Security Clearance Configuration Analyst
Resume:
**** ******* **. ***** ****, FL *****
************@*****.***
Colleen M. Davis
Objective
To obtain a telecommuting/remote position in the medical insurance field that encourages professional and personal growth while utilizing my experience, skills, and education.
Skill Set: Medicare, Medicaid, Dual Eligible Benefits, CMS Requirements, Medicaid Requirements, Facets, SQL, Benefit Configuration, Provider Contract Configuration, CPT codes, HCSPC codes, IDC-10, Support UAT Testing, Organization Skills, can work Independently and within a Team Environment
Experience
9/2024 – Present Dexian Minneapolis, MN
Facets Benefits Configuration Analyst
Primary Responsibilities:
Configure capitation payments to capitated providers in Facets.
Configure Provider contracts according to agreed upon specifications in NetworX.
Utilize knowledge of benefit plans and documents to gather details to create/update applicable product configuration elements.
Collaborate with stakeholders to gather, assess, interpret and document customer needs and requirements.
Design, configure and build various product/benefit components in Facets.
Research claims issues to determine configuration gaps, update configuration as applicable.
Audit configuration against benefits plan requirements/EOC, etc, verify configuration following source documentation.
Acts as a SME to other team members to answer questions and coaches on opportunities.
Consistently meets established productivity, schedule adherence, and quality standards while maintaining expected attendance.
Represent benefit configuration in business partner meetings as a SME to research and respond to action items.
Facilitates meetings to partner with others on issue resolution and problem solving, including follow up on action items as needed.
5/2013 – 9/2024 Cognizant Inc. Teaneck, NJ
Claims Configuration Analyst
Prepare the new benefits during AEP to have the Client ready for the new year.
This includes MOOP, deductibles, limit rules, PDVC table updates, SEPY updates for the correct cost sharing, SEDF updates for pricing or auth rules on a type of service, and the IPMC table for auth rules on individual procedure codes.
Utilize Supplemental Tables as needed to map CPT/HCPC codes to the correct
Type of service, both from the front end or via SQL.
Configure benefits as per Client specifications on the Facets platform.
Determines origins of hard errors experienced by processors and troubleshoots the solution
Configures CMS transmittals as they are published.
Ensures Local Carrier Fee Schedules are loaded within the appropriate quarterly and semi-annually timeframes for correct claims payment.
Utilizes Microsoft SQL to load scripting into Facets.
Interpret and configure provider contracts.
Configure both Medicare and Medicaid benefits and other Facets modules as required.
12/2009 – 5/2013 TMG Health, Inc. Jessup, PA
Manager – Performance Reporting
Prepared a detailed analysis of enrollment/disenrollment & claims data to prepare monthly performance reports.
Maintained knowledge of CMS Guidance in regards to Enrollment, Disenrollment, and Record Maintenance to ensure SLAs were measured appropriately.
Delivered monthly performance reports to all TMG Clients within the contractual due dates with a timeliness rate of 100%.
Managed a staff of 18 Analysts and Business Analysts
Analyzed Medicare guidance for changes/impacts.
Assisted the Director of Finance in analyzing client contracts for the Service Level Agreements for opportunities to improve the measurements for the clients.
Audit enrollment records to CMS standards/specifications for accuracy and timeliness.
Perform trend analysis to determine error trending in both audits and performance reports.
7/2004 – 12/2009 TMG Health, Inc. Dunmore, PA
Financial Analyst
Prepared and analyzed performance reports for all Clients with respect to Enrollment, Disenrollment, Record Maintenance, and Claims Timeliness data.
Prepared approximately 19 reports per month and distributed to Clientele as per contractual timelines.
Assisted in writing contract language surrounding Service Level Agreements (SLAs) for inclusion in contractual agreements.
4/2004 – 7/2007 TMG Health, Inc. Dunmore, PA
Compliance Auditor
Conducted mock CMS internal audits to determine compliance with Government regulations.
Prepared universe and sample documentation for review at CMS by their auditors.
Strong understanding of CMS regulations in regards to Enrollment, Disenrollment, Maintenance of records, and sample documentation.
Audited records according to CMS regulations and guidance.
Kept apprised of regulation updates to ensure audit specifications were updated.
Prepared reports detailing findings and defects for Executive Management.
4/2001 - 7/2004 TMG Health, Inc. Scranton, PA
Claims Analyst
Determined if claims were billed correctly for provider or member payment.
Utilized the appropriate CMS and DMERC fee schedules for payment.
Adjudicated 1500 claim types in an accurate and timely manner per CMS guidelines.
Generated and reviewed both inquiry and pending reports to maintain processing in accordance to CMS guidelines and timeframes.
Have knowledge of CPT4 and ICD-9 coding guidelines.
Utilized Microsoft NT systems in conjunction with various programs and websites to perform the duties outlined above.
9/1998 - 4/2001 Blue Cross of NEPA Wilkes-Barre, PA
Claims Analyst II
Processed 1500 claim types in a timely and accurate manner per CMS guidelines.
Processed and reviewed claim attachments.
Entered provider authorizations for members.
Priced non-participating provider claims according to the appropriate CMS fee schedules.
Responsible for following compliance, federal and state regulations with CMS.
1/1997 - 9/1998 Wyoming Valley Health Care Wilkes-Barre, PA
Medical Secretary II
Utilized computer system to order laboratory tests and generate reports to physicians and nursing organizations.
Prepared specimens for various laboratory departments.
Operated technical equipment.
Advised nurses and physicians of proper laboratory procedure.
10/1994 – 1/1997 Visiting Nurse Assoc. Wilkes-Barre,
Medical Secretary
Data entered and generated 485/487 Medicare forms within CMS time and accuracy standards.
Billed various insurance companies with proper ICD-9 codes.
Reviewed charts for admissions/discharge processing.
Assisted in the generation of the end of the month balance reports.
Various other clerical duties as needed.
Education
9/1987 – 5/1991 College Misericordia Dallas, PA
B.S. Biology/Chemistry
Interests
Reading, cross-stitching, music.
References
Available upon request.
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