SUMMARY:

• 10 years of working experience in the Healthcare industry with combination of Configuration Analyst, Business Analyst, QA Analyst and Claims Analyst experience.
• Expertise with Facets/NetworX Provider contract pricing and benefits configuration analysis.
• Proficient with contract interpretation, rate sheet/agreement development and design to improve claims first pass rate, qualifier group and fee schedule design, quality assurance, unit testing and processing control agent configuration.
• Hands on experience with user warning messages, claims adjudication, troubleshoot provider reimbursement and payment vouchers, problem resolution, claim re - adjudication and mass adjustments.
• Focused on performance, Detail oriented and Logical & independent out of the box thinker.

TECHNICAL SKILLS:

Systems/Software/Program Knowledge: TriZetto's Claimfacts 7.1, Facets System 4.61, FACETS System 4.71, FACETS System4.11, 4.21, 4.41. 4.61 &4.81, NetworX Pricing, CITRIX Gtess Imaging System, WMDS, HIPPA EDI, 270/271 documents, 835/837 Claims and Encoder PRO Clinical Editing System, Member PRO for Eligibility, Customer Focus.

PROFESSIONAL EXPERIENCE:

Confidential, Quincy MA

Systems Configuration Analyst

Responsibilities:

• Updated service payment tables (SEPY) within Facets for new Medicare product offering, attaching appropriate service rules required for each benefit category, created new limits (LTLT) for benefits, peer reviewed other configurations, tested build configuration for each product offering.
• Updated and built new and existing supplemental revenue code tables (SRCT) for high dollar radiology project based on the criteria provided.
• Updated service definition tables (SEDF) to in corporate new service ids required for high dollar radiology project.
• Facets Medical Plan configuration, manipulating service procedure, service revenue, supplemental procedure, supplemental revenue, medical utilization edits, service payment, limits, service rules, benefit summary, and class plan tables.
• Create back end data loads through Access to upload tables into Facets system. Retrieve data through table queries within Facets.
• Appointed as Lead for the self insured line of business. Work closely with Sales, interpreting benefits sold into business decisions and system configuration.
• Test, load and configure business decisions into system. Team lead for recent upgrade of Facets system. Test and implement quarterly fixes to Facets.
• Organized meetings with all department management to review benefits in depth discussing the payment type, coding and pricing before implementing Facets configuration.
• Prepared documentation and materials for team members for future of Facets configuration setup.

Confidential, Brooklyn NY

Business Analyst/ Configuration Analyst

Responsibilities:

• Completed loading FACETS provider agreement, hospital contracts, CPT codes, and demographic data encounters, capitation,, provider setup, provider contracts, and benefit plan build.
• Build benefit grids for unit testing and UAT Configuration.
• Accessed ICD-10 for designing payment systems and processing claims for reimbursement.
• Supported client configuration changes and new requirements, including analysis, plan building, and test.
• Handled all Medicare, Medicaid for Facet configuration process.
• Analyzed complex business issues related to ICD-10 and developed systems requirement.
• Conducted detailed system analyst configuration; benefit contracts into the FACETS system to ensure proper benefit payment.
• Provided detailed analysis using access queries, troubleshoots, and correct issues.
• Accessed numerous billing systems: NetworX Pricer, FACETS, Amysis, and along with utilizing Microsoft Access, SQL, Excel for analysis, reporting and updating FACETS data to ensure proper configuration process.
• Used Microsoft Outlook for incoming mail and respond to inquiries.
• Competent with Medicaid, Medicare part D, Third party insurance.
• Worked on Claims processing software’s include EZCAP, Medical Manager, Medisoft, Encoder pro, Facets Test Plan on new rates for 2011 and changes to the Facility and Professional agreements to insure correct payment.
• Analyzed and adjudicated pended claims generated from Ruby reporting system.
• Reviewed Benefit Matrix for specific details of product descriptions; run SQL Queries for each product associated.
• Utilized my indepth knowledge of Agile and Software Development LifeCycle (SDLC) methodologies throughout the duration of this assignment
• Accountable for NetworX configuration of Provider contracts for medical, ancillary and ASC based entities.
• Created rate sheets/agreements, qualifier groups and fee schedules.
• Worked on quality assurance of new or existing contracts/configuration to ensure appropriate/correct payment is made through unit testing on current and regression payment.
• Consulted with relevant contract manager to determine interpretation and configuration of contract terms.
• Data Transfer of agreements from a testing environment into a production environment.
• Researched and corrected payment issues related to NetworX pricing through a Macess queue.
• Accessed queries and table loads.
• Experienced in Facets/NetworX Data Model tables for updates and maintenance, processing control agent (PCA) and warning messages.
• Accountability for meeting deadlines, quality and production measurements.

Confidential, Melville NY

Medical Claims Analyst

Responsibilities:

• Assessed and distribution of work assignments, aging accounts, mass adjustments and special projects.
• Ensured established turnaround time is met. Projection of weekly/quarterly productivity.
• Analyzed monthly account receivables and recoveries.
• Identified pricing issues whether processing, contract or configuration error. Implemented corrective action plan based on analysis.
• Validated reports for payment and recovery accuracy.
• Analyzed claim payments/recoveries based on claims re-adjudication whether the issue was due to provider configuration or member/benefit configuration.
• Worked directly with the provider relations department and provider offices during the Facets migration to ensure the posting of payments appropriately based on payments and recoveries on the provider's payment vouchers and collection processes.

Confidential, Bronx NY

Medical Biller

Responsibilities:

• Obtained medical referrals and authorizations for medical procedures and surgeries.
• Accurately bill electronically and file insurance claims.
• Posted claims payments and correct/ remit claim denials.
• Worked on Medical collections in terms of delinquent accounts, follow up and maintain contact with multiple insurance companies.
• Provided patients with explanation of benefits and assisted with interpreting statements and services.
• Working knowledge of different types of medical insurance such as private carriers, HMOs, Medicare, Medicaid, CPT-4 (current procedural terminology) and ICD-9 CM (international code of diseases) and workers compensation disability.
• Maintained a professional atmosphere, abide by HIPAA Billing regulations and other safety guidelines.
• Associates Degree in Medical Assisting, The College of Advanced Technology, Brooklyn, NY, 2006.