Management Quality Assurance

Mary Herrington, RN, MA

***** ****** ***** ***, ******, GA 30004 * 919-***-**** * ****.************@*****.***

PROFESSIONAL PROFILE

Accomplished RN Healthcare professional with 20+ years of diverse experience providing IT solutions including claims, provider, care management, membership enrollment and benefit applications, quality assurance, system implementation, testing, product development, project management to managing solutions development through all phases of the SDLC.

PROFESSIONAL EXPERIENCE

HPR, Inc., Atlanta, GA

Business Analyst, 2013 – 2017

Business Analysis for Summary of Benefit (SBC) project responsible for eliciting requirements from stakeholders and documenting them within software system used for tracing, testing analysis and approval process. Created business documents to represent current state of SBC and continue to update with future development of document. Coordinated changes made to document among the different platforms to ensure compliance. Worked with Quality Assurance to ensure document is tested to stakeholder satisfaction. Assisted with test case review, and act as liaison during testing phase of each release. Worked with production team to analyze issues identified in production environment. Acted as business analyst for any other project assigned outside of SBC. Worked cross-functionally projects to identify impacts to SBC, which included Medicare Advantage, State & FEP products. Tracked issues to be coordinated and fixed with SBC to ensure compliance is met in timely manner. Assisted stakeholders with code to production to ensure they understood changes implemented.

SME for SBC, analyzing for compliance while working cross functionally with other projects to determine impacts to SBC.

Elicited business requirements, functional requirements, and traceability matrix while identifying gaps.

Conducted internal and external document reviews for all requirements.

Trouble shooting data problems identified regarding SBCs.

Trained off shore QE team PMHS processes to ensure quality testing.

CIGNA, Raleigh, NC

Senior Test Specialist, 2008 –2013

Prepared and conduct acceptance testing of new or modified applications/systems by collaborating with stakeholders, IT management and peers to create test plans & test scripts for multiple test environments. Projects included external pricing system, Finance reporting, upgrade to claims automation, upgrade of ICD-10. Configured test environments for test projects assigned.

Designed, wrote and maintained test automation scripts for claims to manage medical benefit dollars.

Assisted in analysis, and development of QA metrics for assessing quality of delivered application software.

Provided test strategy, test plans and test scripts, including any Medicare claims when necessarys.

Conducted manual test scripts, unit testing, end-to-end testing, user testing and presentation of results with stakeholders.

Trained off shore employees to use automated scripts.

BCBSNC, Raleigh, NC

User Test Analyst, Production Support, Senior Business System Analyst, Senior Business Consultant, 2002 - 2008

User Test Analyst

Developed automation tools to assist stakeholders with manual processes thereby increasing efficiency.

Coordinated, configured and validated enterprise wide implementation current platform onto new platform.

Coordinated and defined data quality queries to assist vendors & stakeholders.

Liaison between stakeholders and IS offering business knowledge & expertise to configure new platform.

Used technical tools and automated reports to improve the accuracy & efficiency of testing.

Assisted with scheduling code migrations throughout multiple platforms.

Production Support

Responsibilies include the identification and tracking of issues found in production for all lines of business including FEP & State plans. Identification and analysis of root cause of issues. Wrote automated macros thereby providing opportunities for efficiency and improvement. Act as liasion with stakeholders to elicit business requirements thereby writing functional specifications to successfully implement yearly renewals for Individual business.

Senior Business System Analyst

Responsibilities include monitoring, trouble-shooting and planning for Individual business on a monthly and yearly basis. My tasks involved assisting stakeholders to understand daily reports to analyze why artifacts were not generated. Assisted IS with resolution. Contributed as business analyst to multiple projects by eliciting requirements and providing business requirement and functional requirement documents including traceability matrix. Assisted Quality Assurance in preparing test strategy. Approved test plan and test scripts to ensure they met project scope.

Senior Business Consultant

Provided consolidated configuration documents encompassing over 600 data information screens for migrating business from one platform to another.

Assisted with analysis of end-to-end processes encompasses over 200 interfaces.

Assisted with the current state and development of future state processes of new platform.

Identified, compiled, and analyzed issues for root cause and provided solutions for improvement opportunities.

Elicited business requirements, functional requirements based on stakeholders needs.

Served as liaison between IS and stakeholders offering industry knowledge and expertise in systems to come to solutions.

Integrated Quality Solutions, Inc.

Co-founder and Healthcare Consultant, 1998 - 2002

Provided onsite project management, system implementations, healthcare consulting and analysis including customized training to small and large businesses. Clients included HMO’s, Blue Cross and Blue Shield plans with FEP membership, Physician offices, State and Medicaid plans. Assisted clients reviewing and revising customer letters to ensure compliance with URAC and JCAHO standards.

Created innovative ways to increase efficiencies by configuring current platform differently and changing current processes.

Developed, tested and implemented workflow redesign of medical management department in order to receive URAC accreditation.

Analyzed and resolved daily problems through customized training, user training manuals and on site sessions.

Developed Ad Hoc reports for clients as requested to monitor daily activities.

Provided customized training using current software however tailoring to client needs and uses.

Provided problem analysis of financials based on client needs.

Provided assessment of medical management department to provide solutions resulting in system changes and process changes.

TXEN, Inc.

Healthcare Consultant, 1996 – 1998

Collaborated on design of medical management GUI application known as PowerSTEPP. Assisted with implementation of application to Beta sites. Performed testing & redesign while working with users & developers. Worked with marketing to sale product once completed.

Provided healthcare consulting for NCQA, HEDIS, claims processing compliance, utilization review, case management, disease management for customers including, Medicaid plans, HMO’s, PHO’s, PTA’s, and MSO’s

PCA Health Plans of Alabama

Health Education Coordinator, 1995 – 1996

Responsible for development and implementation of a disease prevention program for asthma, diabetes and prenatal care patients for HMO.

Established Physician Asthma Advisory Panel along with the guidelines to be used by subscribers and physicians.

Monitored programs for compliance with NCQA and HEDIS standards.

Authored and published articles informing provides, subscribers and employees of health issues pertinent to state in which they lived to comply with NCQA preventive health guidelines.

Blue Cross Blue Shield of Georgia

Utilization Management Analyst, 1994 – 1995

Responsible for providing pre-certification, concurrent review, retrospective review and case management for indemnity, HMO, FEP, ASO, NASCO and PPO products for all specialty areas which encompassed 1.2 million members. Required learning benefits/products for customers to provide efficient and accurate service.

Significantly increased departmental efficiency by developing and implementing a system to track Prior Authorizations requests for services.

Blue Cross Blue Shield of Missouri

Team Leader of Audit and Quality Management, 1988 – 1994

Responsible for planning and coordinating audit functions to produce a savings of $6 million in a single year.

Designed and implemented a corporate IV infusion reimbursement policy. Created customized training program for staff. Yielded savings of $250,000 year.

Organized the Metro St. Louis Private Insurance Task Force to identify and combat healthcare fraud for both private and government sectors.

Coordinated wellness screenings, presentations, provider education, training and statewide immunization programs.

Provided pre-certification, concurrent review, case management and retrospective review. For 1.5 million members nationwide.

Initiated development of healthcare fraud tracking software application.

EDUCATION

Webster University, St. Louis, MO, Masters of Health Administration

College of St. Francis, Joliet, IL, Bachelors of Science in Health Arts

Belleville Area College, Associate of Applied Science, Registered Nurse (RN)

ADDITIONAL LICENSES AND CERTIFICATIONS

Certified Business Analyst Professional (CBAP) by Worchester College & Washington University

Green Belt Training

Certified Managed Care Nurse (CMCN)

Health Insurance Associate (HIA)

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