Business Analyst Process

MICHELLE TORRES

***** ** **** ** ***, Miramar, FL 33025 • C: 305-***-**** • E: *******.****@*****.***

PROFESSIONAL SUMMARY

Experienced Business Analyst IV with over 24 years’ experience in Applications and Business Analysis in the healthcare field. Assisted in multiple systems implementations such as Amisys, QNXT, Optum ICES, and Facets. Energetic presenter and confident communicator with the ability to circulate information clearly and efficiently for end-users. Creative in finding solutions to problems and determining modifications for optimal use of organizational data. Expert at providing realistic projections and establishing various scenarios to determine viable process strategies to utilize. Organized and timely in providing staff, departmental members, and executive management with reports on specific data findings and their impact on organizational growth and success.

QUALIFICATIONS & SKILLS

Problem-solving and troubleshooting MS Office Software EDI Encounter Process Data analysis

Process implementation Strong written & verbal communication Business Process Documentation CenPass Reporting Amisys Teradata Golden Provider Payment Systems (PPS)

PROFESSIONAL EXPERIENCE

Business Analyst IV Meridian Health Plan/Centene Corporation 9/2023 – 08/30/2024

• Encounter errors

• MicroStrategy queries to locate errors within Amysis

• EDI files 835- Claim Payments, EDI files 837P- Professional, EDI files 837I – Institutional

• Deliverables and yearly Compliance update

• Business Process Documentation creation, maintenance, and update

• Development of Business Process Documentation for multiple departments

• Implementation of workgroups to close gaps within departmental procedures

• Issue Management, provider claims complaints, claims research.

• Check Run Reporting

• Service Now Ticket resolution

• Medicare and Medicaid Claims research

Business Analyst III Sunshine Health Plans/Centene Corporation 4/2015 – 9/10/2023

• Encounter errors

• MicroStrategy queries to locate errors within Amysis

• EDI files 835- Claim Payments, EDI files 837P- Professional, EDI files 837I – Institutional

• Daily communications with multiple departments on provider updates being processed correctly

• Assist with Compliance P&P creation, approval, and maintenance for Invitation to Negotiate (ITN) deliverables and yearly Compliance update

• P&P maintenance and updates

• Business Process Documentation creation, maintenance, and update

• Assist multiple departments with ITN deliverables

• Development of Business Process Documentation for multiple departments

• Lead for Onsite meeting with AHCA and DXC

• Implementation of workgroups to close gaps within departmental procedures

Implementation Consultant MedeAnalytics 7/2021 – 01/2022

• Conducting assessments of current project capacities and timelines.

• Performing implementation planning and setup activities for projects.

• Developing sound business practices and procedures for the project.

• Directing team members as needed to ensure successful project implementation.

• Liaising with management and stakeholders on project details and deadlines.

• Training and onboarding new team members as required.

• Presenting feedback and suggestions relating to the implementation of assigned projects.

• Identifying, reporting, and resolving key project issues.

• Ensuring that all project and implementation related documents are up to date.

Intermediate Applications Business Analyst HealthSun Health Plans 03/2015 - 04/2015

Randstad Staffing Agency

• Assessing user needs, analyze business requirements, and translating into business functional and technical specifications

• Developing test cases and executing testing procedures

• Troubleshoot databases, reports, and form issues reported by users

• Provide training, documentation, and implementation of tools as needed

• Process improvement, workflow, benchmarking and/or evaluation of business processes

• Problem-solving, including multiple priorities and research conflicting and/or inaccurate data

• Present analysis and interpretation for operational and business review and planning, Working under contract for Modis for Children's Medical Center of Dallas

• Created test scripts for QNXT Implementation

Senior Encounters Technician Independent Living Services 6/2014 - 9/2014

• Work with Encounter and Ran MS Access queries to quantify the errors

• Made corrections on the file to resubmit to the state

• Encounter Pro software (minimal use)

• Communication daily with Medicaid Customer Service with Provider inquiries

• Process documentation for Encounters

• EDI files 835- Claim Payments, EDI files 837P- Professional, EDI files 837I – Institutional

Systems Analyst Simply Healthcare Plans 8/2013 - 5/2014

• QNXT 4.7 currently in QNXT 5.01 (Hosted by TZG)

• ICD-10 configuration in preparation for CMS go-live date of 10/01/2014.

• Procedure Codes - add/terminate codes as requested by the Claims Department

• ICD Procedure Codes - update and terminate ICD Procedure Codes

• Diagnosis Codes - update and terminate ICD-9 codes

• Run and submit FTPs for Medicare and Medicaid Files

• Testing and troubleshooting system issues

• EDI files 835- Claim Payments, EDI files 837P- Professional, EDI files 837I – Institutional

Systems Analyst Simply Healthcare 8/2013 to 5/2014

• QNXT 4.7 currently in QNXT 5.01 (hosted by TZG)

• ICD-10 configuration in preparation for CMS go live

• Procedure Codes - add/terminate codes as requested by Claims department

• ICD Procedure Codes - update and terminate ICD Procedure Codes.

• Diagnosis Codes - update and terminate ICD-9 codes.

• Run and submit FTPs for Medicare and Medicaid Files

• Testing and troubleshooting system issues

• EDI files 835- Claim Payments, EDI files 837P- Professional, EDI files 837I – Institutional

Applications Analyst Leon Medical Center Health Plans 4/2010 - 8/2013

• ICD-10 configuration in preparation for CMS go-live date of 10/01/2014

• User-Defined Codes configures User requested codes to be specific departments

• User Warning Messages - configure User requested messages for the Claims, Appeals Case Management and Utilization Management modules

• Procedure Codes - add/terminate procedure codes as requested by the Claims Department

• ICD Procedure Codes - update and terminate

• Diagnosis Codes - update and terminate ICD-9 codes

• Explanation Codes maintaining and updating codes from third-party applications/Facets

• Translate business requirements into system configurations

• Evaluate user proficiency and define training requirements to assist in improvement in level of understanding of the users

• Responsible for making necessary enhancements to add or maintain functionality of the Application

Subject Matter Expert Amerigroup Corporation 12/2006 - 4/2010

• Medicare product/Amerivantage

• Updated staff daily on CMS news and mandates

• Provided training for new employees on a one to one basis

• Processed and assigned projects to staff

• Processed claims adjusted payments

EDUCATION & CERTIFICATIONS

SQL - Beginner to Expert https://www.udemy.com/ Jan. 2024 - current

Certificate – MS Excel Beginners-Advanced https://www.udemy.com/ December 2022

Certificate - MS Access Intermediate Level New Horizons Miami, FL 2010

Bachelor’s Degree in business administration Science University of Phoenix Tampa, FL 2005 – 2009

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