Senior Technical CA-MMIS SME Resume Profile

SUMMARY OF QUALIFICATIONS

21 years experience working with the State of California Medicaid government contract.
Subject Matter Expert: reference database, eligibility/aid codes, claims adjudication, provider enrollment, EDI HIPAA x12 transaction sets
HIPAA X12 compliance SME
CAQH Core Operating Rules SME
Extensive knowledge of MITA Principles
Successful Mentor to other analysts and technical staff.
Lead technical analyst responsible for translating and testing the 276/277, 278, 835 and 837 HIPAA EDI transaction.
Ability to successfully communicate with both technical staff and the user community
Quick learner Self starter. Superior communication and presentation skills
Extensive knowledge and utilization of system development life cycle SDLC
Extensive background in developing user detailed specification.
Extensive background in writing detailed system specifications and test plans
Experience facilitate Joint Application Design meetings JAD
Unique ability to research and resolve system problems.
Lead testing analyst for yearly Disaster Recovery/Business Continuity tests.
Experienced in creating user training material and conduct user training

PROFESSIONAL EXPERIENCE

Confidential

Senior Technical CA-MMIS SME

Responsibilities:

Subject Matter Expert SME for EDI HIPAA Transactions Code Sets and Identifiers
SME for CAQH Core Operating Rules CA-MMIS Projects
Created CA-MMIS Business Process Models based of MITA principles
Identified and validated CA-MMIS HIPAA non-compliant issues.
Provide CA-MMIS SME support for Production related issues and problems
Provide CA-MMIS/Medicaid SME knowledge for developing HLRs for new projects
Provide SME required support in the development of accurate new project estimates
Lead claims workgroup meetings with DHCS to explain CA-MMIS system capabilities related to proposed changes.
Responsible for developing the BRD, SFD, TSD and Integration Test Plan for 837 EDI transactions
Responsible for Identifying CA-MMIS business and system impacts related to HIPAA 5010 and ICD-10 changes
Responsible for documenting the relationship between 5010 and ICD-10 compliance and CA-MMIS policy/system requirements.
Attended X12 HIPAA Conferences and participated in WEDI conference calls
Ensure that assigned Business Analysts work with appropriate DHCS and Development team stakeholders to meet all CA-MMIS contract requirements relating to HIPAA 5010 and ICD10.
Work with supporting Business Analysts to validate the integration of cross-functional business areas, and to validate that the solution meets applicable Medi-Cal policy, business requirements, and CMS compliance requirements.
Lead a team of business analysts and technical analysts through the HIPAA assessment and gap analysis activities.
Lead the Business Analyst team in identifying and documenting requirements for the HIPAA 5010 and ICD10 Enhancements.
Lead the Claims workgroup, responsible for implementing all 837s, 276/277, and 835 transactions.
Coordinate work activities of the Business Analyst team based on customer and ACS MBP priorities.
Communicate any requested changes to project scope and coordinates needs with Project Manager.
Oversee evaluation of gaps in solution and documentation of additional requirements.
Attend Peer Reviews to improve the quality of all deliverables.
Provide support to full development lifecycle, testing, training and implementation

Environments/Tools: Microsoft Office Suite including Visio, Visual Basic for Excel. TSO, SDSF, COBOL, JCL, FILEAID, CICS

Confidential

Business Analyst/Technical SME

Responsibilities:

Lead Systems Analyst for the implementation of CCS/GHPP, Healthy Families, CMSP and GMC programs.
Project lead/business analyst for new projects as a result of new contract requirements
Systems Programmer for new program requirements
Liaison between technical staff and lead users
Lead Acceptance testing/systems testing Analyst on large scale projects
Mentor other analysts and technical staff.
Lead analyst for the CDT-4 procedure code conversion
Lead technical analyst responsible for translating and testing the 276/277, 278, 835 and 837 HIPAA EDI transaction.
Conduct Operations Training classes
Perform Gap analysis
Performed Contract compliance verification
Facilitate Joint Application Design meetings JAD
Responsible for scheduling and running both batch and on request jobs for daily, weekly monthly quarterly and yearly job cycles
Research and resolve test and production job abends as well as test and production problems
Write, compile and execute mainframe Adhoc reports used for production and testing purposes.
Lead testing analyst for formulating test plan and test cases for yearly Disaster Recovery/Business Continuity tests.
Created user training material and conduct user training

Environments/Tools: Microsoft Office Suite including Visio, Visual Basic for Excel. TSO, ISPF, OPC, SDSF, COBOL, JCL, SAVERS, FILEAID, STARS, IDMS, CHANGEMAN, IDMS, CICS

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