Business Analyst Member Services
Resume:
D. Denise Douglas
Germantown, MD
Home Phone: 301-***-****
Email Address: adrxk1@r.postjobfree.com
PROFESSIONAL SUMMARY:
Denise is a Senior Facets Configuration/Business Analyst with analytical experience including configuration, data analysis, testing and documentation. Planned and executed client-facing solution implementation.
Supported customers on complex technical issues.
Identified solutions to resolve problems or improve efficiencies.
Strong knowledge of provider contracts and benefits configuration.
Knowledge of lines of business including (EPO, HMO, PPO, Medicaid and Medicare).
Proven ability to learn new application across diverse organizational structure.
Ability to analyze data and understand relationships.
Effective oral and written communication skills.
BUSINESS ANALYST SKILLS:
Facets
Diamond
Amisys
NetworX Pricer
Ingenix Rate Manager
Healthrules/Healthedge
Benefits Configuration
Auditing
User Acceptance Testing (UAT)
Parallel Testing
Database table structure
Application Troubleshooting
Microsoft Dynamics CRM
Requirements Documentation
Implementation/Configuration
Client Interface Experience
Management Consulting
Microsoft PowerPoint
Payer System Applications
Microsoft Excel and Access
Attributes Tracking
Report Generation
Report Maintenance
Reporting and Analytics
Excel Reports
Data Validation
QNXT
SQL Queries
Microsoft Visio
CMU
HP/ALM
CMS
JIRA
Agile
EDUCATION:
TROY UNIVERSITY- Troy, Al
B.S.B.A in Business Administration
PROFESSIONAL EXPERIENCE:
Rose International April 2022 - Present
Business Analyst
Audits loaded provider records for quality and financial accuracy and provides documented feedback.
Assists in configuration issues and loading of provider information, as needed.
Assists in training current staff and new hires as necessary.
Generates and distributes Network Related Compliance/Regulatory/Accreditation reports.
Generates Provider Related reports to facilitate and support Provider Services/Provider Problem Research & Resolution.
Cognizant December 2021 – March 2022
Business Analyst
Facets UAT processing – Test Plan, Test Scripts and Testing Function on Facets 5.9
Performing Provider Configuration and verifying/setup of the Provider Contract.
Interpret business needs and issues by gathering, analyzing, documenting, and validating the Business areas user and technical (functional/non-functional) requirements
Translates business requirements into functional specifications manages changes to such specifications, and educates the organization on the direction of the business.
Gathers information about the organization's work processes and information flows.
Documents existing processes in the technical model format in order to evaluate and define new solutions and implementation processes.
Medway Ambulance January 2019 – November 2021
Business Analyst
Gather business requirements for testing environment.
Tracking and reporting status on JIRA workload cases to Team Lead for assignments.
Performed root cause analysis on implementation issues, documented findings and made recommendations to management.
Processing/Updating CPT/HCPCS and ICD10 procedure and diagnosis codes, place and service codes mapping annually for test claims to pay accurately.
Verifying client benefits with phone call.
Auditing new and old test claims accuracy for correct processing.
Perform auditing with vendor on CPT/HCPCS and ICD10 procedure and diagnosis codes other duties on an as needed bases.
Providing recommendations for production problems, preparing required documents for EDI Transactions
Created acceptance criteria and user stories
Created test scripts
Created JIRA extract for approval Purpose
CareFirst, MD June 2014 – December 2018
Facets Configuration Analyst
Benefit configuration and maintenance of requirement gathering services.
Validate current configuration and Support Product Owner in writing functional specifications.
Provide daily status to management with reviewing business requirements and understand business impacts and product related technical requirements.
Created, Audit, Review and tested of SEPY Prefix, Service Rules and Business Rule
Validate Variable Components and BDDS for accuracy utilizing FACETS 5.2.
Manage deliverables and timeline developing documentation on BRDs/PRDs.
Manage Project and responsibilities by collaborating with Subject Matter Experts to develop accurate documents
Support development resources on the team and research questions on service ticket errors as needed with client
Working with Product Owner to develop documentation, reports and presentations for all level within the organization including executive leadership.
Support Product Owner in writing functional specification.
Created test scripts, Benefit configured, unit testing, defect management using CMU.
Auditing new and old test claims accuracy for correct processing.
Worked on 837/claims and 834/enrollment EDI transactions
Ran SQL queries to validate Benefits Configuration
Added warning messages and Clinical Editing to prefix
Beyond Compare to verify the changes that was completed during testing phase
Resolve Defects and submit trouble tickets, auditing and validating old claims issues
Excellus, NY February 2013 – March 2014
Facets Configuration Analyst
Benefit configuration and maintenance of requirement gathering services.
Validate current configuration.
Troubleshoot Service Request and Review BRDs.
Reviewing Medical Plans, auditing, validating, testing and claims processing.
Resolve Defects and develop documentation using workflow documentation.
Support UAT Testing of releases as needed.
Run SQL Queries to validate Benefits Configuration on as needed bases.
United Healthcare, CA June 2012 – December 2012
Facets Configuration Analyst
Benefit configuration and maintenance
Validate current configuration and Review business requirements and understand business impacts and product related technical requirements.
Troubleshoot Service Request and support Product Owner in writing functional specifications.
Write user stories for Development to understand technical solutions needed and resolve Defects using CMS.
Support UAT and Testing of releases as needed.
Run SQL Queries to validate Benefits Configuration.
BCBS, NY May 2011 – December 2012
Facets Configuration Analyst
Benefit configuration and maintenance; validating current configuration.
Troubleshoot Tracer request via Facets system by correcting the existing issue in a configuration environment.
Assist with documentation of Facets benefits/authorizations and claims configuration assessment.
Provide and recommend solutions, processes and procedures for additions and/or modifications to existing systems.
Analyze Facets for benefits and medical definitions.
Document benefits and medical definitions in Facets.
Created test scripts
Health Plan, NY- CDPHP January 2010- March 2011
Facets Configuration / Business Analyst
Document benefits and medical definitions in Facets
Benefit configuration and maintenance; validating current configuration
Review provider contracts, comparing data to validate provider/pricing configuration environment
Assist with documentation of Facets provider/pricing, benefits/authorizations and claims configuration assessment
Collaborates with Subject Matter Experts to develop accurate workflow documents
Created test scripts
Assist with writing user stories for Development to understand technical solutions needed.
Facets Configuration / Business Analyst
Provide and recommend solutions, processes and procedures for additions and/or modifications to existing systems
Review provider contracts, comparing data to validate provider/pricing configuration environment
Assist with documentation of Facets provider/pricing, benefits/authorizations and claims configuration assessment
New group configuration set-up and maintenance
Review, document and report spreadsheet analyst of missing data including primary grouping, secondary grouping and medical definitions.
Run queries on an as needed bases
Created test scripts
Review and update fee schedules in pricing configuration.
Simply Healthcare - Miami, FL
QNXT Contract Configuration Analyst/Provider & Membership Enrollment January 2008- March 2009
System used: QNXT 2.6, 3.4, & 5.0 and PCMA (Provider Change Management Application)
Ensure that the system configuration meets the user needs and expectations.
Provide status and recommend solutions, processes and procedures for additions and/or modifications for the entire team.
Review provider demographics and contracts specifications according the Network Operations requests within the QNXT system by updating the information in the Provider module.
Assist with researching the Provider module in QNXT for providers that have submitted claims to determine if there is an existing contract and whether or not the contract is valid for the date of service on the claim, if the provider does not have a valid contract during that time, non-par contract are loaded in order to clear the 101 edit for claims processing.
Review the Member module in QNXT to determine if the set-up of the plan is correct and if not, escalate the issue to Member Services.
Report incorrect billing of claims to the Claims Department for processing of denials.
Review the Member module in QNXT to determine if the set-up of the plan is correct and if not, escalate issue to Member Services
QNXT Provider Configuration Analyst/UAT Tester
Built and Maintained Providers for Claims Payments, Credentialing, PCP Assignments, and Auth Processing.
Audited configuration through manual review of the (GUI) and SQL queries of the database
Created test cases and scenarios in Quality Center
Updated Provider Demographics and Contract Information
Configured Provider Contract which include Sponsors, Org Policies, and Rate Codes
Set up capitation and payable providers in QNXT
Prepared test cases using the functional design documents and covered business scenarios and the functionality of each interface.
Tested 834 transactions for Membership Enrollment to ensure accurate subscriber names and ID’s eligibility, and product identification
Followed up to ensure solution achieves expected outcome
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