Sr IT Systems Analyst

Objective

To obtain a leader Business Administrative role in the allied health field where I can utilize my technical skills.

Skills

Contract Interpretation

Medical Terminology

Medical and Dental Claims Examining

ICD-9-10 Coding

CPT Coding

UB-92/CMS 1500

VB Scripts (Visual Basics) Mapping

Reading and Understanding EOB (ERA)

HIPAA Guidelines

Typing (75 wpm)/Data Entry

10-Key

EDI ANSI 4010-5010/Citrix software

Med iSOFT

Commercial/Government Ins. (HMO/PPO)

UBH /PBH Trizetto Facets

PBAR/PAS /ACE/FIRE Systems

Customer Service/Call Center

Eligibility/Credentialing Verification

Salesforce /Microsoft HRIS systems

Access DB/ Microsoft Sql/iCES

Excel / MS Visio / MS Project

Work Experience

OptumHealth (Remote MN, CA) January 2017 – Present

Sr IT Sys Analyst – iCES Rules Development Team (Contracted)

Build and implement simple to complex claim editing logic in support of internal payment policies.

Act as a thought leader/ SME in the design and implementation of claim editing logic.

Develop architecturally sound editing rules for complex business requests using iCES, Standalone Citrix based systems.

Used Excel to Document of customer business processes, workflows (RCLC) and requirements as they relate to the issues identified by a development initiative.

Assured appropriate unit testing coverage.

Review and contribute to overall QC/QA of test plans and UAT.

Participated in project teams with both internal and external customer (s) to assure high quality through management of ongoing processes.

Assisted in troubleshooting of technical issues as identified with Developer, Engineers, and BA.

Worked collaboratively with all key team members and presented in JAD sessions.

CalOptima (Orange, CA) October 2015 – December 2016

Sr. Business Analyst – eBusiness (Direct Contract)

Evaluate, design, test, implement and upgrade rule edits for clearinghouses and CalOptima to ensure proper delivery of claims with less errors.

Supports Run and Maintains reports for the direct manager and claims managers daily.

Utilizes (minimal) VB Scripts, Query, Access, excel and pivot tables to run data statistics on Error Code trends, tracking of all inbound claims and Maintain Imagenet DB for claims examiners.

Developed Databases to ensure efficiency in reporting tracking of inbound claims and error codes and error trends.

Manages and correlates rule edit research with direct manager, EDI, and clearinghouses.

Functions as a liaison between the provider, the clearinghouse and our EDI and claims department for various issues.

Conifer Healthcare (Anaheim, CA) August 2014 – March 2015

QA Applications Analyst (Direct Contract)

Evaluate, design, test, implement and upgrade rule edits for front-end Hospital patient access registration purposes.

Supports and Maintains reports for QA coordinators daily.

Utilizes VB Scripts, Showcase Query, Access, excel and pivot tables to run data statistics on usage, percentages for rule edits feasibility.

Utilize ACE, PBAR and Patient Access systems for rule research and rule testing.

Run Calibration, Daily and Compliance reports during mid-month and month-end with FIRE (Auditlogix) systems for QA coordinators and upper management.

Manages and correlates rule edit research with managers, senor analysts, business clients and vendors on a weekly team meeting basis.

Functions as a liaison between end-user, other analysts, and software developer.

Promed (Ontario, CA) March 2013 – March 2014

Junior EDI Analyst (Direct Contract)

Develops technical specifications for EDI application interfaces using EZEDI/EZCAP and IDX medical software.

Provides technical support during and after implementation of healthcare EDI applications and updated transaction formats.

Responds to EDI inquiries and issues, trading partners and vendors regarding healthcare transactions (enrollment, claims, encounter, status, payments) and clearinghouse activities.

Conducts various analyses of EDI transactions and formats and is responsible for format mappings, processing procedures and other EDI documentation as well as various EDI reporting.

Provides and communicates local expertise regarding standard concepts, practices, and procedures of EDI formats (proprietary, NSF, ANSI, HIPAA)

Communicate with IPA, IPO, Payers, and Providers weekly on updated EDI claims configuration.

Meeting weekly and monthly deadlines for encounter filing on capitated claims reimbursements.

Work closely with software vendors for system updates such as new segments applied.

Implemented the software updates by testing in UAT and applying the updates to production.

Functions as a liaison between end-user, other analysts, and software developer.

Capario (Santa Ana, CA) August 2008 – December 2011

EDI Enrollment Specialist (Direct Hire)

Called Payers to Check on Status of 835/837/237 Claims Set up status.

Coordinated and facilitated training on the Kareo software for clients, providers, and upper management.

Assigned Clients, Vendors, and Business Partners to help w/EDI transmission and set up account.

Used Phoenix, ANSI, Salesforce, DOS, and Internal portal systems to check claim status /submit.

Appealed claims for coding and erroneous denials.

Handled outbound/inbound calls from vendors, customers, trading-partners, and payers daily.

United Behavioral Health/UHG (Costa Mesa, Ca) August 2007- November 2007

Sr. Data Entry Clerk/ Providers Operation Coordinator (Contracted)

Manage Providers Information using UBH and PBH Facets.

Input Demographics, Fee Charges, and Credentialing Dates for Providers.

Check eligibility for providers EDI for reporting purposes using CAQH and maintaining Databases

Education

American Career College (Anaheim, CA) January 2007 – November 2007

Medical Billing/Examining/Coding Certificate

Allied American University (Irvine, CA)

Attained Associates in Business Administration September 2012 – March 2015

Mt. Sierra College (Monrovia, CA)

Bachelor of Science in Computer Technical/Programming July 2015 - Present

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