SUMMARY

• Innovative and results oriented professional with over 18 years experience in the healthcare industry as a manager, business systems analyst, tester and testing lead, auditor, implementation team manager and team leader who possesses strong quantitative, analytical thinking skills, configuration and documentation skills.
• Has supported 12 upgrades and implementations on systems including QNXT, Facets, Power MHS, MACESS, CACTUS, and Witness Auditing System
• Proficient in claims payment managed care systems configuration including benefit plan and benefit code building, enrollment, provider maintenance, provider contracts and medical management on multiple claims payment systems.
• Demonstrated expertise in all aspects and phases of testing and the Project Life Cycle Methodology, and quality assurance related to implementation of software applications.
• Extensive knowledge and Subject Matter Expert (SME) for Medicaid, Medicare, commercial Managed Care products, Blue Cross Blue Shield plans, procedures, guidelines and technical changes.
• Significant experience in dealing with the interrelationships among processes, applications, data and technology.
• Proven ability to manage multiple projects simultaneously, and continuously streamline processes and procedures. Exceptionally well organized with well - developed written and communication skills.

TECHNICAL SKILLS

• Proficient with MS Office Suite (Word, Excel, Access, PowerPoint) Outlook, Visio, Publisher, Project
• TriZetto QNXT
• TriZetto Facets
• NASCO
• PowerMHS
• CACTUS
• CredPro
• Fox Trot
• Foresight
• Form Works
• RRI
• Project Insight
• SunGard MACESS
• Share Point
• Claims Test Pro
• Test Log
• HP Quality Center
• SharePoint
• Blue Print Requirements Center
• Witness Work Force Management & Quality Monitoring Modules

PROFESSIONAL EXPERIENCE

Confidential, Owings Mills, MD

Consultant - Configuration Manager

Responsibilities:

• Application configuration and testing analyst for software implementation and upgrade projects. Conduct gap analysis based on business requirements relative to application functionality and incorporates into project plans
• Lead Model Office testing teams and coordinates the creation, execution, scheduling and testing of all business scenarios prior to implementations. Participate in system integration testing, user acceptance testing, regression testing and post-stabilization issue resolution. Perform testing defect tracking, issue resolution and maintain testing databases. Provide testing status updates to executive and management level staff. Attend scrum meetings and joint design sessions
• Application configuration and testing analyst for software implementation and upgrade projects. Conduct gap analysis based on business requirements relative to application functionality and incorporates into project plans

Confidential, Little Rock, AR

Consultant - Business Analyst

Responsibilities:

• Application configuration and testing analyst for software implementation and upgrade projects. Conduct gap analysis based on business requirements relative to application functionality and incorporates into project plans
• Lead Model Office testing teams and coordinates the creation, execution, scheduling and testing of all business scenarios prior to implementations. Participate in system integration testing, user acceptance testing, regression testing and post-stabilization issue resolution. Perform testing defect tracking, issue resolution and maintain testing databases. Provide testing status updates to executive and management level staff. Attend scrum meetings and joint design sessions
• Create client requested documentation which has included statements of work, requests for proposals, IT action plans, workflows, EDI companion guides, business processes, business requirements, technical specifications, policies and procedures, presentations, status reports, training manuals and other materials, test plans, testing project plans, project charters, test scripts and scenarios
• Assist client with Mental Health Parity combined accumulation extract files for three of their trading partners. This includes extract file layout validation, submitting jobs for file creation, creating test data for import and extract files, job scheduling and extract file delivery to trading partners

Confidential, Philadelphia, PA

Business Analyst - Operations Technical Support

Responsibilities:

• Supported end users, operations and management staff by analyzing application release notes, business processes/operational data and developing, designing, documenting and testing system changes.
• Analyzed business and clinical processes relative to available and new functionality within supported applications.
• Conceived, designed, tested and wrote programmer specifications for proprietary online database driven application for business unit to assign service requests to business analysts.
• Collaborated with project managers to ensure all configuration, testing and business process tasks are accurately accounted for and communicated to appropriate parties to support corporate goals and timeframes and established deadlines are successfully met.
• Worked with senior management, operations managers and project managers to plan business and technology initiatives. Identify and resolve project issues and potential risks.
• Developed and executed test plans for software upgrades and new functionality of existing applications as well as implementation of new software.
• Documented business processes for IT projects and communicate between assigned technical staff and business units’ progress and resolution of issues.
• Provided quality ongoing end user support, ensuring the successful implementation of all assigned software application upgrades and implementations.
• Established project goals, develop and carry out strategic plans to recommend service standards, procedures and policies to support company objectives.

Confidential, Newark, NJ

Specialty Audit Coordinator

Responsibilities:

• Performed Medicaid and Horizon - BCBSNJ third party audits, off-site hospital outpatient, bill verification, credit balance and specialty facility audits on all claims engines used by the Enterprise: QCSI’s QNXT, NASCO, HSII and Blue Care Link (BCL).
• Assisted with desk audits to review and evaluate potential internal claim systems payment error trends and prepared data to assist in the negotiation of discounts with non-select providers.
• Corresponded regularly with hospital Patient Accounts to ensure timely recapture of erroneous payments and proper allocation to Plan accounts.
• Identified error trends in billing documentation or misrepresentation of provider contract stipulations resulting in erroneous payments to institutional providers.
• Lead Model Office team during all testing phases. Thoroughly documented system issues/limitations and recommended workflows, workarounds and/or system enhancements for implementation of new and existing business on the QNXT system via creation of Product Enhancement Requests (PERs).
• Performed root cause analysis on QCSI’s QNXT application during all testing phases to ensure application functionality had capacity necessary to meet the business requirements of the Enterprise.
• Worked directly with QCSI while on-site at vendor headquarters to perform system enhancement testing to determine if functionality upgrades made to QNXT software met the required performance and business standards necessary for application version implementation.
• Worked with other implementation teams to ensure software could accept and process HIPAA compliant standard electronic transactions such as 834, 837I, 837P and 278.
• Assisted with updating the testing database, test scenarios and scripts for all phases of testing and coordinated responsibilities of team members.
• Trained less seasoned team members on application, team workflows and testing databases used by project Model Office Team.
• Assisted with determining the best configuration approach to NY HMO benefits on QNXT application.
• Configuration liaison accountable for configuration of Medical Management for the implementation project. This included initial configuration and maintenance of authorization templates, service groups, pre-existing condition diagnosis code groupings and testing/validation of the configuration in Pilot.
• Accountable for configuration and maintenance of benefits. This included loading employer groups, creating and updating benefit terms and benefit plans, standardizing nomenclature, testing and setting edit rules for the different product lines.
• Consolidated needs of all implementation areas and assisted in the creation of an Access database used by the entire project team to document system limitations and issues that needed to be reported back to the vendor for further investigation and resolution.
• Attended joint design sessions with Subject Matter Experts (SME’s) from various areas within the Organization to ensure system configuration would appropriately accommodate the business need.