Customer Service Analyst

Roger Morris

** **** ******* *****

Newark, NJ 07114

Cell: 443-***-****

********@***.***

Career Overview

. Excess of 30 years of experience in the health care industry.

. 25 years of claims adjudication including grievance and appeals

processes.

. Strong systems expertise with various Facets (4.31 - 5.01), Amisys,

Erisco & QNXT.

. Superior skills in Product and Plan building in Facets NetworX Pricer.

. Script developing and testing in Facets Dev 1 and MO FA Patch.

. Experience HIPAA EDI X-12 conversion from 4010 - 5010.

. Strong 2+ years configuring HMO, PPO, and Medicare health plans in

NetworX's and QNXT.

. Excellent BA skills documenting and gathering requirements for various

healthcare initiatives.

Qualifications

. Extensive Business Analyst experience in healthcare including HMO, PPO,

POS, HSA/HRA CMS Medicare and Medicaid.

. Strong experience with Patient Protection Affordable Care Act (PPACA)

. Experience in simulating EDI data via the compliance maps during the

conversion process from ICD-9 to ICD-10.

. Proficient in EDI HIPPA compliant data via ANSI X-12.

. Experience in various operating systems QNXT, Facets including Facets

Data Model, Facets Claim Xten, and NASCO

. Experience configuring plans in Facets building products in the

Medical Plan includes the Benefit Summary, Product Variable Component,

Service Rules,

Service Definition, Service Procedure, Supplemental Procedure, Limit

Rules etc.

. Developed User Test Cases

. Executed and created various professional and facility testing

scenarios.

. Experience with Agile Scrum and ALM/Quality Center

. Excellent problem-solving abilities

. Strong analytical skills

. Hands-on and proactive

. Comfortable with change

. Fostering teamwork

. Experience and exposure to various applications

. System upgrades; Facets 4.21, 4.51, 4.71 & 5.01

. Excellent communication skills

. Broad knowledge of QA tools

. CPT -4, ICD-9, DRG Coding expertise

Work Experience

Senior Business Analyst

November 2013 - January 2014

Fidelis Care Business Analyst

Contracted to assist documenting and gathering requirements for the New

York state Medicaid claims department in compliant with various mandates in

accordance with the Health Care Reform Act effective January 1, 2014. I was

responsible for ensuring the Explanation of Benefits and Remittance Advice

captured these requirements and consequently developed by the IT

department. Notable requirements were the new delinquency grace period

language for members receiving and not receiving tax credits. Additional

requirements was changing language pertaining to Claim Appeal

notifications, member hours, phone numbers for members as well as TTY that

must be included with the EOB and remittance advices. Developed (UAT)

scenarios in Facets testing environment. Created various SQL queries in MO

FA Patch to assist IT in determining what tables to derive accumulators for

ACA members in Facets. I also assisted in incorporating the requirements

for the member and provider portals and maintaining our Requirements

Specification Document (RSD) in SharePoint. Participation in JAD session to

solicit and discuss requirements with all business owners and users. Ran

SQL (Oracle based) queries to obtain various data including deductible,

copayment and accumulators.

Business Analyst II

February 2013 - November,

2013

Care First Blue Cross & Blue Shield, Owings Mill, MD

Contracted to work in the implementation of the Federal government new

Affordable Care Act. I participate and initiate JAD sessions with the

Facets Configuration business users in gathering and writing High Level,

User, Functional and Non-Functional requirements in designing Medical,

Dental, and Vision products for the On and Off Exchange. My jurisdictions

include Maryland, District of Columbia and Virginia. I analyze current

Facets and surrounding systems to determine changes and impact during the

product building process. My focus centers on the processes for configuring

Product and Plan Identification numbers, Class and Subgroup structure,

Rating demographics and criteria. Discussing and developing procedures for

the new Native American Provider designations and Claim adjudication

impact. Participate in weekly requirements meetings documenting

requirements to assist me in developing and writing the Procedure

Requirements Document (PRD).

Senior Business Analyst January 2012 - December, 2012

Horizon Blue Cross and Blue Shield, Newark, NJ

Contracted as a Product Manager heading a staff of 23 analysts to convert

all health products lines, HMO, PPO, POS, DA, CMM, HMA, Customer Service,

Membership and Provider Portals and all other Benefit Systems including

NASCO & PIBA to CPL (Central Product Library). Gathering and documenting

client requirements. Update and develop new work flow processing procedures

for all business users. Created Change Requests, executed and developed UAT

scenarios in testing environment, identified and corrected all plan

defects, primarily CPT-4 coding. Participated in weekly JAD sessions with

various business teams to establish and ensure all target dates.

Facets Consultant August 2010 to March 2011

Excellus Blue Cross and Blue Shield, Rochester, NY

Load Simply Blue, Healthy Blue, Blue EPO products and plans for Excellus

BCBS on the Front End Tables in Facets 4.51. Verify and assign Product and

Plan ID's on Group Medical, Pharmacy and Incentive plans including

Subgroups, Classes, and Enrollment codes for Active and Cobra members. Load

Premium rates on the Medical Premium Rate Tables. Add/Terminated plans.

Coordinate Group membership implementation with Membership & Billing.

Conduct UAT Membership testing. Document defects via Share Point. Performed

MTM audits to validate and document accuracy. Prepared departmental

standard operating procedures. Ran SQL (Oracle) queries.

Facets Technical Consultant January 2010 to August 2010

Health Plus, Brooklyn, NY

Group, price and adjudicate APR/DRG inpatient Hospital claims for New York

in accordance with state mandate effective December 1, 2010. Initiated and

developed training for the APR.DRG process. Conducted and documented

APR/DRG Audits validating system performance. Implemented and coded UB04

information including patient and provider, demographics, ICD-9, CPT-4,

HCPC's, and Revenue codes in INGENIX. Obtained business requirements and

determined root cause. Performed manual UAT that was to be converted to

Facets 4.61. Developed and Implemented claim policies and procedures.

Business Analyst October 2009 to January 2010

Care First Blue Cross and Blue Shield, Baltimore, MD

Gathering and managing client requirements for Claims, Membership and

Billing, Provider Relations and Utilization Management Departments.

Document functional and technical requirements. Identify issues related to

Claims, Billing, Provider and Utilization Management and determine root

cause and analysis. Implement and design business workflows through writing

standard operating procedures. Created Project Management Requirements

Documents. Created and Ran SQL inquires for volume impact. Tested EDI

batches in anticipation of the conversion from the ICD-9 to the ICD-10.

Review and validate subscriber, including spouse and dependent data for

matching of subscriber name, identification number, dated of birth and

other pertinent information. This data compared to the data generated on

the 270/271 transaction report to confirm positive or negative results.

Created EDI data to run through the HIPAA Translation Manager Compliance

maps which generated the 834 Claims Remittance Advice to identify errors at

either Member, Group and/or transaction levels.

Facets Configuration Business Analyst February 2008 to June 2009

XL Health, Baltimore, MD

Configured Provider and Hospital Facility contracts including Long Term

Care, SNF, and Dialysis in the NetworX' Pricer. Established Service

Agreements and Identification numbers in the NetworX pricer. Uploaded CPT

and revenue codes, including deductibles, coinsurance copays in the Fee

Schedule Module. On the Benefits side configured products establishing

Service Rules, definition, payment, Limit rules, establish provider network

in the Product Variable Components table. Additional requirements were to

build AIAI, BSBS while documenting our product was configured in all

settings such as Office, Out-Patient and In-patient. Added Contract

Sections and Contract Terms based on selected benefit options by the group.

Created and executed test beds logging all defects for all contracts and

Medicare Advantage plans based on contract provisions and exceptions

including time filing. Tested and reconfigured all contract defects before

submitting contract for production review.

Claims Teams Leader/QNXT Analyst August 2006 to November 2007

Bravo Health, Baltimore, MD

Managed 20 claims analysts delegating assignments to analysts ensuring

accuracy and timely adjudicating of Medicare Advantage Claims. Responsible

for several claims projects requiring technical analytic skill to develop

new policies and procedures for grievance appeal claims. Reviewed and

determined liability on all Appeals, Grievances and complex medical claims.

Conducted UAT for claims including ICD-9 & CPT-4 diagnosis and procedure

codes. Written claim policies and procedures in accordance with company

guidelines. Coordinated and produced various claim reports via Crystal.

Supported IT in developing and testing claims for conversion to QNXT.

Senior Claims Analyst February 2002 to November 2005

Office Team Healthcare, Chicago, IL

Employed on multiple assignments ranging from reviewing and determining

HMO, PPO, Medicare and Medicaid benefits based on ICD-9 and CPT-4 diagnosis

and procedure coding. Validating Medicare benefits against the various

inpatient Pricers and Trailblazers.

Claims Auditor/Senior Analyst September 1986 to October 2002

Continental National Assurance, Chicago, Ill

Initially employed as a claims analyst evaluating and determining benefit

liability based on CPT-4 and ICD-9 procedure and diagnosis coding.

Evaluated and determined benefits for HMO, PPO, Medicare, Medicaid, Dental,

Vision, STD claims. Identified and coordinate efforts with Legal Department

regarding Fraudulent and Abuse claims. Assisted in development of the

claims department by writing On the Job training manuals.

Education and Training

University of Wisconsin

Milwaukee, WI

Business Management

Life Office Management Association (LOMA)

Chicago, IL

Insurance Curriculum

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