SUMMARY:

• An experienced healthcare services professional with over twenty years experience in the Health Plan and Health Insurance Industry. I have extensive knowledge of Traditional, Managed Care, Medicare, Medicare Advantage and Medicaid plans and I am proficient in Web - Based Applications. Excellent problem solving and analytical skills with attention to detail. Exceptional multi-tasking and team collaboration skills. Experienced in Provider set-up, Provider Contract reimbursement configuration set-up, Benefit Configuration, maintenance, Claims, Testing, Subscriber/ configuration set-up and maintenance and Medical Plan Application set-up. Configuring EDI transactions (837, 835, 834, 270, 271) through HIPPA Gateway.

TECHNICAL SKILLS:

Systems & Technical Knowledge: TriZetto Facets - 4.21, 4.41, 4.51, 4.61, 4.71, 5.0, 5.01, 5.10 Diamond 725, Diamond 950, Xcelys 6.2 - Amisys 6.0, 6.1, 6.2, 6.4 - Power MHS 2.0, PowerSTEPP, - QNXT 4.8, QNXT 5.01 - WGS - CallCare - Ultera, CAQH, NPI, FileNet, Citrix, Cosmos, MS Word, Microsoft Access, Siebel, PowerPoint, Windows, SQL, Excel, MARX system, SMS, ACS, VAT System, Clipboard/Pinnacle, EDSNET, TPS, WGS, File Net, Discrepancy Tool and Ultera.

PROFESSIONAL EXPERIENCE:

Confidential - Rochester, NY

Facets Configuration Analyst

Responsibilities:

• Configured and tested Contracts and Benefits for Facets 5.10
• Processed/Configured Encounter information based on Capitation Methodology.
• Configuring EDI transactions (837, 835, 834, 270, 271) through HIPPA Gateway
• Performed testing and implementation of required health plan benefits and payment structure changes. Documented business requirements and configured Product builds. focusing on Supplemental Tables, Service Payments, Service ID, Service Definition, Service Rules. Analyzed complex business issues and conducted detailed system analyst configuration.
• Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets data to ensure proper configuration process.
• Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure codes.

Confidential - Long Beach, CA

QNXT Configuration Analyst

Responsibilities:

• Interpreted and configured provider contracts, tested payable procedure codes, and fee schedules in QNXT 5.01.
• Configured, built and tested contracts and Benefits in QNXT 5.01 for new business and renewals.
• Created and updated Fee schedules for new/existing contracts.
• Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure codes.
• Resolved Contract and Benefit System Edits and Claims Workflow issues.
• Support client configuration changes and new configuration requirements, including configuration analysis design, build and test.
• Liaison between client, administrations, and other essential departments in order to ensure overall quality and client satisfaction.
• Participated in customer and configuration/implementation meetings to formulate, clarify and confirm business requirements.

Confidential - Brooklyn, NY

Facets Configuration Analyst

Responsibilities:

• Configured and tested Contracts and Benefits for Facets 5.10
• Processed/Configured Encounter information based on Capitation Methodology.
• Configuring EDI transactions (837, 835, 834, 270, 271) through HIPPA Gateway
• Performed testing and implementation of required health plan benefits and payment structure changes. Documented business requirements and configured Product builds. focusing on Supplemental Tables, Service Payments, Service ID, Service Definition, Service Rules. Analyzed complex business issues and conducted detailed system analyst configuration.
• Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets data to ensure proper configuration process.
• Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure codes.

Confidential - Birmingham, AL

Benefit Configuration Analyst

Responsibilities:

• Responsible for entry of real-time map defects, entry/update of requirements, test scenarios, test scripts/steps and test results.
• Configured, built and tested benefits in PowerSTEPP for new business and renewals. Reported and updated data to ensure proper configuration process.
• Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel.

Confidential - Spokane, WA

Facets Configuration Analyst

Responsibilities:

• Configured and tested Contracts and Benefits for Facets 5.01
• Processed/Configured Encounter information based on Capitation Methodology.
• Configuring EDI transactions (837, 835, 834, 270, 271) through HIPPA Gateway
• Prepared test cases and conducted User Acceptance Testing of Fee Schedules and payable procedure codes.
• Performed testing and implementation of required health plan benefits and payment structure changes. Documented business requirements and configured Product builds. focusing on Supplemental Tables, Service Payments, Service ID, Service Definition, Service Rules. Analyzed complex business issues and conducted detailed system analyst configuration.
• Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets data to ensure proper configuration process.

Confidential - Rochester, NY

Facets Configuration Analyst

Responsibilities:

• Configured and tested Contracts and Benefits for Facets 5.01
• Processed/Configured Encounter information based on Capitation Methodology.
• Configuring EDI transactions (837, 835, 834, 270, 271) through HIPPA Gateway
• Performed testing and implementation of required health plan benefits and payment structure changes. Documented business requirements and configured Product builds. focusing on Supplemental Tables, Service Payments, Service ID, Service Definition, Service Rules. Analyzed complex business issues and conducted detailed system analyst configuration.
• Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets data to ensure proper configuration process.

Confidential - Owings Mills, MD

Contract Configuration Analyst

Responsibilities:

• Configuration of services including: Provider set-up, Group/member premium configuration set-up and maintenance, Employer group/billing configuration set-up and maintenance.
• Performed testing and implementation of required health plan benefits and payment structure changes. Documented business requirements and configured Product builds. focusing on Supplemental Tables, Service Payments, Service ID, Service Definition, Service Rules. Analyzed complex business issues and conducted detailed system analyst configuration.
• Provided detailed analysis using Microsoft Access queries, troubleshooting and correcting issues utilizing Microsoft Access, SQL and Excel. Reporting and updating Facets 5.0 data to ensure proper configuration process.

Confidential - Denver, CO

Contract Configuration Analyst

Responsibilities:

• Performed Configuration of Institutional and Professional Provider Contracts, Authorizations, and/or General Configuration such as System Edit Rules & Fee Schedules updates into Xcelys 6.2
• Built and updated Price Rules & Fee Schedules.
• Maintained detailed knowledge and understanding of Xcelys 6.2 rules relative to claims payment.
• Executed configuration testing, tested payable procedure codes, price rules and fee schedules in Xcelys 6.2.

Confidential - Rochester, NY

Contract Configuration Analyst

Responsibilities:

• Configuration of services including: Provider set-up, Group/member premium configuration set-up and maintenance, Employer group/billing configuration set-up and maintenance.
• Configured the following in Facets 4.71 for all new and active groups(benefit changes):
• Class/Plan Definition
• Premium Rate Table
• Groups, Subgroups
• Billing Entity and Subscriber Family applications
• Conducted unit testing of planned configuration modifications prior to User Acceptance Testing and auditing within Facets 4.71

Confidential - Brooklyn, NY

Contract Configuration Analyst

Responsibilities:

• Provider (HMO/PPO) reimbursement configuration set-up and maintenance
• /divisions configuration set-up and maintenance
• Conducted unit testing of planned configuration modifications prior to User Acceptance Testing and auditing within Facets 4.61

Confidential - Grand Rapids, MI

Group Admin/Configuration Analyst

Responsibilities:

• /divisions configuration set-up and maintenance
• Conducted unit testing of planned configuration modifications prior to User Acceptance Testing and auditing within Facets 4.61
• Configuration of services including: Provider set-up, Group/member premium configuration set-up and maintenance, Employer group/billing configuration set-up and maintenance.

Confidential - Visalia, CA

Group Admin/Configuration Analyst

Responsibilities:

• Performed Configuration of Institutional and Professional Provider Contracts and/or General Configuration such as Fee Schedules updates into Power MHS.
• Executed configuration testing, tested payable procedure codes, price rules and fee schedules in Power MHS.
• Maintained detailed knowledge and understanding of Power MHS rules relative to claims payment.

Confidential - Phoenix, AZ

Benefits Enrollment Recon Analyst

Responsibilities:

• Processed and analyzed Medicare and Commercial enrollment reconciliation
• Enrolled and disenrolled members using the following: CMS (Center for Medicare & Medicaid Services) database, MARX system, SMS, ACS, VAT System, Clipboard/Pinnacle, EDSNET, TPS, WGS, File Net, Discrepancy Tool and Ultera.
• Processed and submitted daily and weekly enrollment and disenrollment discrepancies to CMS.
• Assisted with special CMS enrollment reconciliation projects as needed.

Confidential - Denver, CO

Contract Configuration Analyst

Responsibilities:

• Performed Configuration of Institutional and Professional Provider Contracts, Authorizations, and/or General Configuration such as System Edit Rules & Fee Schedules updates into Xcelys.
• Built and updated Price Rules & Fee Schedules.
• Maintained detailed knowledge and understanding of Xcelys rules relative to claims payment.
• Executed configuration testing, tested payable procedure codes, price rules and fee schedules in Xcelys.

Confidential - Tampa, FL

Contract Configuration Analyst

Responsibilities:

• Configuration of services including: Provider set-up, Group/member premium configuration set-up and maintenance, Employer group/billing configuration set-up and maintenance.
• Provider contract concepts and common claims processing/resolution practices in Facets 4.51.
• Conducted unit testing of planned configuration modifications prior to user acceptance testing and auditing in Facets.

Confidential - Tampa, FL

Contract Configuration Analyst

Responsibilities:

• Updated, built and tested payable procedure codes, price rules and fee schedules in Diamond 725.
• Performed Configuration of Institutional and Professional Provider Contracts, General Configuration such as System Edit Rules & Fee Schedules updates that support claims processing consistent with the provider contractual arrangements and according to a group’s evidence of coverage (EOC) in Diamond 725 & Diamond 950.
• Conducted unit testing of planned configuration modifications prior to user acceptance testing and auditing.

Confidential - Tampa, FL

Contract Configuration Analyst

Responsibilities:

• Updated, built and tested payable procedure codes, price rules and fee schedules in Diamond 725.
• Performed Configuration of Institutional and Professional Provider Contracts, General Configuration such as System Edit Rules & Fee Schedules updates that support claims processing consistent with the provider contractual arrangements and according to a group’s evidence of coverage (EOC) in Diamond 725 & Diamond 950.
• Conducted unit testing of planned configuration modifications prior to user acceptance testing and auditing.

Confidential - Tampa, FL

Contract Configuration Analyst

Responsibilities:

• Performed Configuration of Professional Provider Contracts, General Configuration such as System Edit Rules & Fee Schedules updates that support claims processing consistent with the provider contractual arrangements and according to a group’s evidence of coverage (EOC) in Diamond 725 & Diamond 950.
• Executed configuration testing, built, updated, tested payable procedure codes, price rules and fee schedules in Diamond.

Confidential - Bloomfield, NJ

Benefit Client Services Account Specialist

Responsibilities:

• Responsible for handling Life, Disability, medical claims issues, waiver of premium claims and arrears.
• Prepared and submitted new case submissions and group amendments.
• Responsible for preparing and proofing administrative kits, handling COBRA and issues with s of Coverage, contracts, employee benefit booklets, employee enrollment kits and benefit summaries.
• Responsible for running benefit rate calculations on RASER System and preparing Life & Health quotes.
• Prepared Life & Health and 401(k) proposals also assisted with policyholder renewals.