Shawn Jones

** ******* **

Levittown, Pa *****

267-***-****

215-***-****

aco172@r.postjobfree.com

SHAWN JONES

SUMMARY:

Senior-level database and development analyst with over 10 years of

professional experience in the analysis, design, development, execution,

and delivery of highly complex, customized technology solutions.

. Expertise in diverse development platforms accompanied with

multifaceted programming capabilities with a strong emphasis on

Microsoft-based technologies - including SQL Server and the .net

framework.

. Firm hands-on experience in Software Development Lifecycle with an

experienced approach in SCRUM and AGILE.

. Solid analytical and project management background in formulating

technology solutions for healthcare industries - including a strong

knowledge of Facets Software (version 2.96-5.01), HIPAA 834,835 & 837

(270/271,276, 277, X12) compliance file formats, 5010 formats, ICD-10

and Medicare/Medicaid environments, Healthedge 4.31-4.6

. Skilled team leader; adept in training, coaching, and motivating

members to support broad ranging development, functional, and

operational needs.

. Smart working and focused with exceptional analytical, organizational,

and interpersonal skills.

TECHNICAL SKILLS:

Languages: MS SQL Server 2000, MS SQL Server 2005 (test environment),

Sybase 12.0, Oracle 9i, Access, Informix, FoxPro, TSQL,

PL/SQL, DTS, SSIS (test environment), Visual Studio.NET, ASP, Visual

Basic, Visual Interdev, C, C#, Visual C++, XML, Windows/UNIX Socket

programming, Delphi, Pascal, Perl, Assembler.

Software: FACETS (versions 2.96, 4.11, 4.21, 4.31, 4.51,4.7,5.01),

DataStage 7.5, Microsoft Office, dBase, Excel, Rapid SQL, TOAD,

Crystal Reports XI, CPS, Qiclink

Platforms: Windows NT, Windows 2000, DOS, AT&T/Unix, Sun/Unix, HP/Unix,

Linux

PROFESSIONAL EXPERIENCE:

Facets Configuration Consultant

Excellus BCBS of Roch, NY

11/2013-2/2015

. Analyze current products and recommend configuration for changes

necessary to meet HCR regulations.

. Configure benefit products within Facets 5.01 to meet new sales

requirements and promulgate changes throughout development

environments.

. Product

. DEDE

. LTLT

. SERL

. SEPY

. BSBS

. BSDL

. PDBL

. Recommend business processes to make configuration of benefit packages

more efficient throughout development lifecycle.

. Liaison with Technical and System testers to ensure correct

understanding of system coding and aide with testing scenario

development necessary to effectively test configuration.

. Troubleshoot Facets 5.01 to locate any inefficient configuration

(Product/Membership build) and make necessary recommendation toward

solution in system configuration.

Facets Technical Consultant

Highpoint Solutions,Inc

9/2013-11/2013

. Assess Facets configuration for VNSNY of New York

. Interview key resources to determine actual Benefits and Product

configuration Facets 4.71 and develop recommendations on more

efficient configuration for Facets5.01.

. Recommendations given to Upper management on more effective Business

process and communication opportunities to effect overall

configuration strategies within the company.

. Developed an assessment package which could be followed to achieve HCR

product changes within the new Facets environment.

Principal Consultant

NTT DATA, Inc.

10/12-9/2013

. Manage activities of the Configuration Competency center.

. Lead team of configuration analyst developing Healthedge product in

Provider Contract pricing configuration for Fortune 500 client.

. Developed mentorship programs of the configuration team including

pricing and processing rules configuration of the HR system. Developed

various system architecture to achieve client goals surrounding

provider contract pricing goals.

. Report activities directly to PMO and align development strategy with

corporate implementation planning.

. Manage budget constraints and report resource efforts to manage

overall project efficiency.

. Document and review findings with customer to facilitate solution

design for the business configuration of Health Rules product.

. Configure the system that will include information like benefit plans

and provider payment provisions.

. Work with customers to define and build complete test cases.

. Act as a customer advocate; work closely with all stakeholders,

articulate customer's business.

. Lead and manage a team of customer resources while configuring Health

Rules product.

. Participated in delivery of commercial software, either externally

procured or internally developed, including participation in a SDLC,

within the healthcare payer space.

. Developed business processes between configuration teams and QAT to

ensure timely transfer of test environment data to QA environment for

additional quality measures on client configuration.

. Initiated standards such as second level peer review of Provider

Contract configuration and Unit Test result review of the same

contract configuration. This enabled Quality Assurance teams to have

more effective lead times in preparing test cases.

Hs2 Solutions, Inc. (AON/Hewitt-Motorola)

March 2012 -9/12

Benefits Configuration Analyst

. Develop benefit product configuration for multiple Motorola Client

countries

. Document requirements and troubleshooting techniques for Employee

Benefit Election system.

. Develop Benefit Rules Calculation based on a country on country

requirements basis (Israel/India/China)

. Managed development of 834 transaction set for Benefit Election

System.

. Develop Web Portal visualization and calculations from host

(Motorola) database.

. Document and report status of configuration efforts and relay to

Senior Management

. Lead team of configuration analyst during troubleshooting and

requirements gathering sessions

. Communicated system requirements to country representatives in

India/Israel and China in their respective time zones.

. Project management of tasks necessary to develop in-house Motorola

benefits system and relay development needs to IS team.

BCBS of Rhode Island

Nov 2011-

March 2012

Trizetto Facets Benefit Configuration Analyst

. Analyze exiting client healthcare products and advise on methods to

configure products in Facets environment 4.71.

. Develop Facets Trizetto Benefit configuration for client healthcare

products (Commercial, Medicare, Medicaid) in version 4.71

. Develop tools in MS Access/Sybase to help client quickly access

information from Facets databases. Data then used to ascertain the

validity of claims payment and membership ad-hoc reporting.

. Lead project QA Analysis team in validating current configuration

while training client staff on current Industry testing methods.

. Lead team of client associates in building Benefit configuration in:

1. Service Payment Application

2. Deductible Rules Application

3. Limit Rules Application

4. EOB Information Application

5. Auto Payment Level Application

6. SERL

7. Product Variable Component

8. Unit Testing/Claims

. Developed processes to account for thorough documentation of all

configuration developed utilizing Worksite and SharePoint applications

UNITED HEALTHCARE (UMR)

March 2010 - Oct 2011

Sr. Project Manager

. Contributed to the successful achievement of the Affordability team

goal to improve medical costs

. Successfully deployed projects in accordance with rollout schedule

with minimal disruption using established Road to Deployment, UHC

Operations and Medical Cost Management Team processes

. Utilized business analysis, project management and Six Sigma

techniques to drive root cause identification and solution

implementation

. Use project management tools (i.e., project charters, task lists, risk

management plans, communication plans, benefit models, change

management plans), and software (Microsoft Suite) necessary to be

successful

. Coordinate and complete projects across various functional areas.

. Presented and communicated project progress to core team, work team,

senior leaders in a fashion that makes it easy for the audience to

understand, using the most effective way (right graph, right content,

right formatting) to display work.

. Trained essential resources on newly implemented Enterprise software

using Procedure and Policy techniques.

. Provided subject matter expertise in areas including project

management, project scope definition, cost/benefit analyses, data

mining, risk identification, project methodology, resource allocation,

facilitation, and other areas of expertise based on professional

knowledge and background.

. Generated status reports and metrics as required. Ensuring projects

are completed on time and in control.

. Engaged other key matrix partners / subject matter experts to define

project scope, perform levels of analysis, strategy development, and

project implementation.

. Managed Systems analysts/IT Analyst in the development of HIPPA

compliant EDI Gateway.

. Managed development timetable for enhancing EDI format file deployment

of 837 (claims), 834 (Enrollment/Membership), 835 (Claims Payment

Advice), 276/277 (Claims Acknowledgement), 270/271 (Eligibility) and

X12 EDI file format (837) transaction set.

. Managed development of EDI transaction file formats from four

different healthcare platforms (QuickLink, Facets, QNXT, CPS)

. Engaged IT and Systems analysts in developments sessions on best

practice techniques to mine source data from healthcare platforms in

HIPPA compliant format.

. Developed dependency matrix to facilitate EDI file development and

project development timetable.

UNITED HEALTH GROUP, Moline, IL

January 2010 - March 2010

Facets Technical Consultant

. Facets Provider Implementation technical consultant

. Advised Business/IT staff on best practices for Facets Implementation

. Advised Business/IT staff on best practices for Provider Matching

logic implementation and coding

. Advised Business/IT staff on areas of Provider data cleanup and data

mapping principles

XL HEALTH, Baltimore, MD

February 2009 - July

2009

Quality Reporting Analyst/Facets Configuration and Report Development

Consultant

Organized JAD Sessions to achieve the following:

Developed and Implemented quality reports to determine differences between

client Datawarehouse environment and Facets 4.51.

Documented data integrity issues and coached client through Facets data

mapping to Datawarehouse environment.

Instructed client on Facets 4.51 mapping to Data Warehouse environment in

following Facets modules:

. Enrollment/Membership

. Provider

. Claims

. Billing

. GL/Financials

MVP HEALTHCARE

May 2008 - January

2009

Facets Configuration/Testing Analyst

Configured Facets 4.11-4.51 applications and utilized AGILE (SDLC) to

develop the following applications:

Membership,

. Medicare/Medicaid/Commercial

. Eligibility

. Group

. Rate Date

. Accumulators

. Policy/Info

. Related Entities

. Class

. Plan

. Billing entity

. Premium details

. Component Details

Configured the above applications developed as part of Benefits

configuration per client specifications. Aligned appropriate membership to

applications based on member benefits, demographics and billing

constraints. Benefits/Product,

. Configured Class/Plan

. Subgroup/Group

. Billing Entity

. Deductible

. Limit Rules

. Out-of-Pocket

. Accumulators

. Payment Rules

Configured the above applications based on client benefit specifications

as they applied to the applicable product design.

Networx Pricer (Facets 4.51) Provider Contracting/Pricing

. Networx Pricer 4.31 and 4.51

. Configuration of contract terms in accordance with Hospital contract

rate sheets and relevant lines of business.

. Implemented and configured qualifier groups in Networx Priceras

needed based on hospital contract

. terms.

. Tested and Analyzed Inpatient/Outpatient Exclusions/Case Rate/ Per

Diem and Services sections of Networx Agreements for correct pricing

logic based on operational business rules.

. Developed Complex Qualifier Groups to facilitate contractual variants

and business logic.

. Conducted Unit testing on claims for over 100 hospital contracts by

developing line by line procedural claims scenarios to test proper

claims adjudication and verify pricing as outlined by hospital rates.

MEDECISON INC December

2007 - April 2008

Senior Business/Systems Analyst

Care Management/UM Management Software

. Maintained extraordinary ability to keep current knowledge of

MEDecision products including features, functions, and customizations.

. Supported of specific product functions by taking on the

responsibility of being a specialist for a product or product

category. Involves being the lead on product discussion and mentor to

others in Professional Services as requests or issues arise within

their specialty

. Gathered and analyzed requirements and develop functional requirements

specifications for customer specific projects in JAD Sessions. This

includes the ability to provide analysis for custom and model products

as required, and the ability to provide guidance to stakeholders on

devising effective and efficient approaches to achieve the project

objectives

. Implemented MEDecision's install process including documentation for

items such as project plans, product configurations, and training

materials.

. Directed meetings as the liaison between MEDecision's technical staff

and the client to answer questions and provide clarification on

product specifications.

. Support of Development and SQE processes to facilitate efficient high

quality software deliveries to our customers.

. Trained clients to use MEDecision's products.

. Provided live and continued support on the software application and

document problems and questions as the key functional business

communication point between MEDecision and assigned customers during

the project life cycle.

. Participated in the analysis of system interfaces including patient,

provider, and extract specifications and record layouts as the lead

analyst. Requires detailed understanding of MEDecision data within

these records and experience with legacy systems, which would

facilitate the data translation process.

. Promulgated the utilization review, case management, and disease

management functions so as to advise clients of the optimal workflow

as it applies to their MEDecision solutions.

. Ascertained current changes in the Managed Care Industry and made

recommendations based on current client business processes.

. Created client status reports and facilitate client review meetings on

a regular basis

. Conducted project management and planning activities including

facilitation of group meetings, management of project plans, regular

project status reporting and post project review reporting. This

includes the ability to participate in large and small projects as

defined by MEDecision's project management process.

. Demonstrated ability to drive business and produce project estimates

or statements of work in conjunction with current client projects.

. Understand and developed the client's reporting needs.

. Participated on committees or work groups to represent the

Professional Services staff in product design, specifications, or

customer documentation.

. Participated as a leader within the Professional Services

organization. Includes identification and resolution of process

issues, training other personnel on existing processes, and assisting

management to create efficiencies and contributed in a positive manner

toward morale.

. Used ChangePoint software to log issues, research problems, and record

time in accordance with company policy.

INDEPENDENCE BLUE CROSS BLUE SHIELD, Philadelphia, PA

May 2007- August 2007

Senior Business Analyst

. Developed enrollment business processes, which verify pharmacy

(Commercial and Medicare part D) and IBX membership in a mentoring

environment for current IBX business analyst staff.

. I mentored IBX Enrollment staff on AS400 environment database

management, advising personnel on best practice adhoc enrollment

querying techniques against an Advanced MHS database.

. Developed operational processes for IS and Enrollment staff, where

essential download of Advanced MHS member data could be assimilated

into high level reports such as HIPPA and ERISA compliance reporting.

. Developed detail oriented documentation process by the creation of an

2003 MS Access database application; where IS Development and

Enrollment operations staff will be able document inter-department

system upgrade requests.

PHP LANSING, MI

September 2006 - April 2007

Senior Business Analyst

. Developed analytical, logical, physical, dimensional and statistical

Data Models for data warehouse and data mart development and

testing.

. Performed Integration, system, unit, regression, backend, user

acceptance and quality assurance testing, using manual and automated

testing scripts.

. Tested and analyzed and validated front end and backend Facets data

loads to protect data integrity standards and assessed the maximum

proficiency of SQL updates versus manual Configuration.

. Facets Claims Adjudication Process lead transactions test analyst for

PCA and Variable Component builds, EDI interfaces and downstream

Eligibility and Billing component configuration builds.

. Prepared Facets test plans for Billing, Enrollment, Capitation,

Commissions and Claims testing during the Configuration phases in

Systems Integration and User Acceptance testing environments.

. Validated Configuration efforts in Facets 4.31 database testing

environments and documented all changes, fixes or missing components

that differed with client functional designs.

. Key resource for extracting/migrating data out of legacy/disparate

systems (Facets 4.21, MS Access, customer/external sources, etc) into

the Facets 4.31 production environment for new lines of business.

Also responsible for business analysis and identification of essential

data elements - these duties include: creating requirements/project

plans, developing mapping strategies to Facets data tables

(source/destination), and generating ETL solutions using TSQL

scripting, DTS, stored procedures/triggers/queries, batch processing,

BCP utilities, UNIX scripting, etc

. Reviewed client's current business operation specifications and

translated the requirements to Facets Configuration specifications.

Facets applications included:

. Provider Pricing

. Member Enrollment

. Billing

. Claims Adjudication

. Medicare Billing Processes and Reporting

. Commissions

. Capitation and GL functions

. PCA and Variable component builds

. Product and Benefit Configuration

ESSENCE HEALTH CARE March

2005 - August 2006

Systems Analyst

. Lead the project management team through all phases of SDLC utilizing

AGILE.

. Advised and analyzed Facets development and configuration in versions

4.11 and 4.21 upgrades during JAD Sessions.

. Created departmental processes for more efficient uses of the product

based on Configuration.

. Main client contact in Configuration support and new development

providing peak performance standards in the following areas:

. Provider Pricing

. Member Enrollment

. Claims Adjudication

. Medicare/Medicaid/Commercial Billing Processes and Reporting

. Systems Interface Integration

. Enrollment and Eligibility

Analyzed edited stored procedures in SQL, Sybase, and Oracle to achieve a

higher percentage of claims adjudication by reducing the number of manually

pended claims.

. Main Configuration consultant for development of new Medicare line of

business.

. Identified previous configuration errors and constructed new

configuration in the following Facets applications for correction:

. Provider Pricing

. Service Rules

. Service Payment

. Product

. PCA

. Variable Component build

. Service Limits

. Service Definitions

. Procedure Conversion Table Configuration/Revenue Conversion and

Auto Room Type Configuration

. Advised client on improving the pricing configuration to reduce

claims backlog and manual claims processing.

. Provided clear and concise documentation for future

configuration projects.

. Rewrite complex business logic for member and provider eligibility

process. Eliminated using keywords and bypassing MMS batch process.

Improve member eligibility accuracy and reduce monthly inbound member

eligibility processing time from ~18 hours to ~8 hours.

. Wrote HEDIS report process to output ~15 millions claim detail,

member, provider from large scale FACETS database.

. Wrote process to correct 3 years FACETS member and provider

eligibility data needed for HEDIS member, provider, and claims

reports.

. Implement FACETS xml billing batch operations for custom

calculation.

. Modified custom interest calculation for claim check batch.

. Wrote inbound claim auto-adjudication using UNIX scripts and

Sybase stored procedures.

. Wrote Claim Remittance Advice to be sent to providers and

billers.

. Wrote General Ledger process Improve accountability for Medicare's

payments to physicians, hospitals, and other providers servicing

Medicare beneficiaries.

. Configuration, test, debug capitation batch process for new Line

of Business

SAMARITAN HEALTH SERVICES

March 2005 - July 2005

Facets Product Lead

Configured Facets Medicare product in the following components:

. Service Definitions

. Deductible Rules

. Limit Rules

. Provider Agreements

. Variable Component

. Service Rules

. Service Payments

. Medicare Rates

. Subscriber Rates

. APCC Rate Configuration

Implemented Best Practice Training for client personnel.

Designed and developed training and documentation to facilitate reporting

needs across all lines of business (Commercial, Medicaid and Medicare).

AMERIGROUP, INC.

November 2004 - March 2005

Facets Consultant

. Analyzed provider contracts for Configuration in Facets 4.11.

Contracts types included

. Hospital

. Professional

. Ancillary

. Implemented provider contracts and built provider fee schedules by

analyzing provider rates for configuration continuity. This resulted

in greater UM pricing integrity.

. Configured Facets provider applications for flexibility in future

upgrades to existing contracts and fee schedules.

KEYSTONE MERCY HEALTH PLAN October

2002 - October 2004

Business Analyst Specialist II

. Coordinated and documented business requirements of the stakeholders

and communicated these requirements to the system programmers on the

team.

. Assisted Project Managers with Unit Testing and User Acceptance

Testing to achieve the best possible project results on behalf of the

stakeholders. Coordinated the implementation of each project from

beginning to end phase (Migration to Production Environment).

. Performed data analysis for internal departments for all lines of

business. This included: Creating MS Access databases for data

analysis, creating Crystal Reports, querying Facets databases for

requested information and coordinating meetings to discuss new issues

or workflow processes.

. Managed project resources to achieve successful implementation as

measured by project management and stakeholders. Coordinated

resources for project plan, and mediated configuration issues between

functional teams

. Participated in the interview process of new team members, provided

guidance and support for team members.

. Actively participated in design, development and implementation of

Facets. Attained expert knowledge of Facets pertaining to functional

areas of responsibility. Achieved global understanding of Facets for

all functional areas.

. Used accurate and appropriate data capture to properly configure

Facets to administer the business of KMHP and other lines of business.

. Configured provider contracts for appropriate lines of business.

Implement provider agreements based on per case/per diem, provider

profile limits and tier them in accordance with Facets build.

. Engaged client on logical ways to build products based on provider

network, contracts held with provider network, member demographics,

and existing contractual obligations (i.e. State regulations, Benefit

plan). This included arranging members into class and group

structures based on benefit, and building shell member/provider

configurations to test final claims adjudication rates.

EDUCATION:

. Computer Information Science DeVry University, North Brunswick, NJ

2005

. Associates Liberal Arts Leeward Community College, Pearl City, HI 1995

. Facets 2.61a and 4.11 Product Configuration Training 2003 and 2004/5

(TMI/Daou)

. Facets 4.7.1 Trizetto Configuration Training 2010

. Certified Health edge Consultant 2013

. Ongoing QicLink and CPS process education through Project FOCUS

migration EDI Consolidation work stream responsibilities.

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