Claims Examiner

Michele Francis

**** ***** ****** ***** ** ***** 718-***-**** adnqml@r.postjobfree.com

SUMMARY

Senior Facets Consultant experience including benefits, membership/billing, pricing, testing and auditing

Ability to analyze, interpret and configure business requirements based upon client’s design documents

Ability to analyze data and understand relationships

Re-engineering business processes and process mapping

Proven ability to learn new applications across diverse organizational structures

Effective communication skills (written, verbal, and listening)

Knowledge of provider contracts (Institutional and Professional)

Knowledge of lines of businesses including (EPO, HMO, PPO, Medicaid, and Medicare)

ACCOMPLISHED SKILL

Facets/Diamond/Cosmos/SQLQueries/Databasetablestructure/Workforce Planning/Workforce Negotiation/Requirements Documentation/Data Validation/Microsoft SharePoint/Excel Reports/Pivot Tables/Client Interface Experience/Application Troubleshoot

Professional Experience

NTTData (Configuration Analyst) (July2019-Jan2020)

• Accountable for NetworX configuration of Provider contracts for medical, ancillary and ASC entities. Performed Quality Assurance of new or existing contracts and configuration to ensure appropriate or correct payment was made via unit testing

• Updating Reimbursement configuration on the back end

•Testing Reimbursement using live claim examples and SQL

• NetWorx's, Medical Provider Agreement, Medical Plan, Claims and Application Support Modules

•Participated in Claims Configurations; building and testing members • Created Agreements, Qualifier Groups, and Fee Schedules.

Affinity Healthplan (Claim Specialist) (Jan2019-June2019)

•Accountable for NetworX configuration of Provider contracts for medical, ancillary and ASC entities.

•Performed Quality Assurance of new or existing contracts and configuration to ensure appropriate or correct payment was made via unit testing

•Updating Reimbursement configuration on the back end

MVP Healthcare (consultant) Networx (Sept 2016- Dec2018)

• Testing product build to make sure claims hit the correct benefit rule

• Updated limit rule according to benefit grid

• Updated Deductible rules according to benefit grid

• Created test cases for product configuration, Negative and Positive Test performed.

DB Healthcare (Dell Consultants) Networx analyst Facets 5.2 (June 2014- March 2016)

• Create qualifier groups and fee schedules in medical agreement application

• Exclude non covered services in exclusion section

• Responsible for uploading rate sheets on the backend and rate sheet maintenance

• Pulled in inpatient DRG pricing thru Optum for correct pricing

Kaiser (Dell Consultants) Networx analyst Facets 5.1 (March 2012- April 2014)

Facets Configuration/Business Analyst

•Accountable for NetworX configuration of Provider contracts for medical, ancillary and ASC entities.

•Created Agreements, Qualifier Groups, and Fee Schedules.

•Performed Quality Assurance of new or existing contracts and configuration to ensure appropriate or correct payment was made via unit testing.

•Participated in Claims Configurations; building and testing members

•Troubleshooting and problem resolution of provider reimbursement utilizing reimbursement policies, methodologies and standard.

•Analyzed configuration across Medicaid lines of business

•Created and modified queries utilizing Facet's data tables

•Create Service Id for benefits configuration

•Create Limit Rules and Deductible rule for Benefits Configuration

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UAT Tester/Configuration Analyst (Health Plus) (November 2011-March 2012)

Facets Systems Analyst

•Provide and recommend solutions, processes and procedures for enhancements, additions and modifications to improve existing system.

•Analysis configuration across commercial and government lines of business

•Researched/planned products and plans for new markets

•Networx: Modify/update Medical Agreements via Medical Agreement Configurator

•Manually price claims by modifying agreements in Networx

•Updated/Modified Facets Fee Schedules

•Utilized Facets Data Model to document, map and query data required for the 271-benefit response

•Built Medicaid products for new markets. Assisted configuration team in building SEPYs-modifying service rules-, creating modifying LTLTs and attaching those to the variable component's rows.

United Health group (January 2005- September 2011)

Claims Tester/Configuration Analyst

•Planned and executed client-facing solution implementations, supported customers on complex technical issues, identified solutions to resolve problems or improve efficiencies, reviewed and tested configuration of application products (revisions, updates, and critical fixes prior to distribution.

•Migration and system conversion team member for PRGS client (Special Projects): Participated in the planning and implementation of Facets installations and/or upgrades.

•Tested all claims data using SQL and comparing tables using excel for data verification

•Entered Dev track issues in Dev test system to be corrected and retested upon completion

•Created continuous testing loop for testing, error reporting, correction and re-testing.

•Entered Dev track issues in Dev test system to be corrected and retested upon completion

•Analyze health care claims raw data validating source has been imported accurately into target database

Education & Certifications

Monroe College — Bronx, NY

Business Administration

Certifications:

Certificate of Completion for Implementing and Maintaining SQL Server 2008, August 2010

Certificate of Completion for Medical Billing and Coding

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