Houston, TX

US citizen

SUMMARY

Over ** years of experience in the healthcare industry providing business analysis of process and procedures, revenue management and system applications.

Experience comprises over 10 years of consulting skills gathering requirements, developing, redesigning and/or training on policy and procedures, documenting workflows for current/future state, and working with Client’s on system replacement or implementations

Proficient in Work Flow Analysis, Requirements Gathering and functional written requirements documentation for software development and system replacement and implementation

Experience in conducting analysis of legacy systems resulting in the production of either a UB92 or CMS 1500 claim for all lines of business including Medicare and Medicaid

Experience working directly with existing or startups of newly acquired healthcare providers and payers for system upgrades or replacements, process redesign and or implementation for both large and small scale projects.

Audited claims to adhere to different State and Federal programs, Managed care, Medicaid, Medicare and Private Insurance.

Proficient in documentation for industry compliance for HIPAA, State and Federal guidelines.

Experience in conducting Billing and Medical Records audits for compliance for both State and Federal plans

Direct experience working with hospitals, health insurance plans, physician offices, physical therapy facilities, home health, long term care, assisted living, with a strong focus on the patient financial services (Membership, Billing) and Medical Records departments.

Over 10 years’ experience on client facing projects interfacing with Client C-level, Business Owners and Stakeholders, Client Vendors and SME’s

TECHNICAL

Facets – Membership and Enrollment modules

Epic Resolute – Hospital and Professional

QNXT – Reporting Module

BOSS, HAMS, Datacron, ARRS, MediTech, PatCom, Lewis, HBOC

WC3 Health Insurance Card production tool

Premis, ePremis and Cirrus claims editors

CCP – Customer Care Portal

Caliber Requirements Tool

Pivotal Tracker

HP Quality Center, Test Director

SharePoint, LINK

MS Office Suite – Word, Excel, PowerPoint

Visio

EXPERIENCE

Proje, Inc Houston, TX 03/14 - 03/15

Healthcare Business Analyst

Projects:

Business Analyst for a Pharmacy Benefits Manager replacement project; along with Project Manager developed scope document, gathered requirements from business owners, worked with vendors to obtain project documents and files, formats, data dictionaries. Setup of documentation retention site, LINK, similar to SharePoint for project management of documentation and collaboration.

Coordinated the transition for the area of Paid Claims transactions, Medicaid, Pharmacy Networks, Prescription Drug Events, Transition letters and remediation of all current Pharmacy Reports and system applications.

Collaborated with the Client Vendor representatives and client to determine timelines and schedule rollout of any changes to related processes.

Managed a dedicated team of Client Developers to ensure all tasks and requirements were completed and timely, as it applied to changes to the databases, files or hardcoded data.

Oversight and monitored activities of Client Developers, Business Owners and SME's with the following:

oUser Acceptance Testing and documentation

oID Card changes and distribution

oCMS Regulations as it applied to changes to Prescription number changes to files and letters

oNon-standard or custom reports required from new Vendor

Blue Cross / Blue Shield ICD9 to ICD10 transition project providing assistance to the Benefits and Operations, Business Readiness team by developing a file tracking inventory, by line of business and product type, for claims test files.

Developed an approach and strategy for any unidentified business requirements, by domain.

Facilitated and met with Client Business Owners to identify Key Performance Indicators, by line of business, for testing. Worked with Client clinical team to determine remediation status of Medical Informatic reports.

Conducted review of all Pending Requirements to ensure remediation and conducted follow-up on requirements with no remediation plan.

Facilitated weekly Benefits and Operations meetings with Client Business Owners to discuss outstanding requirements. Attended Equivalency Testing training sessions and provided assistance to interns.

Utilized SharePoint as a document retention and project management tool for collaboration

Dr. Clifton Baldwin DDS, Houston, TX 03/11 - 05/13

Business Analyst/Manager

Engaged as a consultant, to elicit requirements from the clients’ end users for the purpose of providing documented procedures and operational policies.

Coordinated with the Client’s outside Vendor computer technician to assess current computer operations for potential upgrade and to monitor computer daily business operations

Established a remote office location to provide the ability to access, monitor and process all daily functions remotely

General responsibilities included accounts payables for three (3) companies. Additionally, established and documented process and procedures for these functions

Payroll for (2) companies - Additionally, established and documented process and procedures for this function

Marketing for the dentist office - Established, documented process and procedures for this function, and monitored various marketing avenues for the purpose of increasing new patients and referrals

Submitted needed content, assisted with the design/development of a custom website, and provided oversight throughout its launch

Liaison with Client’s attorney and accountant on multiple businesses, legal issues, taxes, and accounting functions

Setup, implemented, and performed daily maintenance of three separate QuickBooks applications for accounts payables. Established and documented the process and procedures for this function

Established processes and procedures for processing payroll. Responsible for oversight of payroll record keeping and payroll reporting functions

Maintained personnel files and performed oversight of quarterly and annual payroll tax reporting

Hewlett Packard, Dallas, TX 06/10-09/10

Business Analyst

Engaged as a consultant to provide business analyst services for the Client’s Pricing area for a large scale Insurance Provider implementation

Conduct work sessions for the purpose of gathering and documenting requirements with Client SME’s

Develop workflows for current and future state for the Pricing area

Project was cancelled due to lack of funding. Time spent with company was focused on learning the Client's background policies, company systems, and procedures.

Additionally, attended training on HP company software, policies and procedures, attending planning work sessions, and developing the client project setup tools.

Computer Science Corporation, Sterling, VA 08/06 - 01/10 Healthcare Business Analyst

Projects:

Blue Cross Blue Shield of Rhode Island - large scale system replacement project - encompassed support and management for the implementation and conversion of a new system for a Health Plan Organization for the Membership area (in conjunction with multiple vendors

Reviewed and documented client's current flows and processes and developed future state flows and procedures. Facilitated meetings with Client’s users and business stakeholders and developed associated procedures for each process change and cross-functional area impacts. Developed Operational Impacts documentation as it was related to Issues Management, Project Management, and system changes based on business decisions. Collaborated with key stakeholders across multiple cross-functional departments developing and implementing key initiatives. Assisted with testing team in order to develop test scripts and resolved failed scripts. Provided ongoing support to end-users after conversion and worked with the training team in order to develop out materials.

Setup and utilization of SharePoint for utilization of project management documentation

United Health Group - health plan insurance card data conversion project - Responsible for project setup documents and management for UAT testing for Health Plan Card conversion project, working with the Client’s SME’s preparing test scripts, managing defects and reporting, and file transactions and requirement validations. As part of the integration worked with vendor on file transfers, validation and cleanup efforts

Humana Health Plan - multiple IT projects conducting work sessions, gathering requirements and documentation for customization of a consumer call tracking application - As part of a customized application development team, responsible for gathering requirements from the Client’s SMEs for the development of Use Cases for the Customer Care area of a health plan organization in order to provide a more streamlined access to Consumer information through a custom developed call tracking portal. Conducted and participated in JAD sessions and facilitated meetings with Client’s business stakeholders

Sentara Health Plan - assisted with an operation assessment and documentation for the company current and future strategic objectives Conducted Operational Assessment of the Account Services department within a Health Plan organization to determine current state in order to ensure organization was prepared to handle the addition of new product roll-out and to ensure operations were in line with strategic objectives. Facilitated meetings with Client’s department heads and business stakeholders. Developed and delivered final assessment document

Texas Children Hospital - Conducting work sessions, gathering requirements and documentation for customization of Membership and Financial report development - As part of a team at Texas Children's Hospital responsible for implementation, as a consultant I provided services to gather requirements from client users to develop reports for multiple departments, primarily membership and financial

Kaiser Permanente, Oakland, CA 03/05 - 04/06

Senior Business Analyst

Along with Client’s Director, Business Stakeholders assisted with developing the approach and data gathering tools for remediation of automated processes to improve existing business systems for revenue cycle management

Assisted with assessing timelines, documentation of requirements process and defining project scope to be approved by Client’s Business Stakeholders and C-Level

Conducted analysis of legacy systems to determine any business process or system process issues, across the clinical and billing application space, which resulted in the production of either a UB92 or CMS 1500 claim for all lines of business including Medicare and Medicaid.

Provided Client with research and Solutions Alternative documentation for MMA billing of Part D drugs to be approved by Client Business Stakeholders and C-Level

Assisted with documentation of Business requirements for MMA Part D billing

UICI - Student Insurance, Dallas, TX 10/02 - 01/03

Senior Business Analyst

Researched, documented and provided client with functional written requirements for a Web Enabled Claims Inquiry application (8 modules)

Researched and produced functional requirements to Client for moving data from legacy application to the Web enabled Inquiry system

Provided Client with a User Document to be used as a future training tool and received Client Business Stakeholder approval

Accomplishments - came in on budget, within specified time allocated for this project, and asked to remain for additional weeks to assist staff Business Analysts with their workload.

Georgetown University Hospital, Washington, DC 04/02 * 07/02

Manager, Billing & Special Accounts

Provided oversight and direct management for Client of Patient Financial Services Billing Staff and conducted related Human Resources activities (approximately 15 employees)

Provided identification and resolution of revenue cycle issues, edit issues, accounts on hold, unbilled claims and claims processing issues

Developed Standard Operational Process and Policies manual

Worked with client departmental Managers to resolve downstream effects to billing – Admissions, Medical Records, Charge Master, Accounts Payables, Payer Contracts Administrator, and Information Technology department

Managed Client’s Claims processing department (approximately 5,000 claims daily) for Medicare, Medicaid, and private pay claims and claim editor application

Accomplishments – Discovered and cleared over $23 million in claims by correctly modifying system application edits, updating the charge master, and implementing new processes. Lead for software transition for DC MCD intermediary, which resulted in zero effect on processing. Met with Managed Care Payers to evaluate and comply with correct coding procedures that improved cash flow and AR. Improved employee productivity and decreased in the number of AR days, by reviewing and correcting the way each payer claim was submitted.

Tremont Medical, Inc. Dallas, TX 03/00 - 09/01

Project Manager / Client Liaison

Worked with client to develop Work Flow Analysis, Requirements Gathering and functional written requirements documentation for software development, assisted with Application Testing and Quality Assurance for all software products and maintained Project/Client schedules

Accomplishments - Created / authored a User’s Guide for an Electronic Physician Prescription writing application as well as provided a Physicians Network (0ver 50 doctors) with a customized Web Portal. Researched and provided documentation for industry compliance for HIPAA, State and Federal guidelines as it applied to the system application / utilization.

Keane, Inc, Hunt Valley, MD 04/99 - 03/00

Healthcare Systems Implementation Consultant

Traveled weekly, on national bases, to assist and direct multiple site software implementations and provide training. Met with client to determine business requirements, time frames, costs factors, documentation of workflow and onsite support / maintenance of product

Working with the Client Corporate Office and staff Implemented a Claims Processing and Accounts Receivables software application for Long Term Care, Assisted Living Facilities, and Community Retirement Centers

Hands on setup with Client Corporate and Users to load financial class, health plans, General Ledger coding, charge master databases, patient accounts and claims processing activities

Audited claims to adhere to each of the different State and Federal programs, Managed care, Medicaid, Medicare, Private Insurance, and was consistent with client’s policy and procedures.

Accomplishments - Designed, wrote, and training to Keane Implementation Consultants on a Client Report Writer application. Setup, tested, installed, and interfaced the first databases sold to a client to process claims for Physician and Psychiatric facilities. Instructed client on how multiple facilities could be setup in one database, which generated a cost savings to the client. Successful installation and training to a national provider with multi-facilities and each of their databases.

Columbia Homecare Group, Dallas, TX 0/94 - 11/98

Business Analyst

Traveled weekly, on national bases, to conduct operational assessments, thru

interviews with Client and User’s. Met with client to determine business requirements and

outstanding issues, time frames, costs factors, and to provide documentation of workflow.

Developed, implemented and trained on company policies and procedures, provided assistance

with computer systems and subject matter expertise for revenue cycle management

Provided ongoing education and support for CBO’s or business office facilities located nationally (300+)

Provided management oversight to each facility, based on need and agency status

Conducted Billing and Medical Records audits for compliance for both State and Federal plans

Assisted in resolving issues associated with AR

Interacted with hospitals to electronically submit home health care financial data

Accomplishments –Setup a team to conduct audits, complete claims information and delivered to CBO for processing to recover 5 million in un-billed claims. Team was able to collect over 5 million in 4 month’s period and reduced Days Outstanding significantly, while having a good time. Streamlined documentation for Policies and Procedures used by Implementation Consultants and conducted In-Services for training Managers, User’s and Business Analysts

Reimbursement Compliance Specialist

Traveled weekly to client site to conduct internal reviews of homecare agencies focusing on compliance with federal and state regulations, reimbursement requirements for Managed Care claims, as it related to homecare services

Provided Client staff education on appropriate procedures to ensure integrity of claims processing, to prevent fraud and abuse

Compiled statistical information and maintained reporting and evaluation tools

Working with Client Corporate level, participated in Due Diligence for agency acquisitions and start-up’s

Accomplishments - Upon request from the Company’s Legal Department conducted "Special Inquiry Reviews" as part of the company compliance program. Was able to detect charges billed inappropriately due to incomplete, missing, documentation, procedures not authorized, covered or were improperly coded. Instructed Agencies on how to notify payers and submit corrections.

Westway Rehabilitation and Sports Medicine Centers, Inc, Houston, TX 01/90 – 10/94

General Manager

Direct oversight of nine (9) agency’s complete revenue cycle, financial reporting, software updates to charge masters, coding updates, and billing requirements

Supervision, HR activities and training of business office staff for all nine (9) locations

Troubleshooting of computer system problems

Analysis of agency status, financial reports and AR

Regional Operations Manager

Staff, AR, AP, Payroll, and financial reporting management

Software system application updates

Monitored and implemented employee health and dental insurance programs

Inventory control and purchasing

Assisted with the acquisition of eventually nine (9) locations

Accomplishments – Promoted to assist with the management oversight, financial restructuring, and software application updates and training for all locations

Office Manager

Responsible for Patient Financial Services staff, HR coordination, financial management and reporting

Responsible for auditing of claims with medical records

Responsible for Scheduling and Admissions personnel and coordination of information / data with Clinical department

Updates to and trouble shooting of software system applications

Accomplishments – Led development / implementation of a custom patient accounting software application. Facilitated and converted business office paper processing to a more effective solution; Technology. Promoted to assist with coordination, transition, and implementation of company policies and procedures, hiring personnel and training on the application for all future facility acquisitions

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