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QNXT Configuration Specialist

Location:
Worcester, MA
Posted:
May 02, 2016

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Resume:

Laurie Brunell

aculsu@r.postjobfree.com

** ********* ******, *********, ** 01603

508-***-****

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.



Contact this candidate