Customer Service Software Engineer

Xixue (Moses) Zhang

***** ******* **. *******, ** 48152

Cell: 248-***-**** E-Mail:abla4p@r.postjobfree.com

Objective:

Software Engineer with strong HealthCare EDI and system experience seeking

a challenging position in HealthCare industry as a software engineer or EDI

business analyst.

Highlights:

. More than 9 years of extensive healthcare related experience,

including business analysis, system development, project management,

system integration, IT and claim processing/adjudication outsourcing,

technical consulting;

. Extensive experience with all versions of HIPAA transaction sets 837,

835, 834, 271/272, 276/277, 278

. Working knowledge of other EDI formats used in the healthcare

industry, such as NSF 3.0, EZ-CAP 4.x 5.x, RIMS, as well as various

proprietary formats;

. Thorough understanding of health insurance claim processing life

cycle, such as claim adjudication, provider/eligibility maintenance,

claim routing/repricing, COB payment interpretation

. Deep knowledge about healthcare insurance claim data, data

relationship, and their impact in claim processing lifecycle

. Extensive experience with EDI interfacing with various system,

building test cases, creating companion guides, interpret issue

reports and providing solutions

. Very familiar with value added services implementation commonly

associate with EDI transactions such as provider/eligibility/code set

matching, claim auto repricing using fee schedules, format conversion

. Strong analysis and problem solving skills using VB, VB Script, C#,

SQL server, Access

. Strong expertise in various adjudication systems, such as LuminX,

Eldorado, EZ-CAP, Mediweb;

. Very familiar with Wintel based system and technologies used in

HealthCare industry, such as MS Office, Project, Citrix, VPN, secure

transfer through SFTP, HTTPS, SSL, file encryption. Knowledge of

Linux environment;

. Familiar with server virtualization technologies using MS Hyper-V and

VMWare ESX/ESXi

. Strong communication and customer service skills with both technical

and non-technical people;

. Self-motivated team player, good at managing multi-tasks at the same

time

List of some completed projects:

. EDI data mapping and file analysis

Performing EDI interfacing for healthcare insurance claim with various

clients. Providing business analysis, project development or project

management, building test cases for different scenarios, testing

transactions, issue report interpreting during test cycles and provide

corresponding updates or solutions, create companion guides. Projects

usually also require member/provider/code matching against

eligibility/provider/code tables, using various formats such as X12N

837, v3040/v3051, v4010, 835 v4010, NSF v3.0, EZ-LINK v4.x, v5.x, and

different proprietary formats.

. EDI interfacing between clients and third parties

Implement systems to client and third parties, usually repricing

networks. Provide services such as format conversion/validation,

provider or eligibility matching, claim separation by client/group,

claim tracking and various reporting require by the clients.

. Claim automated repricing

Implement systems to provide automated claim repricing using fee

schedules supplied by the clients, perform EDI to EDI transactions with

the client's systems. The systems will provide provider/eligibility

validation, specialty/location checking, find the corresponding fee

schedule and perform automated repricing for each procedure performed by

the providers.

. Claim processing services

Providing business process analysis, EDI interfacing, implementing data

and connection security, review plans with clients, review plan

documents and create training documents for the team, have training

sessions and review issues with processing team, communicate with the

client for errors and audit reports. Helped the clients to drastically

increase auto adjudication rate and lower the claim processing cost.

Some major accounts successfully outsourced all major claim processing

services including member enrollment, member and provider maintenance,

claim data capturing, adjudication, auditing(including Flex claims),

correspondence management, plan testing, etc.

. Member eligibility auditing system

Develop a member eligibility auditing system for the client that will

help to gather insured and dependent information to audit the

eligibility of each individual. The system provides functionality to

auto audit member eligibility status, allow the auditors to audit

complex cases in their own queue, review associated images, record

communication history, provide various Access reports for the audit

. Data capturing system

Develop a data capturing system that supports both data capturing from

electronic images or paper documents. System support the complete data

capturing process that including profile definition, job log, work

distribution, data entry/verification, exporting in various predefined

format and reporting.

Computer Skills:

. Operating Systems: MS Windows (All versions), Linux

. Programming Tools: Visual Basic, VB Script, C#, Flex

. Database: SQL Server (All versions)

. Network Equipments: Cisco, Sonicwall, Netgear

. Application Administration: SQL Server, SSIS, SSRS, Active

Directory, IIS, DNS, DHCP Server, FTP Server, RRAS, VMWare Server,

Symantec Backup Exec

. Certification: MCSD, MCDBA, MCSE, CompTIA A+ Service Technician

Working Experience:

01/01-Present: Software Engineer/Business Analyst - JMS and

Associates

. Business projects analysis, evaluate required resources and costs,

provide solutions and proposals to the management team

. Directly work with client's teams to gather the business needs,

provide business/technical solutions

. HealthCare data analysis and reporting using SQL Server, SSRS, Access

or customized solutions

. Healthcare claim data mapping to various EDI formats, building test

cases, result testing and interpretation

. Software development project implementation to provide added value

services to healthcare service providers

. Process automation using SSIS and various programming/scripting

tools.

. Manage HealthCare Business Project Outsourcing on various EDI

interfacing and remote processing projects

. Configure firewall, setup VPNs or secure FTP for EDI data

transmission or using the client's system remotely, providing

documentations for operational team

. Provide disaster recovery plan for system/network

. Maintain AD network, configure virtual servers using Hyper-V

. Providing technical/business support for both internal and external

users

09/07-present: System Administrator - Saphran

. Setup servers, maintain Active Directory network

. Setup virtualization environment through VMWare ESXi and VSphere

. Maintain various websites, domain registration and DNS update,

configure IIS, manage SSL connections, working with the development

team on new site launching or major updates

. Administrating SQL Server Database, mail server, configure system

backup

. System/Network troubleshooting

04/05-08/08: System Administrator - VR-Tech

. Setup servers, maintain Active Directory network

. Configure firewalls, set up VPN connections Maintain various

websites, domain registration and DNS, IIS

. Administrating SQL Server Database, mail server, configure system

backup

. System/Network troubleshooting

07/94-07/97: Software Engineer/System Engineer - Golden 4D

Active Graphics and Images

. Create and administrate the company Clients/Orders Database

. PC based video system integration, Local network management, Hardware

and software installation

. Customer Service Supervisor

. Technical recruiting and training

. Customer training and Customer support

Education Background:

01/00-12/01: Wayne State University

Detroit, Michigan

MS in Computer Engineering

09/97-12/99: University of Rhode Island

Kingston, Rhode Island

MS in Chemistry

10/89-07/94: Peking University

Beijing, P. R. China

BS in Chemistry

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