Data Analyst Health Plan
Resume:
Andrea Marshall
Houston, TX
********-******@*******.***
100% Remote
Objective:
Searching for a fully remote position utilizing Trizetto Platforms such as QNXT, Facets & NetworX with an extensive Medicaid history of problem solving, trending analysis and reporting with a zest for learning new things.
Wipro
Business Data Analyst - Requirements
7/2024- 02/2025
Facets: Managed Medicaid workflow and ensured each ticket meets the respective markets State requirements & contractual obligations. Validate the requested changes through review of Medicaid Guidelines. Input the ticket into the Interact system for tracking & status updates. Reach out to the Health Plan for restrictions, limits or exceptions that should be included in the update. Submit a ‘mock up’ of the new design for Health Plan review. Integrated TriZetto solutions to streamline Medicaid claims and improve workflow validation processes across market segments. Supported the Billing lifecycle by identifying inconsistencies in provider charges and aligning updates with Medicaid reimbursement guidelines. Played a key role in Invoicing accuracy by performing rigorous ticket validations against service codes and Health Plan specifications. Contributed to Revenue Cycle Management by facilitating timely processing of updates that directly impacted claim resolution and payment cycles. Work closely with the Configuration Analysts for awareness & understanding of client intent. Attend daily Stakeholder meetings in a SME capacity providing guidance on inquiries related to the project, configuration and any other policies related to Behavioral Health. Support a positive work environment. VC5 Consultants
Configuration Analyst
4/2024 – 7/2024
Quick Caps: Medicare Advantage Implementation. Load Quick Caps platform with all necessary components to welcome new business and process claims through auto adjudication. Research edits & Medicare Rules and Regulations, identify areas of opportunity and close gaps that might disrupt workflows, audit the Benefits module to ensure codes are assigned to the correct benefit services. Includes unit testing and regression testing. Worked closely with TriZetto systems to manage configurations that directly impacted claims auto- adjudication and revenue accuracy. Focused on the Billing aspect by investigating discrepancies in Medicare fee schedules and correcting system configurations accordingly. Audited Invoicing logic within Quick Caps to ensure that benefit assignments translated into accurate billing statements. Strengthened RCM by minimizing provider payment disruptions through proactive configuration and fee schedule alignment. Worked closely with internal partners to recognize “no pay” claims and providers with incorrect Medicare Fee Schedules assigned. Resolved high priority provider complaints. Maintained both CARC and RARC databases to ensure accurate messages are assigned to the CARC & RARC codes. Cognizant
Sr. Associate
8/8/2022 – 11/2023
QNXT 6.0-6.1 Translate paper contracts into QNXT system logic. Validate coding and compliance through Texas Medicaid. Build or update contract terms in QNXT and build rate Andrea Marshall
Houston, TX
********-******@*******.***
100% Remote
sheets in NetworX. Unit & regression testing performed to ensure system stability after updates are complete. Generate various claim reports using Microsoft SQL Server. Collaborated with TriZetto/QNXT to automate contract-based pricing logic tied to Medicaid Billing guidelines. Improved Billing workflows by ensuring clean translation of contract details into system logic to reduce payment errors. Reviewed and validated Invoicing line items tied to reimbursement models to ensure regulatory compliance and payer contract adherence. Contributed to RCM by monitoring and optimizing claim lifecycle processes that directly influenced provider reimbursement and inventory aging. Resolve escalations raised by internal/external partners. Participate in Client meetings with focus on performance and aging inventory with a recommendation on areas identified as opportunities. Impact Consulting
Pricing and Configuration
03/2022 – 6/2022
QNXT: Analyze the request, confirm compliance & coding through AZ Medicaid, determine if request is impacting benefits or contract terms. Update the QNXT system logic to meet business requirements and satisfy client intent. Utilized TriZetto/QNXT tools to perform system configuration that influenced Medicaid claim adjudication and billing integrity. Ensured Billing protocols aligned with state requirements and benefits coverage, minimizing downstream processing issues. Validated Invoicing rules in tandem with service code modifications to maintain system accuracy. Supported RCM by reducing delays in payment cycles through timely configuration updates and documentation for future reference. Document all aspects of the configuration and steps taken to complete the request in Onbase as the ticket will be loaded to the Knowledge Bank for new Analysts to reference. Texas Children's Health Plan
Configuration Analyst
05/2019 - 11/2021
QNXT: Performed activities related to complex QNXT Medicaid configuration, new business implementations and TCH conversion to Epic. Collaborated with the Implementation Team, IT department & Claims team to collaborate about Medicaid compliance & client intent. Specifically, supported the transition from QNXT to EPIC team to create crosswalks between QNXT and EPIC allowing the systems to communicate. Led a Service Groups project validating the code sets loaded are active and mapped to services appropriately. Leveraged TriZetto's QNXT for Medicaid configurations impacting provider reimbursements and service authorization workflows. Strengthened Billing accuracy by identifying claim edit issues and root causes within the 837/EDI transaction lifecycle. Collaborated across systems (QNXT and EPIC) to ensure Invoicing transparency and integrity post-system transition. Played a key role in RCM optimization by reducing claim denials and improving turnaround time for claim reimbursement cycles. Monitored claim reimbursement for inefficiencies including EDI Acute Care /Long Term Care claims. On occasion submitted forms for 276/277 to the EDI team for claim status inquiry authorization transactions. Some troubleshooting to determine if a claim, 837 was billed by a Provider or a problem with the batch, possibly an issue originating from the clearinghouse requiring additional review from the vendor, EDI code 278 or submitting additional info, code 275 relating to institutional claims, 837. Performed UAT testing to identify defects impacting the stability & integrity of QNXT after updates were complete. Analyzed and resolved Medicaid claims firing Edits to either deny or pend claims. Andrea Marshall
Houston, TX
********-******@*******.***
100% Remote
Attached newly built contracts to the Provider files for testing. Built Provider files that included demographics, accumulators, contract builds, affiliations, attestation and Provider type. Used MySQL Server for system reporting to identify variances. United Healthcare Configuration /Auditor
02/2012- 05/2019
Configuration and Data maintenance of Integrated CSP Facets 4.7 & 5.2. Responsible for accuracy and quality of the Integrated CSP Facets systems set up. Engaged in configuration & implementation / installation, troubleshooting of Medicaid claims & service code mapping. Build Provider records in the FACETS system, included loading provider type, specialty, attestation, demographics, affiliations & Provider directory. Extensively worked with TriZetto Facets to build and maintain provider configurations for accurate Billing and service mapping. Supported Invoicing processes by validating contract terms and ensuring proper linkage of service codes to payment logic. Contributed to end-to-end Revenue Cycle Management by resolving Medicaid claim discrepancies and ensuring accurate fee schedule assignments. Provided audit insights that reduced system errors and improved claim throughput and provider satisfaction. Attach contract (s) to provider files for claim processing. Define, develop and document actions. Quality assurance and unit testing performed. Participate in test development and execution activities with internal and external partners i.e. Cognizant/ Trizetto. Initiate effective learning materials that detail validation steps, communications, configuration, test findings and recommendations supported by fact-based outcomes. Perform root cause analysis to offer solutions for quality improvements.
Molina Healthcare Provider Resolution Analyst
10/2011 - 06/2012
QNXT
Complex root cause analysis associated with Medicaid high dollar & high-volume Providers, identify trends and improper system configuration impacting Medicaid reimbursement. Concerns raised by Providers, Network Managers & Claims team relating to reimbursement were analyzed, paper contracts reviewed, claims in question were recalculated line by line & documented uncovering a strong need for internal education and need for additional internal processes to be developed & implemented. Utilized TriZetto/QNXT systems to conduct deep dive into system misconfigurations impacting Billing and Medicaid payment structures. Ensured Invoicing adjustments reflected accurate reimbursement rates after recalculating claims at the line-item level. Collaborated with providers and internal stakeholders to streamline Revenue Cycle Management and address state escalations. Introduced operational SOPs that aligned billing resolutions with compliance requirements and RCM best practices. Immediate system corrections were performed. Initiated process development and a detailed Standard Operating Procedures which included guidelines how to research CMS/HHSC & TMHP guidelines. Responded to State complaints (Texas Department of Insurance) and participated in bimonthly conference calls with Texas Dept. of Ins. in relation to reimbursement and provider complaints. Memorial Hermann Healthcare
Billing Data Analyst
2/2006 - 11/2011
Developed the Insurance Appeals Team for the SW facility. Monitored denied claims, determined if Memorial Hermann followed the appropriate procedures to receive Andrea Marshall
Houston, TX
********-******@*******.***
100% Remote
reimbursement, if procedure was followed, created the appeal letter and included necessary supporting documents. Denied claims were reduced 99% for this facility. Submitted monthly reports indicating reimbursement profit/loss related to denied claims, unpaid claims, and comparisons against other facilities within the Health System. Use of Pivots & charts were presented to the CFO to present a clear snapshot. Edit errors from unprocessed and denied claims was another source included in assessment development. Communicate with management and provide education to staff regarding trend development. Prepare/ generate various compliance, productivity, and comparison reports. Audit claims, employees, and vendors for quality assurance. Work closely with physician’s offices regarding billing and authorization concerns while providing support for reimbursement. Additionally, provided feedback with supporting data to implement or streamline workflows throughout the facility and present to the partnered physician offices.
Memorial Hermann accomplishments
Andrea Marshall
Houston, TX
********-******@*******.***
100% Remote
2009-2011 Decreased denied dollars by approximately $2 million. In addition to the above, implemented successful process improvements to eliminate PCCM Medicaid claim denials which increased annual reimbursement $67,000. 2010 Nominated for Memorial Hermann's President's award for multiple projects focused on increasing revenue.
2011 *Closed the year out with only 3 denied claims for this large Acute care facility*.
Molina Healthcare
2012 Identified $6 million in underpaid claims.
Identified $1.2 million in overpaid claims.
Skills:
Texas Medicaid, Medicare, Healthquest, Pathways, Interact, Pluto, OnBase, TFS, Salesforce, Facets, QNXT v.5.20.001-6.1.002 and NetworX Pricer (certified) SharePoint, CACTUS, Care4, COSMOS, Confluence, EVIPs, MIDAS, MACESS, NDB, PhyCon, HIM & PFS Sovera, Microsoft Teams, MySQL Server, CES, JIRA, Microsoft Suite including Intermediate level Excel, Word, Visio, Access, PowerPoint.
Education:
2004-2012 No degree obtained.
Attended Houston Community College (took classes as time and affordability allowed) 2009 completed Medical Terminology 1 & 2
** Currently, enrolled in Udemy.com actively taking classes. 2024 Completed “MySQL for beginners”
Actively participating in MySQL for intermediate learners. Learning to write the query from scratch.
2024 Enrolled in Agile fundamentals.
Enrolled in Jira for beginners.
Enrolled in .Net and Java for beginners.
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