SUMMARY:

• Senior level Configuration Analyst with over 20 years of experience and niche expertise in the health care industry. Strong organizational, analytical and project management skills. Implemental strategies that impact organization’s bottom line by utilizing configuration payment methodology as it pertains to PPO - HMO-EPO plans/Medicare/Medicaid and more.
• Analyze client’s needs for product implementation to help reach their goals
• Translate reimbursement methodologies into configuration requirements Responsible for writing business decision documents for implementation Coordinated testing medical plans against supplemental tables, limits, deductibles and accumulators Built products & claim components in the medical plan application Configured Provider Contracts and Benefits Translate group benefits to uploaded into Facets Accountable for benefit package configuration setup and maintenance Conducted interviews, hiring process & training for support staff Managed and motivated a team of 35 consultants to ensure optimal performance to client

TECHNICAL SKILLS:

• Oracle Configuration
• EDI Amisys
• Facets ICD - 9/ICD 10 conversion
• Cactus WGS ITF RIMS
• Ultera PRODHOSP
• Mainframe Configuration On Demand Legacy
• FEP Direct Max MC IPD
• MS Office Products 837
• Reader Image (Electronic Claims System) Visio

WORK EXPERIENCE:

Confidential, Boston, Mass.

Oracle OHI Configuration Analysis Advisor

Responsibilities:

• Translate reimbursement methodologies into configuration requirements
• Configure Provider Contracts and Benefits
• Strong configuration experience can do configuration design, build and validation
• Accountable for pricing configuration setup and maintenance

Confidential, Las Vegas, NV

Project Manager (Consultant)

Responsibilities:

• Managed project meetings using project plans to meet key deadlines and ensure progress on the project.
• Assembled and maintain project plans and documentation of project progress and tracking key milestones using standardized project management tools, in accordance with departmental and organizational guidelines.
• Collaborated with project team to assure that applicable interfaces with other pertinent interfaces are established and maintained.
• Developed internal quality performance measures and regular reports, to support departmental and organizational improvement goals.
• Assured timely and accurate data submission to regulatory and external quality performance measurement.
• Provided operational support and training for all phases of the claims process. Ensured accurate and timely processing of local and ITS claims to meet customer’s service level agreements. Overseen day-to-day activities of a group of 25 team members.
• Coached, motivated, and guided team members. Trained staff on efficient system utilization and encouraged the use of workflows within the system. Managed claim inventory and workflow. Created complex SQL queries and stored procedures for reporting.

Confidential, Boston, Mass.

Oracle Sr. Business Configuration Analyst / Configuration. Mgmt Advisor

Responsibilities:

• Currently working with a project team of Oracle OHI Senior Configuration Analyst on contract defects and configuration utilizing the OHI processing system.
• Impacting the revenue cycle for the organization utilizing a strategic process of investigating defective claims, complicated claim payments and difficult contracts.
• Work claims ques to adjudicate and resolve claims-engineering and improving configuration process.
• Investigates and provide solutions for daily production issues. Audit contract loads for adherence to quality measures and reporting standards.
• Review and correct co-payment and accumulator fields for correct claim processing.

Confidential, New York, NY

Sr Business Analyst

Responsibilities:

• Work closely with project managers to test system specifications and document business/system requirements to facilitate validation of implemented solutions.
• Responsible for participating on projects related to Confidential ’s strategic plan for ICD-10 conversion.
• Complex system integration and high-priority projects to facilitate organizational re-design and process improvement.
• Support successful completion of project objectives related to business analysis, system analysis and implementation in accordance with best practice processes.
• Create test scenarios within the system to ensure that system functionality satisfies testing requirements, log issues, communicate and prioritize accordingly.
• Serve as liaison between senior staff and team leads within the Claims Operations’ group concerning business requirements, planning, testing and execution of projects.

Confidential, Chicago, Illinois

Facet Benefits Configuration Analyst

Responsibilities:

• Facilitated training for the Federal Employee Program (FEP).
• Collaborated with key department heads to improve the quality of the configuration process and test scenarios for system enhancements.
• Resolved and addressed new or unusual configuration errors and issues as they arise. Applied appropriate knowledge from prior experience to work function.
• Full understanding of all configuration types and the respective processing.

Confidential, Albany, New York

Testing Analyst-Facets/Configuration Analyst

Responsibilities:

• Lead implementation for customer accounts, while adhering to quality measures and reporting standards, while building a high performance structure.
• Assisted with the implementation to improve the quality of claims processing, and test scenarios for system enhancements on user acceptance testing.
• Created test scripts; created test claims, testing grids and gap analysis, code benefits, configure contract/benefit limits and code benefits.
• Managed contracts loading and utilized various databases and/or source documents.
• Collaborated with several departments within the organization to ensure an effective and efficient process.

Confidential, Chicago, Illinois

Facets Benefits Configuration

Responsibilities:

• Strong configuration experience can do configuration design, build and validation.
• Claims Operations, IT, Project Management, Health Plan Operations Serve as subject matter expert on benefit configuration methodologies.
• Accountable for Facets benefit configuration solutions supporting providers.
• Identified and resolved operational issues using defined processes and methodologies.
• Identified issues that might impact quality or quantity.
• Coordinated configuration teams in cross functional projects and achieved timely and accurate deliverables.
• Participated in project management, analysis and sign-off of system enhancement projects.

Confidential, Bronx, New York

Claims Supervisor

Responsibilities:

• Provided expertise and/or general claims supports to project team; reviewed, researched, negotiated, processed and adjusted claimed.
• Responsible for a project team which focused on back log reduction for claims.
• Analyzed and identified trends ran queries and provided reports as necessary.
• Collaborated with business partners to identified issues related to the claims process and procedures to ensure legal standards were met.
• Identified and communicated opportunities to improve claims processing efficiency and reduce rework. Organized, prioritized and distributed assignments to project team.
• Interviewed, hired and orientated all new hires. Conducted annual employee evaluations, and time and attendance issues. Create incentive for team building and cross training.
• Lowered claims back log from 120,0 00 to 45, 000 in 6 months turn around period.
• Collaborated with the Accounts Payable Department on a weekly basis to determine efficiency of claims processing to ensure that the bottom-line was satisfied.

Confidential, Brooklyn, New York

Business Analyst / Corporate Trainer

Responsibilities:

• Wrote detailed description of user needs, business rules, user acceptance criteria, and steps required to develop or modify computer programs.
• Participates in the testing process through test review and analysis, test witnessing and certification of software.
• Reviewed, analyzed, and evaluated business systems as it related to the Medicaid claims process.
• Utilized the DRG grouping and pricing methodology process for provider claims. Also utilized CPT, Diagnosis, ICD-9 and HCPCS Codes to pay providers.
• Facilitated needs and functional requirements with internal and external stakeholders.
• Sanctioned of Amisys Database for the Configuration Department.
• Work closely with Project Manager to ensure resources are properly coordinated to complete project task assignments.
• Provided reports regarding identified problems and errors made in the claims’ department.