Data Entry Business Analyst

LAWRENCE CRICHLOW A.

562-***-**** ********.********@*****.*** Killen TX 76542

Carrier Objective:

Trained and dedicated medical billing and coding specialist seeking full-time position. Passionate about the healthcare system. Trained in CPT codes, ICD-10 coding, medical terminology, data management, data entry, conducting billing practices, and other administrative tasks. Familiar with various computerized coding programs and electronic health record. Business Administration Degree with specialization in Banking & Finance 1999 Medical Insurance Billing and Coding Diploma 2018

Resident Insurance Producer Accident and Health Agent, Life Only Agent # 412****-**** Experience

Business Analyst IT – NTT Data 2022-2023

Business Systems Analyst – Molina Healthcare 2012-2018 o Evaluated/Update Fee Schedule configuration new Guideline Mandate by CMS to ensure accurate claims processing through the health plan’s core claims processing system. o Review-Provider Contract configuration before Production environment, for all LOB including PCP, Ancillary, Specialist, Clinic, Hospital, and IPA contracts. o Responsible for oversight of benefit configuration to ensure health plan following compliance with government mandated benefits and services CMS.

o Conduct analysis on system impacts due to newly released or changed guidance from regulatory agencies. o Responsible for research and timely resolution of pended inpatient & outpatient claims related to complex contracts, to ensure proper reimbursement payment. o Work with corporate counterparts on custom solutions to facilitate claims processing to improve auto- adjudication rate per Processing Guidelines.

o Serve as resource to internally & externally team members to facilitate resolution on identified Billing Claim & Contracts reimbursement discrepancies on Provider Reimbursement rate. o Participate in weekly calls with all department involve directly with Provider reimbursement discrepancy, high and low dollar amount.

o Evaluated/Update Fee Schedule configuration new guidelines Mandate by CMS to ensure accurate claim processing through the health plan’s core claim processing systems. o Created & Develop test case scenarios, perform functional Unit testing, support user acceptance testing UAT, BRDs, APL and regression testing. o Review data post-system realization of result with project managers, programs owners and process owners assisting with recommendations to stakeholders and process owners. o Analyze data requirements, evaluate information gathered from multiple sources, reconcile conflict, decompose high-level information into details abstract up from low-level information to a general understanding, and distinguish user request from the underlying requirements. o Development functional and business requirements using individual and group interviews. process walks, process re-engineering workshops, requirements workshops, and peer site visit. o Document functional BRDs, business requirements using best practices method including high- level system diagrams, requirements traceability matrices, user stories, functionality specification documents, data maps test cases, workflow diagrams, system interface and user, report requirement according to standardized methods. o Understanding high Standards HIPPA requirement guidelines. o Configuration of Facets subscriber/member applications, worked on facets data tables and created audit report using queries, understanding requirement of facets business rules. Core Competencies & Skills

o Extensive customer service experience.

o Proficient oral and written communication skills, including Bilingual communication (Spanish). o Demonstrate advance skills in analyzing complex information and situation independently – identify problem and relevant factors, formulate logical conclusion, and recommend and implement alternative solutions.

o Exceptional internal and external relationship and teambuilding skills. o Adaptability – Flexibility.

o Problem solving looking for best effective option resolutions. Applications & Software

o Medicaid, Medicare, and Marketplace payment and reimbursement system applications. o Medicaid & Medicare CMS, HIPPA, HCPCS, CPT Codes, Rev Code, Diagnostic Code – ICD- 9/10, ASC, APR- DRG’s, Itemized Bill, NCCI Edit, application/research. o Knowledge of HMO, PPO, Medicare, Medicaid, and Marketplace – configuration payment-recovery- reimbursement system applications.

o Claim Viewer, Claims Workflow applications.

o QNXT production/testing environment,

o JIRA project tracking system,

o Microsoft Office, including Word, Excel, Outlook, PowerPoint, SharePoint. Outlook.

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