation Regression Testing Negative Testing UI Compatibility Testing Data Interface Migration Testing Performance/Load/Stress Testing Automation Testing Defect/Bug Tracking Developing Test Strategies Coverages Writing/Adhering to QA QC Standards
• Knowledge: Mainframes Health Connect MARX Lotus Notes Outlook Sametime Net Meeting Internet Research Common Working File Macess Facets iCES HTML XML SOAP Medicare Medicaid Tricare Commercial Insurance Pharmacy Recovery Audit Contractor Experience Healthcare Coding, Medicaid Fraud Abuse Medical Billing Experience Claims Processing Experience Implementations QA Testing Data Business Analyst Experience Technical Writing WSDL Business Intelligence Project Management Operations Management Strategic Planning Database Structuring Product Development/Management Process Improvement Account Recovery SAS
• Healthcare Applications: ICD-9 CPT HCPCS EPIC Tapestry HealthConnect Premis EPremis SSI FSS Florida Shared Medical Manager HBOC-Star Meditech EFADS EDI 270 EDI 271 EDI 835 EDI 837 pharmacy messages ePrescribing
• Operating Systems-Test Environment: Windows XP professional Windows 2000 HP Mercury Quality Center JIRA Clearquest Requisite Pro/Web TestDirector ClearCase TOAD WinRunner LoadRunner Quick Test Pro QTP E-Tester E-Load