Analyst

Motivated, personable seasoned IT Professional with healthcare experience both in the private sector and government based. Talent for quickly learning new systems and policies. Diplomatic and tactful with professionals and non-professionals at all levels. Accustomed to handling sensitive, confidential records. Demonstrated history of being a tem leader as well as a team player; ability to work with little or no supervision.

Flexible and versatile – able to maintain a sense of humor under pressure. Poised and competent with demonstrated ability to easily transcend cultural differences. Thrive in deadline-driven environments. Excellent team-building skills.

Skills Summary

Team Management

Typing-50 wpm and 10 key

MS Excel

MS Access

MS PowerPoint

MS Outlook

Windows SharePoint Services

Government Programs

Medical Terminology

Claims/Claims Testing

Amisys Experience

Amisys Advanced Experience

MCO (Managed Care Optimizer) Experience

EDI experience

Aldera Experience

HealthRules Experience

Facets Experience

Siebel Experience

TIERS & SAVERR Experience

MaxeIE (Oracle)

MaxeCHIP (Oracle)

JIRA Software (Atlassian)

Agile Methodology

Professional Experience

CONFIGURATION ANALYST-CONSULTANT, HIGHPOINT SOLUTIONS, AUSTIN, TX, 2013-2015

Configure Provider, Pricing, and Benefits through Implementation of Healthrules for a New York managed care organization.

Gather requirements and artifacts for BRD, determine best practices/appropriate path to meet requirements, and evaluate risks.

Create Provider Structure and Provider Naming Convention used to differentiate facility from practitioner records.

Configure Providers: Tax Entities, Practitioners, Suppliers, Practitioner Roles and Supplier locations.

Identify, define, and create future workflow processes, apart from current processes, for Provider Data Maintenance post Implementation and conversion, due to periodic system upgrades and enhancements.

Participate in Provider Conversion from MCO (Managed Care Optimizer) to Healthrules process and brainstorming sessions.

Responsible for provider configuration management and lifecycle management.

Collaborate with managers, testing team, engineers, and data architects to ensure approved configuration management processes are incorporated into configuration management.

Create and maintain shared configuration folder to collect and store configuration imports/exports.

Create/update JIRA for purposes of tracking issues and enhancements throughout life-cycle.

Configure Provider Pricing: Contracts, Fee Schedules, Fee Components, Pricing Categories, and Supplier Networks.

Configure Benefits: Benefit Networks, Benefit Categories, Referral Categories, and Benefit Plan Components, Cost shares, and Wraparounds.

Claims Testing and Troubleshooting: Including ICD-10 Claims Testing, Workbasket Issues, Service Requests, and 835 & 837 provider and claim files.

Participated in peer reviews and inspections of system documentation to ensure the change requests and system requirements were accurately implemented into software.

Configure Healthrules system financials: Bank account, Business Calendar, and Claim Cycles.

Provide training to client end users.

Facets Claims Testing on other Highpoint Solutions projects/assets part-time.

oReview claims for provider, pricing, benefits, and member inaccuracies.

oReview contracts/pricing in NetworX to determine if claims paid accordingly.

oReview member to determine if member is attached to correct benefit plan/group.

oReview benefits to determine if service billed is covered benefit.

oCreate test cases and claim scenarios; communicate to Configuration Team changes needed/inconsistencies found.

SENIOR PROVIDER DATA ANALYST, FIRSTCARE HEALTH PLANS, AUSTIN, TX, 2009-2013

Acting Manager when Manager is unavailable.

Interview perspective employees.

Create training materials and PowerPoint presentations.

Train employees on software, policy/procedures, and dual maintenance.

Create and implement new policies and processes for loading providers as business needs grow and/or change.

Evaluate and audit new hires to identify areas of improvement.

Identify user requirements and evaluate risk.

Configure provider subsystem in Amisys and PIMS (Provider Information Management System).

Create/update CMDB (CA Service Desk Manager/ServiceNow) with new CI information and status, for purposes of tracking provider processes, open issues, and change requests.

Point of contact for in-plan provider requests from Provider Relations and Contracting in Amisys.

Assist Claims department with appeals, aging or time sensitive claim issues, and member reimbursements in Amisys.

Assist Finance, Recovery, and Adjustments departments with returned checks, address changes, refunds, and adjustments in Amisys.

Configure provider pay class inquiries(pricing) and corrections in Amisys needed for configuration.

Review HCFA-1500s and UBs for billing inaccuracies.

Assist Credentialing department with expedition of provider applications and loading.

Add and update information in Provider Directories and SharePoint.

Benefits configuration in Amisys- review, update, and term benefits based on provider plan coverage, as well as create new benefit plans based on new state plan offerings document.

Idenitfy areas of retention caused by erroneous provider loading.

Assist Contracting department by identifying and contacting prospective providers for contracting purposes.

Assist Enrollment department by identifying members who have TPR (third party resources/other insurance). As well as review 834 EDI enrollment files for analysis.

Point of Contact for Customer Service escalated issues involving provider change requests.

Assist Nurses and Authorizations departments with completing pre-authorizations for members.

Configure provider addresses in Amisys to be compliant with 5010 EDI Compliance implementation.

Process HMO, PPO, Medicaid, Medicare, CHIP, and dental claims in Amisys.

Verify provider info through use of NPPES, TMB, and TPI Report Manager.

Joined HealthRules Implementation Team in April of 2012 reporting to the Vice President of Firstcare, serving as a subject matter expert and consultant for all provider issues.

oAssist with planning and execution of integration of the new HealthRules software into existing network infrastructure.

oDevelop models, scenarios, and perform analysis to uncover actionable insight in HealthRules.

oResponsible for implementing/managing, and documentating departmental changes, as well as tracking processes through life-cycle.

oCreate/update CMDB (CA Service Desk Manager/ServiceNow) with new CI information and status, for purposes of tracking processes, open issues, and change requests regarding provider configuration implementation.

oIdentify user requirements and evaluate risk.

oPresent research and recommendations to executive team.

oParticipate in meetings, and collaborate with technology team and other members of implementation team and business units, throughout the organization.

oCreate PowerPoint presentations for HHSC Readiness Review, as well as participate in HHSC Readiness Review.

oCreate training materials, workflows, and training manual.

oConfigure Provider Pricing: Contracts, Fee Schedules, Fee Components, Pricing Categories, and Supplier Networks.

oConfigure Providers: Practitioners, Suppliers, Tax Entities, and Provieder Networks.

oConfigure Benefits: Benefit Networks, Benefit Categories, Referral Categories, and Benefit Plan Components, Cost shares, and Wraparounds.

oConfigure Claims: HCFAs, UBs, Financials, Denial/Approval/Pend Codes.

oClaims Testing- HMO, PPO, Medicaid, CHIP, CHIP Perinate, and Medicare, including create test cases and claim scenarios.

PROVIDER RELATIONS/DATA COORDINATOR, CENTENE-SUPERIOR HEALTH PLAN, AUSTIN, TX 2007-2009

Reseearch, track, and configure providers through use of Amisys and Amisys Advanced.

Receive provider demographics, attestations, and contracts from Provider Relations and ensured timely and accurate execution of configuration.

Act as liaison between Provider Relations and Corporate office.

Perform audits to identify providers still needing to obtain NPIs, TPIs, or EPSDT (THsteps) numbers.

Process timely provider delegate configuration based on CQIC (credentialing committee) reports received from Credentialing department.

Train/educate Provider Relations department on change requests and corporate processing policies.

Process change requests received from Provider Services and Superior Health Plan website.

Research and resolve pended claims received from Claims department.

Point person for Provider Urgent Requests and State Complaints.

Verify provider info through use of NPPES, TMB, and TPI Master File.

Review 835 and 837 EDI provider and claim files.

Train co-workers on departmental policies and procedures.

oDeveloped departmental policies and procedures for processing pended claims received to the department.

Professional Experience, continued

COMPLAINTS & APPEALS GENERALIST-CONTRACTOR, ACCENTURE, AUSTIN, TX 2006-2007

Investigate and resolve eligibility issues, customer service, CBO (community-based organization), Civil Rights, and “IE”: Integrated Eligibility (TANF, Food stamps, Medicare, and Medicaid programs; including but not limited to Long Term Care, Foster Care, SSI, CSHCN, and Women’s Health) complaints and appeals.

Investigate and resolve SKIP/CHIP complaints and appeals.

Document and verify case findings, explain program requirements, calculate income and resources to determine program eligibility.

Respond in writing to IE & SKIP/CHIP Legislative Inquiries and State Complaints resulting from legislative/ombudsman/external relations submissions.

Process SKIP/CHIP applications and case corrections or additions.

Research Member issues through use of TIERS, MaxeIE, and MaxeCHIP systems.

Prepare notification letters being sent to members regarding status of processed complaints and appeals.

Maintain files/records according to HIPAA laws.

Work KPR12 Report and identify departmental processed complaints and appeals needing corrections.

Contact HHSC regarding issues requiring escalation.

Train CHIP/SKIP Complaints & Appeals workers and new hires on “IE” complaints and appeals.

Employment History

EZ CORP – Austin, TX

Data Administrator, 2005-2006

ACS-TMHP– Austin, TX

Customer Analyst, 2004-2005

Education

PFLUGERVILLE HIGH SCHOOL – PFLUGERVILLE, TX

Received Diploma, 2001

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