Professional Summary:

Has 8 years of Clinical Billing and Claims experience. Have strong Business/Data analysis experience serving as liaison between the developers and users to translate business requirements into functional/system specifications and Testing / QA Life Cycle. Have proven business insight gathering requirements, analysis, design and implementation of projects with strong facilitation, negotiation, delegation, and mentoring skills.

• Worked in various technologies such as EpicCare Ambulatory, EpicCare Inpatient, IDX/GE Centricity, Cerner PowerChart, Citrix, HL7 (v 2.3/2.4), PACS, DICOM, XML, Java, .Net, Oracle and HTML.
• Extensive knowledge of Object Oriented Analysis and Design (OOAD) using Unified Modeling Language (UML), Rational Unified Process (RUP), using various methodologies such as Agile, RAD (Rapid Application Development), JAD (Joint Application Design) and Prototyping.
• Experience with Software Development Life Cycle (SDLC) and Testing Life Cycle.
• Extensive knowledge in clinical practice management, medical and laboratory billing, and insurance Claim processing with process flow diagrams.
• Experience in Medicare and Medicaid coverage guidelines.
• Familiarity and experience with the ICD-9-CM/ICD-10CM, CMS and CPT code set.
• Participated in requirements Analysis reviews, Business reviews and working sessions to understand the requirements and system design.
• Extensive experience with MS-office (Outlook, Word, work, Excel, Visio, Power Point, Project)
• Knowledge in Diagnostic Statistical Manual IV (DSM) diagnosis coding for behavioral health care claims.
• Extensive knowledge in Healthcare, Insurance and Finance business domains.
• Extensive knowledge in ANSI X12, NCPDP 1.1/5.1, Electronic Data Interchange (EDI) transactions (270/271, 276/277/278, 820/834/835/837, 997) mapping and translation.
• Familiarity and experience with HIPAA 4010/5010 regulations.
• Extensive knowledgeable in BABOK, ITIL and CMMI processes.
• Have proven business insight and the technical know-how to implement large-scale EMR and EHR engagements.

Skills and Knowledge:
Software : Inform, Oracle Clinical, EpicCare Ambulatory, EpicCare Inpatient,
IDX/GE Centricity, Cerner PowerChart, Citrix, HL7 (v 2.3/2.4), PACS,
DICOM, Crystal Reports
Operating Systems : Windows 95/98/2000/2003/XP
Testing tools : Test Director 8.0/10.0, QTP
Front office Tools : MS-office (Outlook, word, Excel, Visio, Power Point, Project), Lotus
Notes, HP service desk.
RDBMS : DB2, Oracle, SQL Server, MS Access
Middleware : BizTalk, WebSphere v6.0, Web Logic 8.1, TUXEDO 8.0, MQ 5.3/6.0,
EAI
Language : VB, Java, .Net, COBOL, SQL, UML
Hardware : SunOS, IBM-AIX

Certifications:

CPC (American Association Professional Coder)

Experience:

Confidential, 6/09 – current
Business Analyst
Client: Confidential,

Confidential,is the world\'s largest pharmaceutical, biotechnology and healthcare industries services company. Quintiles performs routine and non-routine research for companies engaged in drug development. The assigned project was to build a system to support all phases of Cancer clinical trials and global Data Management to capture, analyze and report patient-related data.

Responsibilities:

• Responsible for analyzing requirements and develop functional specifications.
• Responsible for performing root cause analysis on all product support related issues.
• Responsible for Collecting and documenting business processes as well as business rules.
• Translated the business needs into system requirements, communicating with the business on a non-technical level, and with the System Analyst on a more technical level.
• Accountable Discrepancy Management and Quality Control.
• Responsible for writing study summaries and review protocols.
• Developed view templates and key templates for Data extraction.
• Responsible for serious adverse events and Case Report Form (CRF) completion, writing study summaries, and review protocols
• Responsible for entering clinical data and run Data Validation Reports.
• Enter unverified records and flag any issues via an operator comment to ensure that data is available for validation.
• Study summary investigator brochures and IND annual updates for safety data verification.
• Created Use Case diagrams using UML and Business Process Models using MS-Visio.
• Create and maintain Responsibility Assignment Matrix (RAM), define Application Deployment Schedule (ADS), Distributed Application Implementation Plan (DIP), Deployment Staff Plan (DSP), Distribution Lists (PDL) documentation and training materials for application changes.
• Develop rollout, transition, and implementation checkout plans.
• Lead project strategy meetings and JAD sessions.
• Support process improvement efforts, EDP compliance.
• Conduct reviews to assure compliance to specifications and standards.
• Provide production support for applications 24hrs a day, seven days a week when assigned as a contact.
• Respond to user/operator requests and inquiries, as appropriate.
• Aid in structure testing and enter validation test data.
• Develop and execute test scripts for unit testing.
• Verify unit test results.
• Responsible for creating master project test plan (Regression and UAT).
• Determine test approach for unit testing stage for releases/enhancements.
• Prepare cycle test environment for user acceptance test (UAT).
• Assist in UAT process with business customers.
• Obtain sign-off from business customers on UAT.
• Resolve testing issues and correct defects.
• Document any testing issues and resolutions.
• Update Change Control schedule with upcoming production releases.
• Initiate and complete Turnover Package Process when necessary.
• Monitor production of recently migrated components.
• Participated in cross training initiatives.
• Assist Team Lead in estimating level of efforts (LOE) and scoping with the input of SME team members.
• Provide timely work request status to the Team Lead.
• Contribute to the development of training materials for new processes developed by the team.

Environment: Inform Oracle Clinical, Oracle, Java, Windows XP, Crystal Reports, MS-office (Outlook, word, Excel, Visio, Power Point, and Project), HP service desk, HP QTP (Test Director 10.0), Crystal Reports.

Confidential, 11/07 – 5/09
Business Analyst
Client: Confidential,
Confidential,is a professional services company, providing a comprehensive range of business services, products and solutions by better managing their finances, employees and technology to the Medical management practice firms. The assigned project was to build a system to support Functionality: ability to create and manage electronic records (EMR) for all patients, as well as automating workflow in a physician’s office. Interoperability: ability to receive and send electronic data to laboratories and Security: ability to keep patients’ information safe.

Responsibilities:

• Responsible for executing Epic workflow / flow sheet analysis, system setup and configuring Epic ambulatory and inpatient templates according to the specialty clinic patient order sets.
• Acted as primary liaison between the client departments and the Information systems IT department; performed analysis, review, and estimation of client requests.
• Tracked the day-to-day activities, responsible for new requirements and enhancements associated with EMR system.
• Worked with ANSI X12 4010 including medical transactions such as 837 (medical claims), 835 (medical claim payments), 270 (eligibility inquiry), 271 (eligibility response), 276 (claim status), 277 (claims status response), 820 (enrollment).
• Performed project assignments, scheduling and tracking.
• Utilized Agile software development processes.
• Facilitated JAD sessions with all levels of the business community for requirements gathering, project development, design considerations, impact and risk analysis.
• Worked in various technologies such as EpicCare Ambulatory, EpicCare Inpatient, Citrix, HL7 (v 2.3/2.4), PACS, DICOM, XML, Java, .Net, Oracle and HTML.
• Aligned requirement documentation with use of UML for object oriented software development.
• Ensured that each test case was documented with expected results and actual results. Documented errors and bugs on an issue log. Worked with the developers to ensure that issues were understood and corrected in a timely manner. Once issues were resolved, processed test cases again to validate that the errors and bugs were fixed. Processed weekly status reports showing status of all test cases. Once implemented, assisted end user to ensure functionality.
• Incorporated HIPAA standards, EDI (Electronic data interchange), and code sets, ICD-9 /CPT.
• Responsible for mentoring new team members.
• Assisted with unit and integrated testing efforts.
• Testing of Epic billing reports (hospital billing and insurance billing) for Epic billing output and interface accuracy.
• Create and execute revenue cycle medication Epic billing data and reports from decision support and billing systems. Analyzed all related medical codes for accuracy to ensure maximum benefit allowed is accurately billed.
• Ensure that data interfacing into the application meets business needs – both for ongoing interfaces and one-time data conversions.
• Liaised with end users on system design challenges and preferences in relationship to clinical processes and procedures; presented these findings to application. Development team, making recommendations according to billing workflow and end user needs.
• Provided rotational 24X7 on-call revenue cycle and billing applications technical application support.
• Troubleshoot and track issues and problems related to Epic ambulatory care solution and inpatient management system. Developed Epic patient billing representative training manual, provided new hire operational and application training.

Environment: EPIC, Java, .Net, Windows 2000/XP, EPIC Reports, MS-office (Outlook, word, Excel, Visio, Power Point, and Project), Test Director 8.0, Citrix, HL7, HTML, Oracle, Oracle Developer, Epic/Clarity reports.

Confidential, 2/05 – 10/07
Clinical Billing and Claims Analyst

Confidential,is a faith-based, not-for-profit aligned health system committed to the highest levels of excellence in providing health care and health related services in a caring environment.
Responsibilities:

• Anesthesiology, Emergency Medicine, diagnostic and Treatment Coding and billing using ICD-9-CM and CPT.
• Medicare, Medicaid, and other Health care claims.
• CCI editing (Work Suspended, Denied and Rejected Claims).
• Review Physician documentation for coding accuracy and compliance.
• Performs workflow analyses and recommends process changes to enhance departmental charge capture.
• Analyze clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Ensure physician documentation accurately reflects the appropriate level of service delivered to patients.
• Audit patient’s account. Medicare and other Health care claims.
• Laboratory billing. Medicare Direct Data Entry (DDE).
• Working Suspended, Denied and Rejected Claims.
• Billing Secondary Payers. Billing Secondary Payers.
• Appealing Denied Claims.
• Eligibility Verification.
• Review medical record and billing documentation for coding accuracy and Compliance.
• Participate in enhancing a clinical documentation & coding integrity program.
• Communicates to departmental and Medical Center associates any necessary charge related process changes and corrections that are identified.
• Develop recommendations for charging changes based on chart and charge discrepancies. Attend Medical Center in-services related to documentation or charging procedures as directed by Corporate Responsibility Officer.
• Coordinate and assist departments with resolving their charges that are a “Candidate for billing” on a daily basis.

Environment: IDX/GE Centricity, Windows 2000, MS-office (Outlook, word, Excel, Visio, Power Point, and Project), Test Director 8.0, Citrix.

Confidential, 7/03 – 12/04
General Physician
Responsibilities:

• Transcribed preoperative history as well as physical, consultation, transfer and discharge summaries. Transcribed predominantly multispecialty operative reports.
• Conducted patient examinations.
• Supervised patients during rehabilitative therapy.
• Carried out planned patient care programs.

Environment: IDX/GE Centricity, Windows 2000, MS-office (Outlook, word, Excel, Visio, Power Point, and Project), Citrix

Confidential, 8/02 – 3/03
Internship – General Physician
Responsibilities:

• Transcribed preoperative history and physical, consultation, transfer and discharge summaries. Transcribed predominantly multispecialty operative reports.
• Conducted patient examinations.
• Consulted with patients about rehabilitative therapy.
• Carried out planned patient care programs.

Environment: IDX/GE Centricity, Windows 2000, MS-office (Outlook, word, Excel, Visio, Power Point, and Project), Citrix

Education:

• MBBS (Bachelor of Medicine and Bachelor of Surgery)
• Certificate in Medical Transcription
• Certificate in Computer applications

Vocational Training:

Business Analyst , UML

HL7, DICOM, PACS

Software testing in practice Test Director 8.0/10.0, QTP

ICD-9-CM and CPT coding