Mia Russell

**** ********* *****, ******* (Metro Atlanta), GA 30012

475****-***-**** Skype ID: miar2120

acpw7w@r.postjobfree.com

Industry Summary

• More than 20 years' experience in the Healthcare Industry with extensive implementation

experience of Medicare, Medicaid and Commercial lines of business (HMO, PPO, TPA)

• ACA / Exchange Benefit Analysis, Design and Configuration

• MLTC (Managed Long Term Care), experience with 1 client from New York (supported go-live)

• FIDA - have managed member data enrolled in Medi-Medi plans

• Utilization Management - Able to comprehends plans requirements for services that require

authorizations and create templates for providers to swiftly and correctly detail the necessary

information and have the authorizations correctly adjudicate against units whether based on dates or

service or units used

• Care Management - Able to design specifics required for a member's condition that will identify clinical

and non-clinical sources of information in which the member's with identified conditions may benefit

from

• Knowledge of CMS guidelines/regulations

• Membership-Eligibility-Enrollment implementation/conversion professional - data elements and

specific details needed for successful member enrollment for claim adjudication and premium billing

• Manage All Provider Data as it relates to their demographics, contracts, network and health plan

affiliations

• Documenting requirements and recommended solutions for conversions/implementations/upgrades

(identifying GAPS with possible work-a-rounds

• Document current state and future state and requirements to achieve those goals

• Work flow documentation - reviewing with or/and training clients as needed

• Excellent analytical skills

• Excellent verbal and written presentation skills

• Excellent team player but can also work solo

Training/Certifications

• AHIP Medicare and Fraud Waste and Abuse Certification

• QMACS QNXT Whole System Certification

• Microsoft Office Suite

• Business Requirements Development

• Coaching/Mentoring

• HIPAA Certification Training

• Fraud/Security Training

Professional Experience:

Highpoint Solutions

VNSNY (Contract)

4/2015 - 5/2015

New York, NY

Consultant

• Identified and documented necessary changes to workflows, processes, staffing, member

materials, pricing for each affected functional area

• Define performance metrics,measured actual performances and managed functional

partners to improve results

• Defined and prioritized key initiatives, enhancements & changes to the product

Catalyst Solutions

Colorado Access (Contract)

10/2014 – 3/2015

Denver, CO

QNXT Configuration Analyst

I worked as a Claims and Benefits SME (subject matter expert).

• 2015 Benefit Plans analysis and design

• Claims Analysis (analyze fall outs) – electronic and manual

• Claims Pend Reports – manually reprocess claims which fell out during mass adjudication,

determining why edits fired by analyzing configuration and determine best practice for

configuration for correct claim adjudication resulting in proper provider payment and member

benefit detail

• Processing claims for inpatient, outpatient facility and professional services

• Document best practice for current configuration

• SIT/UAT – creating claim test scenarios based on client’s business requirement, running claim

scenarios (UB’s and HCFA’s), documenting results, reviewing results with client.

• Mentor lower level contract consultants and client’s permanent QNXT Configuration Analyst

KForce Staffing

6/2014 – 9/2014

Molina Healthcare (Contract)

Long Beach, CA

Senior Configuration Analyst (QNXT)

I worked as the Executive Sponsor for the 2015 updates for the Premium Billing and Accounts Receivable

tasks.

• Reviewed 2015 business requirements for all states that Molina has active membership

• Documented and reviewed business requirements with client

• Created files for backend loading to update new premiums for 2015 (9 states)

• Created ‘Approach’ Documents which outlined step by step configuration needed to update

QNXT regarding premium rate changes, Benefit Plans QHP ID and Global Benefit Plan ID.

• Created test scripts for UB and HCFA, Premium Billing and AR Testing

The Trizetto Group (formerly QCSI)

9/2002 – 6/2014

Englewood, CO

Senior Product Consultant (QNXT)

Work as either a consulting team member or an individual consultant on product implementations,

enhancements, integrations or audit projects. Consulting expertise and work effort focus on analysis and

definition of customer business goals, objectives and current state business process. Upon clear

definition and understanding of client objectives and business structure, lead the attainment of those

goals through detailed application design documentation; system configuration; knowledge transfer and

business process re-engineering.

Product Consultant skills include:

• Business Process Analysis, Documentation and Re-Design

• Leading Implementation and Business Design Sessions

• Designing Configuration Blueprints

• Interpretation Design

• Reporting Design/Extract

• Mentor & Managed 12 Junior Consultants

• QNXT Certification

• Work flow documentation

• Medical Terminology, ICD-9, ICD-10, CPT, HCPC

• Process Improvement

• Value Based Benefit Knowledge

• Entire QNXT System Design/.Analysis and Configuration (Program, Policy, Sponsor Org/Policy,

Policy Plans, Benefit Plans, Provider Contracts, Utilization Management, Care Management, Fee

Schedules, Rate Codes, Coverage Codes, Edit Rules, User Security, Accounts Receivable,

Premium Billing, MRDTs, templates

• Configuration Testing - Use Case / Test Design (SIT/UAT)

• Issue Research/Resolution, Documentation

• GAP Analysis

• Proof of Concept Demos

GeoAccess

3/2000 – 8/2002

Overland Park, KS

Project Manager

• Worked as a Project Manager specializing in Human Resources solutions for healthcare,

banking, consulting, oil industries

• Utilize Project Management tools

• Sets client expectations concerning deliverability, performance, maintenance, design and cost of the

project.

• Estimates timeframe, quality and quantity of resources required to successfully implement project.

• Monitors and adjusts for budget and schedule variances of entire project and provides accurate and timely

status reports to supervisor.

• Develops and implements detailed project plans, including the completion of requirements definitions,

functional specifications, system and technical architecture definition, development and system testing

• Prepare and present sales presentations

Cerner Corporation

12/1998 – 3/2000

Kansas City, KS

Implementation Specialist

• Worked with my assigned specific Cerner software product (Power Chart)

• Responsible for service request investigation and resolution providing input for defining user needs,

functional design and testing

• Investigate, analyze and establish solutions for service request per established protocols

• Provide troubleshooting support and knowledge transfer for internal and external clients

• Consult with clients to create process improvement workflows

HCA (formerly Columbia/HCA)

5/1995 – 11/1998

Nashville, TN

Project Installation Coordinator

• Coordinated the installation of Meditech applications (pharmacy, pathology, laboratory, medical records,

B/AR, patient care systems, order entry, materials management, microbiology)

• Provided leadership and direction of the project

• Develops and implements detailed project plans, including the completion of requirements definitions,

functional specifications, system and technical architecture definition, development and system testing

• Monitored other departmental and vendor tasks as it relates to a given project

• Assisted in training Client Core Team associates

CIGNA

4/1993 – 5/1995

Nashville, TN

Regional Quality Administrator

• Tested Provider Data Management

• Documented results for individual testers

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