Business Analyst/Quality Assurance Project

ANTHONY D. SHIELDS

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

Virginia Beach,VA 23464

757-***-**** (H)

757-***-****

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

SUMMARY

. Qualified Business Analyst with 15+ years in the healthcare arena

. 10+ years in the Medicare and Medicaid Industry

. Proposal Writer - Prepares proposals by determining concept; gathering

and formatting information; writing drafts; obtaining approvals.

. Extensive HIPAA experience and ICD-9 knowledge

. Worked on transformation from ICD-9 to ICD-10

. Project Management, HIPAA Security Rule Compliance (5010, 4010)

. Proven ability to identify problems, analyze requirements and develop

solutions

. Strong communication skills including interviewing end-users and

technical team to develop specifications particular to a specific group

. Knowledge of Healthcare Systems and Applications, Systems Analysis and

Project Management Tools and Techniques

. Experience with EDI - X12 and HL7

. Experience using MMIS for Transactions Codes,834, 835, 837/P,

276/277,270/271

. Assisted and maintained Sarbanes-Oxley (SOX) Quarterly Audits

. EDI Daily reconciliation for paper and electronic claims for daily and

quarterly review

. Knowledge of Member Enrollment, Provider Information Management, Claims

Processing, and Call Center

. Comprehensive knowledge and experience of ANSI 837v 5010, 4010A1Claims

and 837 v 5010, 4010A1

. Ability to manage customer meetings to help customer define and

articulate business requirements

. Provides leadership and consultation across multiple testing phases

SIT,UAT, and End-to-End

SKILL Sets

Business Skills

Applications: Healthcare, Medicaid, Medicare

MMIS Subject Areas: Claims, Member Enrolment, Provider, HIPAA, ICD,

EDI,AVRS

Methodologies: Waterfall

Phases: Requirements Gathering, Requirements Definition, Functional

Design, System Test Planning, System Testing, UAT,SIT, Proposal Writing

Tools & Standards: Use Cases, AMISYS, Facets, Faciledi, Macess, ICD-10

Discovery Tool, MS Word, Excel, Visio, PowerPoint, SQL,

SOX,Sharepoint,Rational Clearquest (CQTM),Rational Manual tool (RMT), IBM

Rational Clearquest, Rational Requisite Web,MMIS Web Portal (SIT,UAT)

EMPLOYER EXPERIENCE SUMMARY

Employer From To Position

S2Tech Jan 2013 Present Business Analyst

SENTARA Medical Group Nov 2012 Business Applications System

Jun 2011 Analyst

MVP Healthcare/ HP/BCBS Feb 2010 Jan 2011 Business Analyst/ 5010

of MA (Independent Business Tester

Contractor)

Amerigroup Corporation Jan 1999 Jun 2008 EDI & Business Systems

Coordination II / Claims

Analyst I

EDUCATION

Bachelor of Business Administration

American InterContinental University (Currently

pursuing)

PROFESSIONAL DEVELOPMENT / CERTIFICATIONS / COURSES/ AWARDS

Year Training Program Training Source

2014 Ambassador Teamwork Award S2Tech

2013 HIPAA Training S2Tech

2011 5010 refresher courses GE

2011 BAR Boot camp GE

PROJECT DETAILS

S2Tech, Mississippi

Dec 2013-Present

MS Medicaid Enterprise Solution Project

Position: Business Analyst Proposal Writer

Prepares proposals by determining concept, gathering and formatting

information, writing drafts, and obtaining approvals.

Responsibilities:

. Determines proposal concept by identifying and clarifying

opportunities and needs, studying request for Proposal, and attending

strategy meetings.

. Develops Proposal by assembling information including project nature,

objectives, writing and editing drafts.

. Maintains Quality results by using templates, following proposal

writing- standards including readability, consistency and tone.

. Meets proposal deadline by establishing priorities and target dates

for information gathering, writing, review, and approval; entering and

monitoring tracking data; coordinating requirements with contributors;

contributing proposal status information to review meetings;

transmitting proposals.

. Gathers proposal information by identifying sources of information;

coordinating submissions and collections; identifying and

communicating risks associated with proposals.

. Obtains approvals by reviewing proposal with key providers and project

managers.

. Improves proposal-writing results by evaluating and re-designing

processes, approach, coordination, and boilerplate; implementing

changes.

. Accomplishes organization goals by accepting ownership for

accomplishing new and different requests; exploring opportunities to

add value to job accomplishments.

Skills Used: Written Communication, Problem Solving, Market Knowledge,

Deadline-Oriented, Presentation Skills, Technical Documentation, Strategic

Planning

S2Tech, North Dakota

Jan 2013-Dec2013

Implementation, UAT

Position: Business Analyst (Subject Matter Expert)

Business Analysis and Quality Assurance project with emphasis on Functional

requirements and design specifications for new applications along with

enhancements to existing applications. Renders support to Project Lead

throughout the project lifecycle including development of project scope and

Coordination of User Acceptance Testing and System Integration Testing for

EDI and AVRS.

Responsibilities:

. Participate in Quality Assurance efforts during each phase of the

software development life cycle and ensure their effective

implementation

. Responsible for implementation of QA testing processes on assigned

projects following ITD methodologies and standards

. Create QA project documentation and deliverables including test design

specifications, test cases and automated test scripts

. Develop and execute functional regression and system test cases

. Test integration points between internal and external systems

. Execute test cases manually or with test automation tools

. Collaborate with QA Analyst, Project Leads and Project Managers on

metric gathering and reporting

. Perform defect tracking and defect resolution management and

communicate defect issues to the development team

. Ability to work with technical resources to support technical software

implementation of requirements.

. Plan coordinate and supervise testing teams Excellent verbal, writing

and interpersonal skills.

Skills Used: Problem-Solving, Deadline-oriented, Quality Assurance, Testing

(Manual and Automated), Defect Management, Traceability Matrix, EDI

(820,834,835,837,270,271,276,277,278) and Automated Voice Response System

(AVRS)

SENTARA Medical Group, Norfolk, VA Jun 2011 -

Nov 2012

Position: Business Applications System Analyst

Identified required information fields and updates, created claim edits and

claim logic within EDI 5010 guidelines with use of XML. Successful system

tests performed within IDX Data dictionary with use of SQL.

Responsibilities:

. Created and coordinated workflows, implemented and planned project

around application release

. Supported software applications, through maintenance of tables/files

to support business operations

. Developed system test plan and performed testing of software upgrades

. Successfully met the 5010 2012 compliance date by assisting in

transitioning all 837 files to 5010

. Responsible for testing IDX functionality to contribute to a

successful GE Centricity Business upgrade from 4.3 to 5.0

. Responsible for technology and business process feasibility studies

of replacement software or new acquisitions to include development of

cost/benefit analysis

. Developed system test plans and performed testing of software upgrades

and patches

. Analyzed customer needs, evaluated software releases and new products

. Identified required information fields and developed data dictionary

. Performed system tests in Bar Data Dictionary for transformation of

ICD-9 to ICD-10 with use of ICD-10 Discovery tool

Skills Used: HIPAA 5010, EDI 837, 270, 271, ICD-9/10

Independent Contractor, MVP Healthcare/ HP / BCBS of Massachusetts

Feb 2010 - Jan 2011

Position: Business Analyst/ 5010 Business Tester

Business Analysis project which required identification of requirements for

EDI 5010.Performed Analysis for various claim systems for UAT testing.

Responsibilities:

. Evaluated and performed User Acceptance testing within the Facets ITS3

environment for PCS EDI, hospital and Medical claims

. Evaluated and performed User Acceptance testing for GTESS within PCS

Simulation for EDI, Hospital and Medical claims and within Facets &

Macess for Rejected QA Scenarios

. Performed claim Defect testing and Re-testing for EDI, Hospital and

Medical claims within Facets and PCS Environments

. Gathered and defined the requirements with the Business and Subject

Matter Expert

. Produced the Requirements Functional Document with use of Use Cases

. Detailed the Functional specifications across the respective

requirements

. Performed System Integration Analysis of the production system for

Metavance Billing and Banking for FM 140,141,142, 260 & 270

. Performed Gap and Risk Analysis for Cigna Systems IBOR, HBOR, XCCR,

ACCR

. Produced the Requirements Traceability Matrix

. Gathered requirements across work streams through testing and use of

Use Cases

. Created the Functional Specifications Document which detailed the

functional specifications across the respective requirements with use

of Use Cases

. Performed the configuration and systems analysis of the production

system utilizing Visio for the implementation of EDI 5010 (835, 837)

. Performed the risk analysis of the HIPAA Security and Compliance Audit

utilizing lifecycle principles and methodologies for the

implementation of 5010

Skills Used: Facets, Claims, EDI 835, 837, Use Cases, Metavance Billing,

HIPAA 5010

Amerigroup Corporation, Virginia Beach, Virginia Dec

1999 - Jun 2008

Position: EDI & Business Systems Coordination II (Medicaid/Medicare)

EDI Coordinator provided technical support for providers submitting claims

electronically with use of Facets, Faciledi and Macess. Evaluated and

performed system testing for EDI transaction codes.

Responsibilities:

. Worked on Service Payment rules per market specifics (HIPAA

Implementation)

. Worked on Facets-Amisys Claims/ with use of Data module in XML

. Worked on mapping of Contracts/ Product Variable Setup (x12

Transaction Readers)

. Provided technical support for providers submitting claims

electronically with use of Faciledi and Macess

. Acted as lead liaison and advocate between the technical staff,

trading partners, third party vendors and business users

. Maintained Macess EXP process work flow and EDI database from claim

processing platform

. Reviewed reports and output files generated to ensure data integrity

with use of Paper Free EDI Software (XML)

. Evaluated and performed testing for Transactions (834, 835, 837/p,

276/277) for moderate to complex modified programs, clinical

applications and operating systems

. Familiar and experienced with mainframe development environments

. Incorporated EDI and Amisys logic for HCFA and UB procedure codes

. Performed Service Procedure and Service Revenue Code Mapping in

Relation to Transaction codes 835/837p and ANSI 276/277

. Maintained pending claims and processing reports for Facets XC below

10% on daily basis

. Experienced with process flow diagrams, with use of WEB-based

development environments

. HIPAA Security and Compliance Audits (SOX) for Daily and Quarterly

Reconciliation

Skills Used: Medicaid, Medicare, HIPAA, XML, X12, Faciledi, Macess, EDI

834, 835, 837, 276, 277, SQL, Mainframe, HCFA, UB, Facets, SOX

Amerigroup Corporation, Virginia Beach, Virginia Jan

1999 - Dec 1999

Position: Claim Analyst I

Responsibilities:

. Processed inpatient and outpatient medical claims as well as

electronic submissions within Amisys Processed correspondence and

claim adjustments within Amisys

. Maintained statistical and financial quality scores in accordance with

claims department and company guidelines

Skills Used: Claims Analysis

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