Senior Healthcare Business Consultant

Ivy C. Woods

********@*****.*** 502-***-**** Riverview, FL

Professional Summary

Strategic and results-oriented Senior Healthcare Business Consultant with 20+ years of experience in payer systems, benefit configuration, and claims adjudication across Medicare, Medicaid, and ACA programs. Proven expertise in leveraging platforms such as FACETS, NetworX Pricer, and QNXT, combined with advanced SQL and QA methodologies, to deliver scalable, compliant, and cost-effective solutions. Adept at translating complex regulatory and contractual requirements into auditable system logic, optimizing operational workflows, and enhancing cross-functional collaboration. Recognized for bridging the gap between business and IT, driving enterprise transformation, and ensuring regulatory alignment.

Core Competencies

• Benefit Configuration & Claims Adjudication

• Medicare, Medicaid, ACA Regulatory Compliance

• SQL Query Development & Data Validation

• FACETS, NetworX Pricer, QNXT Implementation

• Agile Methodology & DevOps Collaboration

• Unit, Regression & QA Testing Leadership

• Provider Contract Modeling & Pricing Logic

• Cross-Functional Stakeholder Engagement

• SOP Development & SLA Management

• Healthcare Data Integration & Optimization

Technical Skills

Platforms: FACETS, NetworX Pricer, QNXT

Languages/Tools: SQL Server, Oracle, Jira, SharePoint, Teams, EncoderPro

Methodologies: Agile, Waterfall, DevOps

Documentation: SOPs, SLAs, BRDs, Process Flows

Professional Experience

AvistaTech – Benefits Analyst III

Remote ️ Feb 2025 – Present

• Constructed and maintained benefit grids to support accurate claims adjudication and system integrity across multiple lines of business.

• Collaborated with policy, product, and market teams to resolve benefit conflicts, streamline implementation timelines, and ensure regulatory compliance.

• Conducted peer reviews of benefit documentation, identifying discrepancies and recommending corrective actions to uphold quality standards.

• Partnered with configuration, QA, and operations teams to support benefit testing, triage issues, and validate outcomes.

• Authored and maintained SOPs, SLAs, and process flow diagrams to support knowledge transfer, audit readiness, and continuous improvement initiatives.

eMids Technologies – Senior Consultant

Remote ️ Jan 2023 – Jan 2025

• Incorporated NetworX Pricer with QNXT, improving pricing precision and reducing manual intervention.

• Maintained Medi-Cal rate sheets in alignment with DHCS methodologies and reimbursement schedules.

• Engineered pricing models including DRG, APC, and Medicaid-specific fee structures.

• Guaranteed compliance with Medi-Cal regulations by translating policy updates into system logic.

• Interfaced with cross-functional teams to define scalable, reusable configuration deliverables.

• Drafted business requirements and spearheaded process redesigns to streamline benefit workflows.

CitiusTech (formerly SDLC Partners LP) – Sr. Associate Consultant II

Remote ️ May 2022 – Jul 2024

• Directed claims analysis and solution architecture for payer clients using FACETS and NetworX Pricer.

• Composed technical documentation and business rules for DevOps configuration teams.

• Orchestrated Agile ceremonies and sprint planning to drive iterative delivery.

• Refined Machine-Readable Files (MRFs) to meet CMS compliance standards.

• Functioned as a liaison between executive stakeholders and technical teams to resolve escalated issues.

Imetris Corporation – Benefit Configuration & QA Testing Consultant

Remote ️ Nov 2020 – Jan 2022

• Structured ACA benefit plans in FACETS, NetworX Pricer, and QNXT environments.

• Developed business requirements and maintained documentation repositories in SharePoint.

• Converted business rules into configuration logic across SPCR, SRCR, SEPY, and related tables.

• Assessed claims and service conversions using TPCT and RCCT tools for accuracy.

• Facilitated benefit claims processing and resolution to ensure timely adjudication.

UnitedHealth Group – Configuration & QA Analyst

Remote ️ Jan 2013 – Feb 2020

• Assembled Medicaid/Medicare benefit contracts in FACETS, including service IDs and payment rules.

• Verified ICD-10 configuration through comprehensive claims testing.

• Structured SQL queries to validate configuration and troubleshoot NetworX logic.

• Delivered test plans for provider contract implementation across multiple lines of business.

• Deciphered federal and state mandates and translated them into system configurations.

Education

Indiana University Southeast – Business Administration

Hillsborough Community College – Business Administration

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