SUMMARY:

Sr. Benefit Configuration Analyst, Tester and Quality Auditor Professionally - trained Quality Auditor and Business Analyst persistent in combining 20+ years of distinguished member and provider service, system and payment methodologies, claims processing, configuration, and extensive auditing experience with real-world industry practices. Analyzing BRDs (Business Requirement Documents). Problem solving within Facets Network. Review and Analyze Facets System to ensure accuracy of the operations. Documenting errors within the system and provide recommendations and feedback. Proposing an unparalleled leadership style in the facilitation and management of membership and group audits designed to tap further into the controllable degrees of complex system and procedural auditing regiments. Profound interest in the diverse and valuable industry strengths that assist in encouraging advancement and achievement through complexly challenging opportunities in the auditor and configuration fields. Interested in advanced opportunities to contribute to and learn from the responsible and ethical industry practices that define the fundamental aspects of the employee healthcare field

TECHNICAL SKILLS:

• NASCO
• AMISYS
• MACESS
• BENEFITS CONFIG.
• HP/ALM
• MCS
• MEDICOM
• BENEFACT
• SQL
• MEDICAID
• MEDICARE
• QNXT
• FACETS
• ORACLE
• AUDITING
• GROUP Enrollment
• AS400
• POWER MHS
• Product Build
• MEMBER ENROLLMENT
• EXCEL

PROFESSIONAL EXPERIENCE:

Confidential, Scranton, PA

Sr. IT Business Analyst/Sr. Configuration Analyst

• Test Provider’s Agreements using NetworX Pricing Modules for all the Procedure
• Codes for various regions in MT State.
• Test Subscriber/Member Application and execute test cases and test scenarios for MT Medicaid members
• Resolving Clinical Edits
• Created Claims test cases and test scenarios
• Validated both Medical and Hospital claims in Health Rules Application
• Verify Claim Deductible, Copay, Coinsurance and Allowed Amounts
• for Pilot Group Benefit Plan and also validating Institutional and Professional claims
• Validate EDI/X12 transactions
• Defect management using HP/ALM
• Worked on 837, 834, 270/271 transactions
• Worked on enrollment files and validated 834 transactions
• Cancel and voided terminated members within FACETS
• Audit configuration files
• Configure Provider Pricing Agreement and update all terms as needed
• Enrolled Medicaid Members using FACETS 5.30

Confidential

Senior Facets Business Analyst/Facets Configuration Consultant   

• Responsible for review, audit, and Benefits Configuration, as well as corrections to SEPY and Service Rule to ensure accuracy and tight internal controls to minimize fraud and abuse and overpayment related issues within FACETS 4.87
• Product Build and Development
• Created Service ID and Service Rule to Product to ensure proper claim processing to adhere to respected Medical Plan benefits
• Adding warning messages and Clinical Editing to prefix
• Analyzed Business Requirements to configure Product
• Reviewed and validated PDVC (Product Variable Components)
• Audited incoming External Claim via 837
• Responsible for review of 834 and corrections to enrollment file errors through Electronic Data Interchange
• Configure Provider Pricing Agreement and update all terms as needed
• Worked directly on Medicaid and Medicare enrollment files
• Reviewing Accumulators, limits and OOP (out of pockets)
• Provided feedback on incorrect benefit configuration and provided solution
• Participated in review sessions for various system interface meetings
• Provided project management support by coordinating and facilitating weekly Detail Business Requirements review sessions
• Assisted in the scope analysis for enhancements identified and developing the Scope and detail requirements as needed
• Assisted with Test Case Execution and Test reports preparation.
• Reported and tracked defects in the defect tracking system.
• Coordinated with release managers and conducted production check outs after every releases
• Utilized SQL to run queries and validate Products Components for Benefit Configuration

Confidential     

Senior Facets Business Analyst/Benefit Analyst

• Creation, review, and audit of SEPY Files, SEPY Prefix, Service Rule, Business Rule, Variable Components and BDDS for accuracy utilizing FACETS 5.2.
• Product build and development
• Adding warning messages and Clinical Editing to prefix
• Resolving Clinical Edits
• Created test scripts, benefit configured, unit testing, defect management using HP/ALM
• Configure Provider Pricing Agreement and update all terms as needed
• Documented claims error and provide recommendations and resolution
• Creation, audit, and review of new and existing products    
• Reviewed edits, analyzed and created detailed documentation of business systems, BRDs and user needs
• Monitored project and requested status and workload, and ensured deliverables of high quality
• Managed assigned enhancements, automations and implementations from concept through implementation
• Ran SQL queries to validate Benefits Configuration
• Reported and updated FACETS data to ensure proper configuration process
• Review 834 Medicaid and Commercial file and made corrections as needed

Confidential 

Sr. Configuration Analyst

• Conducts analysis, configures, tests and document configuration solutions for the following functions:
• Benefit package configuration setup and maintenance
• Membership/divisions configuration set-up and maintenance using Amisys
• Group/member premium configuration set-up and maintenance
• Medical management configuration set-up and maintenance
• Define and document Client specific business/development requirements ensuring quality of all deliverable. 
•  Evaluate and Develop functional design specification(s) that align with client overall functional goals.
• Evaluate and Develop technical design specification(s) that align with functional design specifications. Updating upload new group into Rally Stories
• Perform queries and create tables for analysis using Access database.
• Product building and developing
• Oracle enhancement 1, 2 and 3

Confidential

Benefit Coding & Configuration

• Charged with utilizing the most appropriate resources for contract implementation, review of federal & state mandates, account set-up, and auditing. Principle accountabilities involving group and member enrollment auditing tasks.
• Audits of membership or group enrollment in accordance with the Member Touch point Measures Program guidelines.
• Submission of MTM Audit Memorandums (MAMS) to Operations Management to ensure any inaccuracies in procedures, controls and system integrity have been assessed and corrected.
• Perform follow-up activities related to audits/reviews, special projects, and other duties as assigned thus ensuring that corrective action have been appropriately taken.
• Active in training sessions that teach the Senior Auditors accountabilities and require the teaching of additional auditing measures, such as claims, inquiry, and membership and group enrollment for all products, to staff auditors.
• Review and correct Medicaid claims as needed
• MS Access and the use of Query Analyzer. Master Spreadsheet: Versed in utilizing the master spreadsheet furnished by NASCO for variegated Plan updating, including adding new requests. Knowledgeable in using master spreadsheet as a foundational source for accompanying Plan Variable Requests, such as:
• Creating new selections
• Adding new values to existing variables
• Changing the class (i.e., DED, Limit, COINS, etc.)
• Changing Service Type (i.e., Emergency room Mental & Nervous, Home Health Care, Orthodontics, etc.)
• Update Variable Description (editing the description of a variable)
• Removing a variable (requesting a deletion of a variable)
• Creating a variable (requesting a new variable be made from scratch)
• Adding a variable (requesting an existing variable be added to a specified string)

Confidential

Technical Assistant

• Primary responsibility included loading and updating provider files.
• Routinely provided support to accompanying IT Staff, administered test claims, and updated deductibles and co-pays.
• Processed hospital, physician and dental claims resulting from backlog using Facets 4.6 software.
• Test enrolled new and existing members as needed
• Manually enrolled new members to Commercial accounts as needed
• Responsible for adjusting claims due to any over- or underpayment submissions.

Confidential

Technical Assistant

• Expertly processed test claim and updated provider price, deductible, coinsurance and co-pays.
• Commanded and tested claims for medical, dental, facility, and professional clients and provided recommendations upon completion.
• Exercised routine measures of support to IT staff and updated and loaded provider files as needed.
• Maintained control and supervision of conversion process from FiServ to Metavance 2.8

Confidential

Business & Configuration Analyst

• Collaborated with equally qualified professionals to satisfy time and cost estimates tasks and identify the most appropriate resources for the successful completion of all projects.
• Represented expert knowledge in the ongoing maintenance and support of defined configuration and change management processes, some of which included production support.
• Charged with reviewing and updating dated benefit files and provider pricing through the use of AMISYS and FACETS systems.
• Processed flow-charts in connection with reviewing and performing test claims.
• Performed Medicare claims transactions that included Medicare secondary payer, Medicare Part A and Part B, and CMS regulations using the MCS system.
• Analyzed and Reviewed complete business systems in regards to user needs, and processed Dental, Vision, Inpatient, Outpatient, Medicare, DME, COB, Workers Compensation claims.