Customer Service Medical

P.O. Box *****

Conyers, GA *****

E-mail: ********@*****.***

Phone: 678-***-****

Summary Analyst with 15+ years of solid experience working in the Health Care

Industry performing both front and backend tasks in Billing, Systems,

Practice Management, and Quality Assurance. Claims Payment and Financial

Management experience along with knowledge of Medicaid, Medicare,

Commercial, and Managed Care Insurance companies. Knowledge of HEDIS

Measures, NCQA compliance on Quality Assurance in patient care, HIPAA and

PHI. Experience working with EHR systems. Detail oriented with great

customer and client service skills. Team oriented with the ability to

multitask and manage tasks independently.

Professiona Clinical Quality Analyst/HEDIS at United Health Care

l 12/2013 - 05/2014, Telecommute/Contractor with Equity Staffing, Englewood

Experience CO

Managed and participated in the various activities relating to the

HEDIS/NCQA process.

Abstracted medical record data for HEDIS measurements using Electronic

Medical Record (EMR) application.

Provided system support on various QA projects relating to rate

improvement.

Worked with a variety of system databases for data retrieval in support

of various tasks pertaining to member research and rate improvement for

meeting goals on Hybrid Measures (i.e. CDC, CMC, ABA, WCC, PPC, CBP, COA,

CIS, and COL) for Commercial and Medicare plans across assigned market.

Outreached to provider offices for follow-up on data collection and

provider participation on HEDIS tasks.

Worked closely with HEDIS Project Manager on various methods to reach

stated goals for plans.

Sr. Systems Analyst/Consultant at Cognizant Health Care Business Services

10/2012 - 12/2013, Telecommute/Conyers, GA

Business Analyst for Claims Payment and Financial Management functional

areas working with Department of Public Health and Human Services (DPHHS)

for Xerox, Inc.

Conducted client meetings for various design stages of Medicaid

Management Information System (MMIS) in development of Health Enterprise

System implementation in partnership with Cognizant IT.

Interacted with system architects and developers on Requirements

Specification Documents (RSD) and Design Specifications Documents (DSD)

based on client requests and System Gaps.

Abstracted health care data for usage in project requirements,

development and testing.

Created and modified design documents for MMIS development team (i.e.,

letters, reports, use cases, and interfaces).

Assisted with audits of data and testing of system design

Documented technical design of the system, i.e. Batch process flows, etc.

Produced mock-ups and update requirements for presentation to client.

Analyzed defects for validity and resolve design issues as needed.

HEDIS Contractor at Health Data Vision/InStar Solutions, Conyers, GA

01/2011 - 05/2013, Telecommute/Contractor - Seasonal, part-time

Worked with clients in overflow on data collection and abstraction for

HEDIS Hybrid Measures relating to the quality of care for plan members.

Used Electronic Medical Record (EMR) application keeping 95% accuracy

rate on all assigned Hybrid Measures.

Over read of Medical Records for MRRV process.

Performed outreach to provider offices for follow-up on data collection

and provider participation in HEDIS efforts.

Physician's Billing Systems Analyst at MedStar Health-HCMG, Washington,

DC

05/2005 - 12/2011, Telecommute

Maintained Physician's Billing System (PBS) databases for claims and

provider services with Washington Hospital Center for Health Care

Management Group.

Abstracted data for core HEDIS measures and performed medical record

reviews for inpatient and outpatient medical services.

Assisted with correct code usage for Hospital and Physician's billing

procedures.

Produced reports for corporate initiatives and compliancy projects using

medical records and clinical data.

Performed monthly audits of medical billing codes, charges, and payments

according to NCQA/CMS measure specifications.

Ran compliance and audit reports on an ad hoc, weekly, quarterly, and

monthly basis.

Coordinated the retrieval of medical records for HEDIS and NCQA requests.

Reviewed documentation for quality oversight auditing as required for

each project.

Helped troubleshoot and resolve issues in billing, coding, enrollment,

and claims.

Assisted with design, building, testing, and maintenance of physician

systems.

Served as a liaison between Information Systems and physicians' billing

department.

Worked with other hospital departments to maintain accurate data in core

hospital systems.

Sr. Systems Health Care Analyst/IT at CareFirst BlueCross/BlueShield,

Washington, DC

11/1998 - 05/2005

Health insurance projects. Included medical coding, inpatient and

outpatient claims, billing and enrollment, and end-user support to

various departments.

Provided day-to-day production, systems support, and customer service.

Systems design & analysis projects. Included defining functional system

requirements and performing system modifications, file maintenance, and

field translations within applications.

Created ad hoc reports for customer service, claims, billing and

enrollment.

Performed user acceptance testing, analyzed data and presented

deliverables in required formats.

Facilitated meetings with users and system programmers for gathering user

and business requirements, translating them into functional and technical

specifications. Provided daily, weekly, and monthly project status

updates to end-users.

Served as liaison between technical and non-technical staff.

Medical Billing/Patient Accounts at Georgetown University Medical Center,

Washington, DC

08/1992 - 11/1998

Worked in centralized billing department for the Department of

Pediatrics. Included patient accounting and filing claims to insurance

companies working with various types of insurance companies. Processed

inpatient and outpatient claims. Patient registration and enrollment in

system.

Provided day-to-day production, systems support, and customer service.

Worked both back and front end office, keying charges into system on

outpatient services.

Worked collections and payment reports.

Arranged with patients and providers payment plans on overdue collection

accounts.

Researched account errors, worked denials, and overpayments.

Assisted with medical coding and updating of charge master for fees for

services.

Worked where needed in both front and back office procedures.

Skills, Strong, solid analytical skills.

Knowledge, Skilled at identifying opportunities for process and quality improvement.

and Able to prioritize workloads and multitask.

Abilities Able to operate independently and collaboratively as part of a team.

Able to gather and summarize data from various sources.

Maintains current knowledge of Federal and State methodologies and

standards.

Knowledge of the following applications:

MS Office, Access, and Excel, Powerpoint, and Visio.

Health Enterprise, Meditech, ClaimsManager/Ingenix, Siemens

Signature/Invision, OLIE Scripting, Monarch, Filezilla, FTP, SQL,

TSO/ISPF, Fileaid, Panvalet, Business Objects, FACETS, FLEXX, SAS, IACS,

Inovalon/QSHR, FileNet, NICE, CMART,TIM, iSET, iLEAD and HTA.

IDX/GE, IBM Mainframe 3270, Horizon, SharePoint, IBM Rational Doors, and

ReqPro.

Education Medical Assisting/Billing Certificate Program, Bryman Medical

and Center/National Education Ctr in 1995.

Training Bachelor of Science in Information Systems Management from University of

Maryland, University College, May 1998.

Health/Life Insurance Program & Certification in 2004

Completion of medical terminology, anatomy and physiology courses at

Hermelin ORT Resource Center, July 2013.

Medical Terminology/ICD-9-CM and CPT-4 training, July 2013.

Medical Billing and Coding Course, completed July 2013.

ICD-10-CM Online Training Course Completion, December 2013.

HEDIS Education & Training, 2011, 2012, 2013, & 2014.

Contact this candidate