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Click here or scroll down to respond to this candidateCandidate's Name , CSMSenior Business Analyst Deep Core Skills ~ Scrum Master Scrum Alliance Certified, SAFe TrainedPHONE NUMBER AVAILABLE EMAIL AVAILABLE 1751 6th Street East. Saint Paul MN 55106Conduent 08/2022 to 12/2022SCRUM MasterTexas MMIS ImplementationSCRUM Master for Fee for Service [FFS] Claims and PA.Facilitate Agile EventsRemove any impediments/blockers for the teamServant leader for the teamHelp team members to communicate, coordinate and cooperate to assist team in meeting goal deliveryWorked with outside vendor tasked to deliver Level 1 [L1} documents for BAs to complete L1 templatesCreated over 1000 user stories to track L1 Delivery, L1 Build, L2 Build, L1/L2 Load, Test Case creation, Test Case Execution and DemosMedica 10/2020 to 8/2022SCRUM Master for Keystone Claims Intake and Payment & Communication. Business Transformation Office [BTO]2022/2023 for 2024 go live: Keystone Individual and Family Business.Facilitated Agile EventsParticipated in Scaled Agile EventsRemoved any impediments/blockers for the teamServant leader for the teamHelped team members to communicate, coordinate and cooperate to assist team in meeting goal deliveryCoordinated with other teams on dependencies within the Keystone ART and other Corporate InitiativesSupported the Product Owner, Project Manager and Value Stream OwnerBusiness Analyst 3 BTO Liability Management - Claims2021 Medicaid Project within Liability Management, Claims End To End.Researched and created a tracking spreadsheet for Minnesota Medicaid Requirements for all areas:oBusiness Relationship ManagementoCare ManagementoContractor ManagementoEligibility and Enrollment ManagementoFinancial ManagementoMember ManagementoOperations ManagementoPerformance ManagementoPlan ManagementoProvider ManagementReviewed and documented requirements and obtained business signoff:oHCC Provision requirements for HealthRulesoValidation Policy requirements for HealthRulesoCoordination of BenefitsoPrompt Payment/Interest PaymentsHelped business identify any new work items:oStandard Operating Procedures [SOP]oClaims RobotsoClaims ReportingoValidation PoliciesMentor and assistance to other BAs on the project.Trained on Azure Dev Ops [ADO] for Sprint PlanningoCreated Backlog for Claims End to EndoMoved Stories to appropriate SprintsADO ChampionoTrained others on ADOoHelp create a flow to follow for ADOoWent to meetings to review the flow with various team members2020 Medicare Medicare Advantage Project within Liability Management, Claim Adjudication.Reviewed and documented requirements and obtained business signoff:oFederal benefitsoHCC Provision requirements for HealthRulesoValidation Policy requirements for HealthRulesoCoordination of BenefitsoPrompt Payment/Interest PaymentoHigh DollaroMember and Provider Matching logicoPreclusion List of ProvidersoType of BilloCustom Code to out of the box functionalityoClaim overpayment reconciliation, auto offsetHelped business identify any new work items:oStandard Operating Procedures [SOP]oClaims RobotsoClaims ReportingoValidation PoliciesMentor and assistance to other BAs on the project.Elign Consulting 3/2019 to 10/2020Senior Business Analyst, Consultant Medica BTO Claims Adjudication Workstream2020 Medicare Medicare Advantage Project within Liability Management, Claim Adjudication.Gathering requirements for CES Editing TooloWorking with the business to determinerequired SOP needschanges to status based on what is needed by the business and what is CMS guidancecreating a BRD for the rules needed for configuration to appropriately implement in HealthRulesGathering requirements for Medicare Advantage benefitsoResearched the following to create a comprehensive source of truth for benefitsCMS Medicare Manage Care ManualCMS Medicare Benefits ManualCMS Medicare Claims Processing ManualEvidence of Coverage (EOC)PBPGathering requirements for Coordination of BenefitsGAP analysis of EDI transactions (837, 276 & 277) to determine if changes will be needed for additional Medicare dataBlue Cross and Blue Shield of MN 7/2018 to 3/2019Medical Policy Implementation Consultant Sr.Prepping for Auto Disposition Rules and Surveys meetings.oWriting rules for auto denials of Prior Authorizations (PA) for the list of services/procedures currently identifiedoWriting surveys for the approvals, denials or send backs for the list of services/procedures currently identifiedCreate and maintain a management documentation for CMS NCD, LCD and Article implementationCreate and maintain of updates to CMS NCD, LCD and Article monthly changesoCreation of Blue Alerts for internal communication of the changesoCreation of spreadsheet to track current and future management based on the updatesLogiSolve 6/2017 to 7/2018Business Analyst Consultant with BCBSMN2019 Medicare Advantage Project within Care Management.Prepping for Auto Disposition Rules and Surveys meetings.oWriting rules for auto denials of Prior Authorizations (PA) for the list of services/procedures currently identifiedoWriting surveys for the approvals, denials or send backs for the list of services/procedures currently identifiedPrepping for the PA rules for the new Medicare Advantage Products to be included in EHS coding for managed care.2018 Medicare MAPD Project within Care Management.Conducted Requirements meetings across various government solutions departments to ensure accurate PA requirements were developed.Worked with the coding department at HMHS to ensure accurate coding of the PA list of MAPD for Managed Care within BlueCore.Wrote and reviewed test case scenarios for data configuration accuracy and quality.Helped with the creation of a PA list utilized within the PA Lookup tool and provider communication.York Solutions 3/2016 to 6/2017Business System Analyst Consultant with Prime TherapeuticsVarious projects for quarterly implementation changes to RxClaim.Gathered requirements and wrote requirement documentations for the various project assignments for 16.3, 16.4, 17.1, 17.2, 17.3 and 17.4 system releases.Conducted Scope and Requirements meetings.Worked with the business to garner the requirements and collaborated with Developers on the technical solutions.UCare 6/2015 to 3/2016Business Analyst Claims SCRUM TeamVarious Projects within the backlogCollaborated with various departments to gather ROI.Conducted meetings to discuss the pros and cons.Obtained fast turnaround time on implementations.Collaborated to implement 3 core initiatives.Applied SCRUM methodology to projects to have deployment within a short timeframe.Hollstadt and Associates 04/2012 to 4/2015Business Analyst Consultant for Blue Cross Blue Shield 04/2014 to 4/2015Payment Innovations - Current and future state process flow documentation.Collaborated with Financial, Sales & Marketing, Actuarial, Network Finance, and the project team to document the steps within the flow and assign responsibilities.Conducted meetings to discuss the flows.Obtained sign-off on the flow deliverables on time.UMPR (Utilization Management Platform Replacement) - Triage Hotline for deployment of Aerial to UM staff. Support during training.Gathered information on staff for training; name, phone number, cube number and asset tag numbers.Interfaced with security to obtain additional programs for staff.Created a triage log to track issues during go live.Helped answer questions during training.Prioritized issues and funneled to the appropriate team member or help desk.Daily communication to staff, which included daily download meetings with managers so they would get the same message as staff.Analyzed common triage questions to identify if additional training would be needed.Business Analyst Consultant with Alliant Tech, Sporting Goods Division 02/2014 04/2014Short-term project performing data gathering for client specific definitions database.Gathered requirements what the database will look like, helped develop a prototype for the client to house the data dictionary.Researched clients SAP system to validate the terms.Worked with a developer to create the repository for the data definitions.Collaborated with the SME BA to find out what terms currently defined and by whom.Business Analyst with Blue Cross Blue Shield 04/2012 to 12/2013Desktop migration to a web-based platform for a shared repository that stored written correspondence. Completed requirements for Utilization Management, Case Management, and Disease Management Programs within IHM to move the user from a word document/save to hard drive method of member/provider written correspondence to online tools and testing of those letters to ensure accuracy of requirements and configuration.Gathered requirements and wrote requirement documentation of IHM letters and other supporting documentation.Participated in subject matter expert and configuration meetings for review of the requirements to ensure accuracy and usability.Worked with the subject matter expert to validate the client requirements to ensure all aspects of the requirements were covered.Wrote scenario based use cases for testing and training.Collaborated with other business analysts on their projects when there were dependencies.Created and updated a Test Plan Documentation to assure all test areas identified and test cases/scenarios created for Business Acceptance Testing (BAT).Wrote and executed test case scenarios for data configuration accuracy and quality during BAT.Assigned test cases to the appropriate testing staff for test execution for BAT testing.Analyzed testing defects to determine defect validity for BAT testing.Reviewed defects from System Integration Testing (SIT) to ensure validity of the defect and helped determine defect assignment.Built relationships with teammates so that coaching efforts received in a positive, developmental manner. Took steps to learn the work interests and career goals of teammates.Affiliated Computer Systems, Inc. 02/2008 to 04/2012Senior Business Systems Analyst ConsultantCare and Quality Solutions, MOHealthNet Home Health Care ProjectCompleted requirements documentation consisting of both business and functional requirements.Conducted client meetings for review of the requirements document to achieve project sign-off by the assigned deadline.Conspired with the SME to validate the client requirements to ensure all aspects of the requirements were covered.Led technical meetings to ensure what client is asking for can be completed by development and the end product is user friendly and a workable solution for the client.Health Enterprise proposal Center, Multiple MMIS Request for Proposals (RFP)Completed GAP analysis of the RFP requirements for the MITA Business Areas of Operational Management and Program Management specific to Claims, Service Authorization, TPL, and Financial functions.Completed proposal writing for the above named business areas, to tell the story of how the Health Enterprise solution will meet or exceed their business needs and achieve MMIS Certification shortly after system go live.Conducted Pink and Red team reviews of other business areas to ensure the full complete story.Completed Pink and Red team recovery for final review of the proposal to ensure on time delivery of the Proposal by the due date.Worked with subject matter expert to ensure the statements made were accurate.Health Enterprise, Functional Testing and System Integration Testing (SIT) Claims Test LeadCompleted test case creation for both the Reference Functional Area and Claims Functional Area for our Health Enterprise MMIS Solution; also assisted with Financial and TPL test case creation.Updated Test Plan Documentation to assure all test areas identified and test cases created.Executed test cases for Claims and specifically of the Pricing Exceptions for Functional Testing Suite.Trained testing staff on the various Pricing Methodologies within the Health Enterprise and worked with Subject Matter Experts (SMEs) on questions from the staff.Performed maintenance and tracking of Pricing Test Cases for Functional and System Integration Testing (SIT).Assigned test cases to the appropriate testing staff for test execution.Analyzed and reviewed testing defects to determine defect validity and assign to appropriate area for additional review.Provided data validation assistance on the Data Configuration and Data Conversion reviewing for consistency and errors.Ran SQL queries against the databases to ensure appropriate configuration and conversion accuracy.Assisted Development/Coding teams with aligning business design.Supported the implementation of Health Enterprise, a cross-functional web-based application on a Service-Oriented Architecture model that enhanced interoperability between components and enabled capabilities. North Dakota Implementation ProjectTransferred requirements from the RFP to utilize the client requirements from the proposal to an internal document that defined and aligned with the client needs and the internal products.Completed business documentation for source, gap, and functional systems analysis.Provided work direction to two business analysts and mentored them on best practices and collaboration with clients and subject matter experts.Created Requirement Analysis Documents from a fully operational legacy MMIS and applying it to the requirements of a new web-based claims processing product developed by ACS.Integrated Visio diagrams in the RAD that reflected the entire use case/interface/user interface and reporting artifacts as well as system flows for a specific piece.Responsible for functional requirements, business rules, high-level design alternatives, business level use case models, and process/logic models.Involved directly with TPL functional area.Worked with the LDM (logical data model) and PDM (physical data model); not in the actual production of these models, but in creating database tables, and enhancing fields/columns to existing ones.Created use cases for the QA team to use in creation of test cases.Familiarity with requirements and functionality of Omnicaid, an ACS owned Medicaid mainframe claims processing system.Familiar with COTS Commercially available Off-The-Shelf that attach to the claims processing system; examples; McKesson (enhanced editing), Sungard (EDMS), and Optum (MARS, SURs).BlueCross BlueShield of MN 09/1995 to 02/2008Enterprise Process DeveloperParticipated in the development of, and adherence to, the standards and work methods required to support consistent processes for the capture, documentation and change management of business models.Collaborated with business operations teams to assess and evaluate existing process models for improvement opportunities, and/or facilitated design sessions to develop new processes needed to meet the business strategies and objectives.Facilitated process model validation sessions to ensure understanding and ratification of tasks, decision points and inputs/outputs within assigned business divisions/departments.Collaborated with Business Architecture to ensure departmental level processes are included in the enterprise level process management architecture.Business Systems AnalystAssisted in identification and coordination of organization business needs, completed service requests and proposals.Assisted in the development of business process and identification of best practices to ensure the most effective and efficient processes and operations.Defined project requirements and perform business analysis.Monitored the effects of process changes within the identified business area(s).Developed management reports and customer satisfaction surveys to measure the impact of changes and/or current operations.Pharmacy Combined process development for near real-time processing.Assisted in analyzing organizational needs in such areas as labor and training.Used the Pricing methodology.Supervisor Claims DivisionDetermined work procedures, prepared work schedules, and expedited workflow(s). Issued written and oral instructions and provided feedback. Evaluated and respond to staff training needs.Trained and mentored technical specialists; supervised over 20 claims examiners as well as technical specialistsPromoted teamwork to effectively achieve customer satisfaction, MTM/Index performance and/or account specific performance goals.Studied and standardized procedures to improve efficiency of subordinates.Prepared composite reports and identify trends and communicate recommendations through analysis of data.Ensured compliance with all applicable regulatory, legislative or contract specific requirements.Analyzed customer complaints and/or audit results to determine work flow changes and/or training issues within the unit.Claims Technical SpecialistServed as primary resource for examiners in interpretation of contracts, system procedures or policiesProvided guidance to examiners while assisting in resolution of moderately difficult and/or sensitive issues.Provided supplemental and on-the-job training to new and existing examiners in an individual or group setting.Audited individuals work and provide feedback to examiners while keeping leadership appraised of the progress of each individual.Analyzed and provided recommendations for possible changes in workflow procedures or situations.Responded to internal customers and other Blue Plan inquires.Completed assigned special projects that require research, analysis and documentation.Provided back-up support to leadership. |
