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Click here or scroll down to respond to this candidateCandidate's Name
EMAIL AVAILABLE PHONE NUMBER AVAILABLESUMMARYAccomplished and results-driven professional recognized for commitment to excellence and demonstrated ability to communicate and work with senior management, associates, and customers. Knowledgeable in collaborating effectively with cross-functional teams in the development, documentation, and delivery of process innovations driving the attainment of business goals. Actively seeks opportunities to transform company practices into fresh, cost-effective solutions leading to more efficient operations. Several years of experience working on various projects over 25 years of experience in the Health Care Industry including Medicare, Medicaid, and Commercial Carriers. Configuration Experience with various platforms such as QNXT, Epic Tapestry, NASCO, Power MHS, Metavance, MMIS, IKA, and AMISYS to name a few.RELEVANT SKILLSKnowledge of Procedure and DRG related impacts for ICD-9 & 10.Assignment of Employer and Provider Group plan codes, CPT, HCPCS II, ICD-9, ICD-10, DSM-IV coding. Claims processing in real-time.Worked Problem Logs (P-Logs) and used the ODL onto the EEC Worksheet and OLRX Application.Adjudicated and process claims in EFDE, HEHK, and HEUK (EEC). Used the Message File (MI) to enter internal notes.Edited and entered provider contract codes on various software. Used HINQ in Nasco. Processed HMO, PPO, POS, ASO, self-funded, Cafeteria plans, Capitation, and EPO claims.Billed secondary and Tertiary insurance carriers on Self-pay, Medicare/Medicaid and Commercial Insurances using HBOC Stars and HANS systemExperience with EDI 835/837, 834, 270/271, 276/277 and accumulators, HIPAA 4010 and 5010.A/R functions utilizing Lawson. Posting payments, claim adjustments and creating account receivables to recover and track overpayments.Experienced with NASCO, Q-Blue (QMACS), MCS, QNXT 5.8, ITS, QCARE, Metavance, Epic/TapestryProficient with AS-400, NASCO, ITS, QNXT Benefit, and Provider Pricing File, QBLUE, QCARE, GenC, NCN, METAVANCE, MCS, MHS, MMIS, NETWORX, AMISYS, SPIDER, and IKAPROFESSIONAL EXPERIENCESr. Business Analyst/ QNXT Configuration AnalystTEKsystems Inc./Sentara August 2021-Oct 2022Validating deductible and out-of-pocket maximumsUpdating excel spreadsheets with data for overagesRequesting claims reprocessing using Change GearBenefit configuration for new plans and changes within old plansUpdate benefit configuration for Medicaid and Medicare members for QNXT migrationUpdate benefit configuration for individual plans on the clients legacy systemUpdate benefit configuration to small and large commercial groups on the clients legacy systemAttending weekly conference callsValidating data on Mental Health and Medical claims in the TEST environmentCreated test cases for MACESSCreating test cases for QNXT migration for Medicaid and MedicareBusiness Analyst/Product OwnerApex Systems Inc/Advantasure April 2019-March 2020Creating User Stories/JIRA to facilitate focused issue resolution for incoming client requests to be migrated.As the Product Owner/ Business Analyst validated Medicare Advantage, Medicaid, and Commercial benefit rules.Validated that the configuration was accurate.Gathering requirements for system migration to ensure 100% safety and security.Validating test results, maintaining over 98% accuracy in the systemUpdating Kanban/Confluence boards daily to maintain up to date records and information.Led User Story refinement meetings that would boost collaboration and goal driven teamwork.Triaged defects to determine severity and assigned to the developers to make corrections in the configuration.Medical, Dental, Vision, and some Pharmacy benefits were reviewed for accuracy.Business AnalystTEK Systems/Anthem (Remote) May 2018-June2018Gathered requirements for system migration of business-optimization projects.Reviewed requirements for membership and benefits in Facets to ensure near 100% compliance.Writing User Stories in SAFe Agile for system migration to Spider for WGS, Facets, Blue Exchange, and QNXTConducted User Story refinement meetings to make sure everything was up to date.Reviewed Technical designs for incoming projects and partnerships.Acted as a liaison with technical and business partners to drive company growth up 5%Sr. Denials Analyst/Revenue CycleConifer Health Solutions (Marietta, GA) April 2016-Feb 2018Disputed payment amount with Insurers (Commercial, MVA, WC, VA, Medicare Advantage and Medicaid)Reviewed contract agreements to ensure payments are made accordingly.COB claims submitted to multiple carriers.Balance bills sent to secondary and tertiary insurance carriers or insured.Calculated network discounts and requested adjustments for underpayments to maintain a balanced budget.Issued refunds for overpayments while providing medical records for further review by higher ups to facilitate exceeding annual objectives.Demonstrated proficiency in submitting 270, 834, and 837 EDI transactions.Systems Configuration/Claim ProcessingKaiser Permanente Remote Aug 2014-Dec. 2015Unit Testing for Component Group (CMG) system updatesValidated System ConfigurationValidate ICD-9 and ICD-10 codes Crosswalk for system compliance.Create Test Scenarios Validate ICD-9, ICD-10, CPT and HCPC codesAudit Benefit Plans and Benefit Component GroupsExecute Test Claims using EPIC.Appeals and adjustments for claims denied. Review benefits to determine if error in the configuration. Updated configuration and claims adjustments performed.Running SQL queries to validate benefit configuration.Benefit Configuration using Excel and Benefit Enhancement Tracking System (BETS), Medicare Advantage, Medicare Part C and D.Configuration for Long term benefits for Medicaid and Medicare.Medical, Dental, Vision and Pharmacy benefit configuration.Benefit Plans Medicaid Maryland, DC, and Virginia builds and testing in Epic.Updated configuration of limits and accumulator rules.Defect Management and UAT using HP/ALM.Claim processing utilizing test data.MAP CSS requests/response elements to backend source to BS or FGS.Quality Analyst/ Defect Management/Benefit ConfigurationHarvard Pilgrim Healthcare Quincy, Mass. Mar 2013-Aug 2014Audit customized medical, dental, and vision product builds to validate the accuracy of benefit specifications prior to migrating to the systems testing region.Tracking Build schedule to delegate Quality Control Audits.Advised builders of the errors in the configuration that required corrections.Validated configuration to ensure accuracy for migration.System configuration by coding benefit specifications in Oracle Health Insurance (OHI) development region.Incident management tracking to ensure defects are triaged correctly and resolved timely.Identify and triage the severity of incidents and defects.Evaluated defects identified by UAT team members using HP/ALM.Research and resolution of defects by either disputing defect or updating configuration using HP ALM tool. Validate UAT test case scenarios.Manage Product Builds using Rally Agile tool and PCT WindChill.Systems utilized were AMYSIS and OHI this involves complete knowledge of AMYSIS claim adjudication for conversion to OHI.Claims processing, appeals for claim denials, claim adjustments performed after configuration was corrected and updated.Validated plan benefits, limits, and accumulators configured correctly to insure correct claim adjudication and customer service operations.Medicaid, Tribal Benefits and Medicare Parts C and D. Long term benefits for Medicaid and Medicare were configured and reviewed for accuracy.Assisted team members with processes and procedures.Business Systems Analyst/ClaimsBCBS of MA Remote Jan 2011-Aug 2012Prepared and wrote Conceptual Specific Design (CSD) documents for Large Scale Implementation (LSI) from local system for migration to NASCO.Created Requirements for Business Services (BS)Created Requirements for Customer Servicing Services (CSS)Served as a liaison for IBM/Cognizant and BCBSMA.Facilitated stakeholder meetings for JAD sessions, gathering and writing requirements, Technical Design Review (TDR) walkthroughs that included 837 mapping, MDE transactions.Worked with Membership Business Analysts, HP and IBM Technical Teams on Metavance Members Edge for Customer Requests on Claims, Finance, Plans, and Reporting.Created and monitored statuses of Customer Service Requests (CSR) from inception until completion.Researched Systems Specifications (Spec-View) to assist the Plan in determining which new functionality was required.Tested Professional and Facility medical claims using the Nasco system.Identified defects and errors on claims to allow adjudication.Gathered requirements and ensured that expected results were obtained to successfully finalize claims.McKesson Claim Check to ensure system functionality within Model Office for defect management.Monitored CSRs to update and watch progression to ensure timelines were met. (SDLC) methodology.Triaged and monitored Defects after system updates were made Model Office (testing region) using HP/Quality Center. Recommended system configuration updating after appeals from testing team.Performed Impact Analysis of ICD-10 Coding and Reporting Regions to system change scheduled for deployment.Utilized NShare to access resource materials and documentation.Incident management tracking to ensure defect triaged correctly and resolved timely.Identify and triage severity of incidents and defects.Evaluated defects identified by UAT team members using Clear Quest.Long Term claims for Medicare/Medicaid testedAided in training team members on LSI procedures in PDM, CSR, Defects and CSD.Business Analyst/Claims ProcessorWellPoint/Anthem BC/BS Remote Jan 2010-Dec 2010Used HRUK in Nasco System Configuration to update benefit strings and create Ded/Max files for new and existing groups.Executed a Gap Analysis between NCN, NASCO CSR, and BTRD for a non-par provider discount program.Handled claims processing using EFDE and EEC in NASCO.Reported inconsistencies between business/technical requirements for the implementation team.Update Plan configuration to ensure member and family accumulators and limits reflect sales contracts documents.Created test scripts and scenarios.Tested and validated claims for ded/max, accums, and lifetime max, coinsurance, and other out-of-pocket expenses for Genic and Membership project using Metavance.Reviewed and audited of E.O.B. to validate accumulations, payment, and provider checks.UAT testing and Regression testing on Nasco.QNXT configuration Provider and Pricing files.Loading provider files. Created benefit grid design test scripts for template involving researching the most current provider contracts for accuracy. This process involved creating test cases for all eligible providers of service.McKesson Claim check used during Unit Testing and UATIncident management tracking to ensure defect triaged correctly and resolved timely.Identify and triage severity of incidents and defects.Evaluated defects identified by UAT team members using HP/ALM.Execution of test cases documenting expected and actual results and the recommended issue resolution for any defects resulting from the execution of the test.All line of business that included PPO/PFFS, HMO, Capitation, Medicare Advantage/Medicaid, and Medicaid, Managed Care.Configuration for Long term benefits for Medicaid and MedicareValidate Limits and Accumulators for correct claim processing and adjustments.Review and update accumulators to plans that were configured incorrectly.Test execution for all providers of service included inpatient and outpatient providers, PCP providers of service, independent laboratory and radiology providers, ambulatory service providers, DME service providers, and Skilled nursing home services provided by VNAs such as physical therapy etc.Business Analyst/Claims TestingBC/BS of MI Southfield, MI July 2009-Dec 2009Updated group benefit files for Mental Health and Substance Abuse as mandated by the Federal Government.MAP DD elements to corresponding request/response elements.MAP CSS requests/response elements to back-end source.Tested mental health and substance abuse claims to ensure that same guidelines as Medical/Surgical.Processed and adjusted live claims for backlog.Applied experience in mental health and substance abuse claims as well as knowledge in DSM IV codingTested Claims using NASCO for dedicated groups. McKesson Claim check tool utilized.Used HRBK in Nasco System Configuration to make changes to Benefit File. Accumulated benefit codes in benefit file to calculate correct benefit services.Utilized extensive knowledge of benefit grids, summaries, group booklets, contracts, and benefit group coding.Analyzed Nasco benefits by group, package, and section.Uploaded benefit codes to repository and tracked benefit codes in test environment after loading to repository.Derived accumulation rules from uploaded PDF. Files and from management.Tested benefit codes in queries. Converted to benefit Mnemonics.Reported information to project managers and software configuration department.Benefit Coding P-logs for National and Corporate Groups.Updated Benefit, Limit and Accum Strings.Claims ProcessorEDS Oklahoma City, OK Mar 2009-Jun 2009Tested and Processed Professional, Facility and dental claims.Processed live medical claims for facility and professional providers using Facets version 4.51.Dental claims processed using Metavance 2.8. meeting all production standards.Gathered dental benefit documentation and requirements.Distinguished accidental dental, medical dental, and dental Codes.Corrected dental codes and reported systems errors.Made recommendations for system upgrades and enhancements to IT staff.Incident management tracking to ensure defect triaged correctly and resolved timely.Identify and triage severity of incidents and defects.Evaluated defects identified by UAT team members using HP/Quality CenterCreated test scenario templates for UAT test execution on the Facets and Metavance systems for lines of business that included POS, PPO, HMO, Medicare Advantage/Medicaid plansExecution of test process included full documentation for expected and actual results and issue resolution for defects found.Utilized Medicare CMS for fee schedules and provider contracted specific and ala carte benefits.Configuration for Long term benefits for Medicaid and MedicareProvider of services included all facility services, specialty providers and PCPs.Benefit Configuration Analyst/Claims ProcessorHorizon BC/BS of NJ Sept 2007-Aug 2008Review Benefit Tables and NAEGS.Knowledge of Benefit File Mnemonics, Grids and Booklets. Successfully completed Analysis of Medical Coding and Prior Authorization Requirements within the Q-Blue System (QNXT) and Nasco Database for all lines of business.Completed Comparisons of the for the NJ Future, DOBI, Contract, and Systems lists.Identified the inconsistency in Coding and Reports for all PPO, POS, HMO, Medicare, and Indemnity Products on Q-Blue, QNXT, NetworX, and Blue2.Prepared Reports for all POS, PPO State, and Direct Access and Fully Insured groups on Nasco.Identified and prepared all required coding updates for all products for IT for both Nasco and Q-blue systems.Updated Project Tracker with findings and completion Prepared Weekly Status reports for management.Successfully met all deadlines and updates as requested.Incident management tracking to ensure defect triaged correctly and resolved timely.Identify and triage severity of incidents and defects.Psychiatric Claims Specialist/AuditMagellan, Columbia, MD Dec 2006-Sept 2007Responsible for coding, audit and adjudicating psychiatric claims using QNXT, Nasco, and AS-400.Claims processing meeting all production and quality standards.Processed backlog of claims for outstanding receipt dates.Managed audit of contract benefits for limits, pre-authorization requirements. Handled processing and adjustment of claims for Horizon BC/BS because of appeals made by providers and members. Loaded and updated pre-authorizations for NJ State employees. Validated provider credentials.Priced and reviewed benefit maximumsHMO, POS, and PPO mental claims adjudication.Successfully completed assignment meeting all required production standards.Successfully met all DOI deadlines for 1st submission receipt dates.Group Membership/Recovery Analyst/Claims ProcessingBC/BS of NC/Cahaba GBA Feb 2005-Dec 2006Responsible for membership conversions from legacy system to Power MHS and AMYSIS for specific product lines of business.Accounted for system configuration for New Group membership, benefits, and enrollment.Processed unsolicited and solicited recovery of over payments from providers and subscribers.Posted payments, claims research and adjustments on MCS, Facets, Nasco, and Power MHSIncident management tracking to ensure defect triaged correctly and resolved timely.Identify and triage severity of incidents and defects.Evaluated defects identified by UAT team members using HP/Quality CenterCreated, posted, and tracked A/Rs utilizing Lawson for overpaid claims.Managed COB with BC/BS and Medicare, MVA, W.C., and other commercial carriers.Audited claims for coding reimbursement accuracy. Benefit Coding.Researched/investigated and documented expected results and actual results regarding system functionality when a claim is processed, and an error resulted against current and newly implemented benefit configurations using Amisys.Researched provider contracts and benefits for accurate pricing and benefit information pertaining to the specific procedure code and type of service.Validation and/ or updating of accumulators in benefits plan configuration.Review of claim history to determine if limits and accumulators were calculating within the system correctly.Review of year end carry over deductibles for accurate accounting.Claim testing/auditing, research, and investigation of benefit grid design.Documented results via Project tracking tools (Access and Excel).Tested current CPT codes, ICD 9 codes along with HCPC codes.Ensuring correct payment allowance for services.Recovered overpayments for Long Term Medicare claims.Benefits SpecialistCrawford and Company Atlanta, GA Dec 2004-Feb 2005Processed medical and life insurance 401k enrollment applications using Lawson and Vanguard. Reverse adjustments to notify payroll for deductions made in error.Reviewed member eligibility, billed premiums, and setting payments schedules for payroll department utilizing Lawson. Handled heavy phone contact with employees and new hires regarding benefits, compliance, and underwriting regulations. Notifying payroll for deduction changes for open enrollment and new hires medical, life and 401k plans.Medicare Recovery Analyst MCSBC/BS of AR Little Rock, AR/Trailblazer Dallas, TX Nov 2003-Nov 2004Handled disability, ESRD, and liability claims.Posted solicited and unsolicited over-payments.Set up A/Rs and Research Medicare Part A and B claims.Handled adjustment and processed suspense claims.Audited VA, W.C., MVA, Set up A/Rs against overpaid providers and beneficiaries.Identified fraudulent claims and prepared written correspondence to recover thousands of overpaid claims.Reduced A/R considerably by posting payments timely and accurately, claim adjustments and claims processing.Senior Claims Rep. /Provider Network SpecialistBC/BS of GA and BC/BS of NJ Atlanta, GA Feb 1986-Jun 2003Reviewed, processed, and adjusted Managed Care Claims including PCP Capitation using QCare.Assisted co-workers with medical policy coding issues.Specialized in high-dollar cancer claims and chiropractic claims of more than over $100,000.00 monthly with 100% accuracy.Processed Facility claims and validated pricing.National Account grievances and appeals to Medical Director for review and approvals to adjust claims.McKesson claim check used to recover overpayments submitted by providers. As this was a new tool used by this Plan, several hundreds of thousands of dollars were recovered in error while performing bulk adjustments.Ensured that deductible and out-of-pocket expenses were calculated accurately.Claim audits and troubleshoots for provider contract updates. Bulk Claim adjustments.Accounted for monthly reports and spreadsheets to Department Director and senior staff.Trained staff on operations and databases.EDUCATIONCertified Scrum Product OwnerSouthern New Hampshire University BS in Health Information Systems anticipated grad 2023West Side HS (Newark, NJ) |
