OBJECTIVE:

To obtain an Analyst position where I can leverage over 11 years of experience within the health care insurance industry and in IT for the last 7 years to continue to develop professionally into positions of increasing responsibility.

SUMMARY:

• Detail - oriented, professional analyst with over 11 years of experience within the Health Care Insurance industry including:
• Data Analyst for the Confidential
• Software Configuration Analyst for Confidential
• Senior Medical Network Cost Analyst for Confidential
• Senior IT Analyst for Confidential
• Systems Solution Analyst III for Confidential
• Recovery Analyst within the Finance Department at Confidential
• Internal Adjustor within the Special Teams group at Confidential
• Medicaid Reconciliation Team at Confidential
• I have extensive experience in the analysis of various types of claims data to identify problems with claims processingprovider systems, audits, eligibility, membership updates, postings, codes, etc.
• Thorough understanding of the processing of claims, including Medicaid claims, and strong knowledge of benefits claims industry terminology, policies, and procedures - including work with CMS.
• 8 years of experience with CPT and ICD9 coding, including 3 months of intensive training on both CPT and ICD9 as a new employee of Confidential .
• Exceptional problem-resolution skills from determining root cause of problems to developing “work arounds” for temporary fixes, to working with systems programmers to put permanent fixes in place systematically.
• Works extremely well with internal customers and providers, the “Go-To” person to handle the research and resolution of escalated, high-profile claims issues
• Solid testing experience for claims system upgrades, modifications, or other enhancements both in test environment and live environment
• Excellent communication and presentation skills with informal training experience of team members

TECHNICAL SKILLS:

• SQL
• Toad
• SAP
• Xerox
• Oracle
• Sharepoint
• Enviance - web based
• PROMISe
• CIS
• MC400 - claims processing
• Outlook
• MS Office including Word, Excel and Power Point and Access
• Peachtree Accounting Package
• Adobe Acrobat
• Lotus, Spreadsheet, Database, Lotus Notes
• Power MHC/GATELink
• DIVA
• MSM
• NaviMedix
• 820 Payment transmissions
• 835 ERA/EFT Vendor setup and transmissions
• 837 Claim transmissions
• 277 Encounter Response Files
• Diamond/COSMOS - claims processing
• JIRA

PROFESSIONAL EXPERIENCE:

Confidential

Systems Analyst

Responsibilities:

• Gather and document business requirements
• Create traceability matrices to track requirements through the design and development
• Facilitate and/or support project team in resolving issues
• Work closely with the project team to quickly prototype possible approaches to problems and needs, and help design and implement the final solution
• Gather information from existing systems, analyze program and time requirements
• Evaluate design solutions objectively
• Plan and manage multiple assignments of varying scope
• Lead others through delegation of technical tasks while also completing tasks
• Support testing, validation and audit of solution
• Understand how to engineer quality and validation/controls into design
• Produce and maintain currency of artifacts

Confidential

Project Manager/Process Consultant

Responsibilities:

• To professionally manage customer projects, primarily in the manufacturing industry
• To coordinate our local IT support team responsible for our customers’ ERP systems and supply chain applications, and (out of managing customer projects) to expand current customer accounts and / or projects (concept, design and presentation of solutions)
• To create and implement complex supply chain concepts and applications together with our clients and internal project teams, advising project teams on technical aspects
• (e.g. usage of appropriate SCM tools; parameterization of supporting ERP systems)
• Coordinating and communicating with our subsidiaries in Germany, the US and
• Singapore on globally applicable projects and support topics.
• Driving projects related to optimizing the Supply Chain or parts of the supply chaine.g.: re-designing a demand planning, production planning or material planning process
• Optimizing the material flow, defining push / pull points, etc.
• Coaching and consulting the customer’s SCM team
• Managing projects related to business integration, e.g. harmonizing and automating intercompany supply chain processes of international clients, both from a logistics as well as from a technical (system) perspective

Confidential

Data Analyst

Responsibilities:

• Data Exchanges - Monitoring reviewing and approving inbound and outbound data exchanges and related load reports produced out of interfaces between Xerox, Oracle and other Third Party systems for accuracy and completeness. Escalated known issues and took needed steps/action, including appropriate resources for timely and accurate review/problem resolution
• Data Conversions, Analysis and Reporting - coordinated and ensured accuracy of conversion loads of data from legacy systems to the Benefits system and Oracle. Identified reported and analyzed and resolved errors from data conversion loads and data cleansing activities.
• Provided instructional documentation for Managers to share with reps to teach them how to use the new system.

Confidential

Software Configuration Analyst

Responsibilities:

• Consult and assist with Software Architects on matters concerning build and release process.
• Configure software per build documents
• Configure calculations
• Test software
• QA build process and documents
• Upload historical data for reporting purposes

Confidential

Senior Network Medical Cost Analyst

Responsibilities:

• Develop and drive provider performance improvement strategies, medical cost containment programs and special projects that directly impact the operational and financial performance of network management using strong reporting, analytical and influencing skills
• Assess and interpret customer needs and requirements
• Identify solutions to non-standard requests and problems
• Translate concepts into practice
• Provide explanations and information to others on difficult issues
• Coach, provide feedback and guide others
• Analyzing information and identifying opportunities for improvement related to claims cost management
• Identify root causes of issues and develop solutions, both short and long term
• Compiling and writing specifications and business requirements for long term solutions.

Confidential

Senior IT Analyst

Responsibilities:

• Work in the business analysis phase of the system development cycle
• Consult with users to define business processes and the information systems for supporting those processes
• Define and document/communicate business requirements
• Develop and document medium to high complexity business workflows
• Analyze scope and resolution of medium to large size operations management and development requests
• Provide clear description of problems/issues for medium to high complexity problems
• Present options for problem resolution
• Contribute in developing organizational functional knowledge
• Demonstrate subject matter expertise in functional/application area
• Assist in estimation of small to medium size

Confidential

Systems Solution Analyst III

Responsibilities:

• Researching, gathering, analyzing information on complex business systems issues.
• Proposing recommendations and helping to determine optimal solutions.
• Developing recommendations including business requirements and business technical specifications for complex perational/system issues and changes that impact revenue, operational efficiency, enrollment, healthcare costsclaim payment claim timeliness or regulatory compliance.
• Security for the Health Plan
• Point on Digital Voice Fax and NaviNet
• Troubleshooting and liason on Power Queue Customer Service
• Deal with multiple departments identifying issues, documenting requirements and pursuing system modification.
• Creating and following documented test plans required to support full regression testing, certifying new software upgrades and testing system modifications.
• Assist in full regression testing of software upgrade and modifications to the TEST system and validation in the LIVE system.
• Conduct informal one on one and/or small group training/mentoring pertaining to the products, programs, systems or production areas concerning administrative systems or reporting issues.
• Participate in the development of policies and procedures in the prescribed format and participate in annual policy review.

Confidential

Recovery Analyst

Responsibilities:

• Report check information to financial institution for checks issued and voided
• Adjust claims for improperly paid claims identified by providers (via refund or return)
• Investigate and follow up on provider issues requested by providers or internal departments
• Pursue and attempt to recover money owed by providers via Negative Balance or Refund Request processes

Confidential

Internal Adjustor/Research Support

Responsibilities:

• Analyzing claims
• Analysis of Reports and Accounts
• Locating System Account Issues for Correction
• Auditing Provider and Facility Claims Accounts

Confidential

Adjustment Specialist

Responsibilities:

• Adjustment experience in local claims and ITS with worldwide Blue Cross and Confidential 's
• In depth claims analysis
• Experience in auditing phases and clean up
• Reporting and account analysis
• Multiple system usage including sophisticated mainframe applications
• Analyzing and troubleshooting system problems including forming workarounds for adjustments
• Training new adjustors

Confidential

Customer Service Representative

Responsibilities:

• Call center experience handling a dedicated account
• Sophisticated software navigation was essential through mainframe application
• Processing of claims and knowledge of medical terminology and ICD9
• Knowledge of adjustments on claims
• Dealing with other plans throughout the country in troubleshooting problems and problem resolution.
• Handled the sorting of explanation of benefits for our unit along with coordinating check payments to our members bank accounts by special request by the group.
• Responsible for handling some group inquiries including investigation and resolution of issues.
• Trained other staff in the unit on software systems and procedures within our unit.

Confidential

Office Manager

Responsibilities:

• Bill and process invoices through the Peachtree accounting package
• Process Receivables and handle Collections
• Track sales for salesmen, state, industry and product
• Prepare presentation materials
• Budgeting and Payroll
• Insurance group administrator, confer with insurance agents on yearly renewals on policies
• Work in conjunction with an accountant on taxes and closing books
• Provide customer service including troubleshooting and handling customer calls