Quality Assurance Business Analyst

GAIL E. MATTHEWS

PROFESSIONAL SUMMARY

Subject matter expert and liaison between the business partners, Network Development, IT, Claims Department, external coding vendor in analyzing current processes and determining changes needed for facility contracts and contract configuration. Highly skilled Quality Assurance/Customer Support/Business Analyst with solid interpersonal and analytical skills. Proven ability to analyze and resolve complex issues in multiple fast-paced environments. Extensive business knowledge of health insurance claims, claims adjudication, various software, project management and gap analysis. Demonstrated ability to effectively manage and train teams driven toward achieving company objectives with emphasis on creating and maintaining strong customer-focused relationships. SKILLS

Quality Assurance, Test Management, HealthCare Insurance, Cognizant True Provider Application, Networx Software, Trizetto Facets, Trizetto Care Advance Application (CAE). Proficient in Microsoft Office Suite, to include Word, PowerPoint, Excel and Outlook, Optum Encoder- Pro, Web Strat, E-Saws, Cognos, Application Lifecycle Management (ALM), Optum Software, and Consolidated Provider File (CPF).

EDUCATION

Port Richmond High School, Staten Island, NY

PROFESSIONAL EXPERIENCE

QCOE- Lead Quality Engineer

COGNIZANT, Emblem Health Account, New York, NY 05/12/2019-Present Analyze functional requirements & seek clarifications from business and review test scenarios, test case and test results with testing teams to ensure coverage of all requirements. Review Test plans, test scenarios, test results with business teams for Approval off. Prioritize test scenarios based on business priorities, resolve, and clarify functional queries raised by testing teams. Assist in creation of appropriate test data requirements as well as QA testing on recent Release upgrade of CAE application. Provide inputs during creation of Testing Task plan & test estimates. Provide support to business end users in conducting User Acceptance Testing (UAT). Provide training and create reusable domain assets for test team. Review test scenarios, test case and results to provide feedback/comments and ensure adequate test coverage. Prioritize test scenarios based on alignment to business priorities for RBT approach. Drive root cause analysis for defects in project.

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Email: ad6llb@r.postjobfree.com Mobile: 917-***-**** 148 Robinson Pl, South Amboy New Jersey 08879

Lead Business Systems Analyst

COGNIZANT, Emblem Health Account, New York, NY 06/2016 -05/11/2019 EMBLEM HEALTH, New York, NY 02/2010 - 06/2016

Subject Matter Expert and Liaison between business partners, IS, Claims Department and external vendors relating to the integration of the Q-Care Legacy pricing system into the Networx Pricer. Adept in identifying gaps and deficiencies has enables me to make appropriate recommendations to enhance current processes. As a Q-Care Legacy System SME, I am also testing the Facets Core Application and UAT Modules referring to technical specifications, performing Claims validation and defect analysis. Defects identified and documented in ALM and reviewed with developers to troubleshoot and resolve. Skilled in developing and completing business specifications, requirement documents, and screen designs for Medical & Hospital Claims system enhancements/modifications within the Q-Care Legacy system. As a Subject Matter Expert and Liaison Lead Tester and key contributor in analyzing and troubleshooting issues between the Rate Sheet Derivation Crosswalk tables in the Q-Care and HCS Legacy system as well as Provider Contract Load, Cognizant Networx System, Facets System and TruProvider Portal.

Senior Business Analyst

TRIZETTO GROUP, Union, NJ 04/2001 – 06/2009

Performed Quality Assurance testing of system enhancements / fixes for Claim’s adjudication and billing software. Skilled Implementation Analyst for HIAA/MDR pricing data tasked to ensure Ingenix pricing data successfully converted into the claims adjudication online proprietary format. Performed gap analysis between business requirement and existing software functionality; initiating solutions that were mutually acceptable. Directed internal and external training nationwide, conducting training sessions presenting system functionality upgrades to multi-level Business Analysts, technical staff as well as to attendees of the annual company Payer Conference. Key member in the HIPAA EDI Committee that provided status updates to clients and resolved escalated issues. I have received performance recognition awards because of managing all my projects to completion within SLA and budget. Eligibility/Claims Processing Analyst

INDECS CORP, Lyndhurst, NJ 04/2000 – 04/2001

Resolved eligibility discrepancies accurately processing and adjudicating medical and hospital claims for self-insured plans.

Claims Coordinator

MCCREARY CORP, Stuart, FL 12/1996 – 02/2000

Accurately processed and adjudicated medical and dental claims, in addition to, administering health benefits for self-insured companies and verifying eligibility discrepancies. Have accountable for all claims adjustments and providing constant support to the claims department staff. I have supported Benefits Analysts in troubleshooting complex medical terminology, answering questions, and identifying acceptable pre-existing claims scenarios. Consistently met and exceeded monthly quality and production standards.

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Senior Claims Coordinator INDECS CORP, Lyndhurst, NJ 06/1991 – 11/1996 Supervised daily activities of Claims staff unit, which included the daily assignment of work to all Claims Analysts. Completed Annual Performance Appraisals for Claims staff and managed necessary Corrective Action Plans. Lead on all escalated hospital and medical claims issues’ ensuring a detail analysis performed resulting in seamless adjudication. Consistently met and exceeded monthly quality and production standards.

Assistant Supervisor ERISCO, Staten Island, NY 09/1984 – 09/1991 I have supervised daily activities of claims staff including determining schedules and resolving employee relations issues and completing performance reviews. Ensured Lead Examiners followed appropriate production and quality standards. Closely monitored employee training on system enhancements, high dollar, and routine claims. This enabled me to conduct specialized training of software applications to clients converting to new claims adjudication software. I have traveled to various clients’ training Claims Examiners on Facets and numerous system updates.

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