Laurie Brunell
aculsu@r.postjobfree.com
** ********* ******, *********, ** 01603
Mission
My mission is to obtain a position as a senior QNXT provider, benefit and/or contract configuration specialist/analyst.
Key Qualifications and Pertinent Professional Achievements
A seasoned QNXT configuration specialist able to configure complex hospital and PHO contracts
7+ years’ experience in QNXT 4.8; 6 months experience in 5.2; 3 months experience in 5.3
4 years previous experience entering providers and configuring contracts into IDX
Identify, review and resolve all issues regarding the setup and configuration of providers, contracts, fee schedules, service groups and codes.
Analyze CMS code publications and changes as they relate to contracts and claims
Update policies as needed based on changes to CMS and/or Health Plan policies
Actively participated and facilitated meetings related to benefit, contract and provider configuration
Fully support internal audits and respond timely to any resulting action plans
Partnered with IT and Trizetto to create and manage uploads regarding changes, deletions or additions to contacts, providers, fee schedules, service groups and codes
Extensive reporting capabilities; excel is Microsoft Access, advanced beginner/intermediate SQL
Self-managed and excel in team work; strong leadership and mentoring skills.
Intelligent, logical thinker
Superior project management skills; excellent time manager
Created over 80 Desktop Procedures used by Configuration staff to enter providers, link providers to contracts, audit service groups, apply CRGs and TRGs.
Developed a reporting system used by QNXT configuration specialists and auditors to ‘automate’ much of the provider and contract configuration auditing process. This reduced the audit time by over 50% and created the ability for configuration specialists and auditors to audit contract and provider configuration ‘at a glance’, reducing errors.
Achieved an average of 4.2 out of a possible 5 on every performance evaluation for the last 17 years.
Top Performers Annual Merit Increase (last 5 years)
Employee of the Year Award
Employee of the Year Nominee every year for the last 5 years
Above & Beyond Award (3 years)
Power of Team Award (2 years)
High Five Awards
Work Experience
Cognizant/Molina Healthcare
Remote position; WinWire
February 2016 thru April 2016
3 month contract as independent consultant
Resolved claim edits/pends due to provider, contract and/or benefit configuration
Fallon Health Plan
10 Chestnut Street, Worcester, MA; 508-***-****
June 4, 1999 thru January 2016
Business Analyst I and Business Analyst II – QNXT 4.8
April 2014 thru January 2016; FCHP – Operation Support Services
Designed and implemented the monthly Executive Dashboards used by the Vice Presidents to analyze performance and workload.
Troubleshoot claims adjudication issues related to configuration
Responsible for all Provider/CMS regulatory reporting, including but not limited to PCIP and PQRS, federal debarment monitoring and reporting
Responsible for all scheduled and adhoc provider and contract reporting
Monitored provider reimbursement by comparing to contract terms in QNXT using MS Access and SQL
Audited and analyzed provider, contract and coding data to ensure appropriate enrollment coverage and payment policies are being applied, to ensure correct provider reimbursement and regulatory requirements are being met.
Validated all provider directories, 15+; reviewed all discrepancies between directory file and database/QNXT. Worked with IT to address errors.
Created and updated Business Requirement documents for all 16 provider directories; collaborated with IT on implementation and hosted project teams for the resolution of complex core, system and capability issues.
Gathered requirements for IT development projects by conducting meetings, work flow analysis, process analysis, with stakeholders at all levels of the organization
Reporting Specialist I and Reporting Specialist II – QNXT 4.8; QNXT 5.2
April 2012 thru March 2014; FCHP – Network Development and Management
Responsible for all of the health plan’s scheduled and adhoc provider and contract reports
Created reports for all of the health plan’s provider, contract, coding and fee schedule updates
Configuration Specialist II – QNXT 4.8
April 2007 thru March 2012; FCHP – Network Development and Management
Configured complex hospital and PHO contracts
Processed all CMS/Medicare coding changes; applying them to existing service groups, contract terms, etc.
Performed updates to fee schedules based on CMS updates using Burgess
Researched and resolved claim pends/edits
Troubleshot claims issues related to configuration
Configured benefits
Researched and resolved daily claim edits/pends including but not limited to: 150, 293, 185, 203
Created claims to test all change paks/upgrades
Training of new employees beginning with provider entry and working up to contract configuration
QNXT Configuration Specialist I/Provider Reimbursement Specialist – PPHS and IDX
April 2003 thru March 2007; FCHP – Network Development and Management
Handled the linking of providers to existing contract
Configured non-complex group contracts
Created and entered claims in the test environment for all new contracts and complex changes to existing contracts
Researched and resolved daily claim edits/pends including but not limited to: 150, 293, 185, 203
Provider Relations Representative – PPHS and IDX
April 2000 thru March 2003; FCHP – Network Development and Management
Responsible for all communication between the Health Plan and our PHOs
Worked with the health plan to create and monitor payment policies
Contributed to quarterly provider mailing regarding changes to codes, payment policies, authorizations, etc.
Resolved problems with members, billing, coding, etc.
Resolved and replied to Providers regarding all appeals and grievances concerning members, claims,
authorizations or payment
Responded to appeals and grievances due to possible provider, contract or fee schedule configuration.
Researched and reported to configuration team issues regarding provider or contract configuration
Administrative Assistant
June 1999 thru March 2000; FCHP – Network Development and Management
Additional Skills and Abilities
Advanced in all Microsoft Office applications Beginner SQL Business Analysis
Intermediate Webi/Business Objects QNXT Contract Configuration Integrity Reports
QNXT Provider Configuration QNXT Uploads to Trizetto Customer Service Cases
Developing Business and Reporting Requirements Provider Directory Validations Disruption Reports
Regulatory Reporting: PCIP, Medicaid, Medicare, Navicare, Federal Debarment
Professional Achievements
Created over 80 Desktop Procedures used by Configuration staff to enter providers, link providers to contracts, audit service groups, apply CRGs and TRGs.
Developed a reporting system used by QNXT configuration specialists and auditors to ‘automate’ much of the provider and contract configuration auditing process. This reduced the audit time by over 50% and created the ability for configuration specialists to audit their work ‘at a glance’, reducing the chance of overlooking errors.
Top Performers Annual Merit Increase (last 5 years)
Employee of the Year Award
Employee of the Year Nominee every year for the last 5 years
Above & Beyond Award (3 years)
Power of Team Award (2 years)
High Five Awards
Professional recommendations available.