Business Analyst Senior
Resume:
PHYLLIS A. SALYERS
Beech Grove, In 46107
Email: *********@*****.***
SUMMARY
Proven professional with deep expertise in Medicaid systems (MMIS) and policies including management, analysis, policy advisory, billing of claims of all provider types, and training of staff and the provider community. Experience implementing three Medicaid contracts with the fiscal agents. Expert knowledge of State and Federal regulations, policies, and MMIS processing system include Medicare and commercial billing and follow-up experience. Experience training and managing a billing department with over 30 employees, an inventory of $14 million, and over 10,000 accounts. Formal training in project management principals.
SKILLS HIGHLIGHTS
Business Skills
Technical Tools
Medicaid Claims Management
Medicaid Subject Matter Expertise
Medicaid Policy
Requirements Development
Business Analysis
Project Management
Team Leadership
Training
Microsoft Office (Outlook, Word, Excel, Visio, Lync)
Bizagi
Enterprise Architect modeling tools
CPT, HCPCS, UB04 coding
Critical Thinking & Problem Solving
Meeting Facilitation
Written and oral communications
RELEVANT EXPERIENCE
NTT Data, Inc. September 2024-current
Senior Business Analyst
Client: State of Alabama
Position: Senior Business Analyst
Project: PMO/MMIS Modernization
Responsibilities:
• Perform role of Subject Matter Expert (SME).
• Define business analysis and requirements.
• Engage stakeholder to identify new ideas and approach.
• Support critical thinking and problem solving.
• Develop diagrams/models for process flows.
• Facilitate communication between organizational units.
• Align the needs of business units with information technology.
• Assist in requirements validation for Provider Services/Enrollment with the customer.
• Mapping business requirements to system objects and panels.
• Provide requirement interpretation and guidance to technical and test teams.
• Assist in the development of the web-based tool for Provider Enrollment processes.
• Created process flows, letter templates, and report mock-ups. • Review test cases
LogicSoft July 2023-September 2024
Senior Business Consultant
Client: State of Ohio/Office of Information Technology
Position: Senior Business Analyst
Project: Medicaid SME for State of Ohio Systems Unit
Responsibilities:
Created Scope of Work document for Ohio Pregnancy Risk Assessment project.
Business Analyst role for oversite of the Grievance and Appeals processes
Oversite of System Integration (SI) module for the MMIS system vendor
Participation with System Integration testing
SIT testing execution for the MMIS claims module
S2tech
Senior Business Consultant/Analyst Sept 2020 – Sept 2023
Client: Computer Aid, Inc. (CAI)
Position: Senior Business Analyst
Project: Project Management Office (PMO) for the implementation of the new statewide automated Comprehensive Child Welfare Information System (CCWIS) for Indiana Department of Child Services (DCS)
Business analyst assignment is with CAI to perform PMO services for the implementation of CCWIS by Accenture for DCS.
Responsibilities:
Manage the application Lifecycle Management (ALM) and ensure quality and consistency of inputs
Own the requirements management process and implementation of the entire CCWIS product backlog.
Mapping of business requirements/user stories to the process flows and identify gaps and missed requirement.
Assist DCS in working with the DDI vendor during requirements confirmation to identify specific rules that need to be added, expanded upon, or rewritten to address any functional requirements missing from these areas. The DDI vendor shall update the high-level requirements to reflect the feedback from these sessions.
Assist the DDI vendor with completion for deliverables.
Ensure the CCWIS system meets all federal and Indiana security, statutory, and regulatory requirements and achieves any federal certification in place at the time of system statewide implementation. Support updates to the Advanced Planning Document (APD), including any annual updates.
Assist with testing phases and document pass/fail results.
Attend and assist with requirements refinement meetings with the DDI vendor and State DCS staff.
Document traceability model within State defined systems Jira and Confluence.
Identify core compliance and certification requirements up front.
Align identified business requirements with project stakeholders
Validate requirements traceability
SENIOR BUSINESS CONSULTANT/ANALYST/CONTRACTOR
CSpring
October 2012- September 2020
Client: United Healthcare/Optum
Role: Business Analyst/Data Analyst
Project: State of Indiana for the Enterprise Data Warehouse for Medicaid/Managed Care/HIP Population
Business analyst assignment is with Optum, the contractor for the State of Indiana to manage member data via the Data Warehouse. Data requests are received from several sources within the State agencies to create reports, ad hoc reports, view trends, manage outcomes on Medicaid data.
Creating requirements for various new data reports/requests and existing reporting
Work directly with State staff clarifying requirements and processes
Attend all stakeholder meetings with the State.
Creating user stories for developers
UAT testing of changes
Creating SQL queries and Cognos queries
Ensure all policy and procedures are being met for compliance
Monitoring the state business and system requirements
Client: Caresource
Role: Senior Business Analyst (Aug 2018-July 2019)
Projects: State of Indiana Gateway to Work Expansion, MCE Power Account Reconciliation
Business analyst assignment is with Caresource, Inc., a managed care entity (MCE) with the State of Indiana. The state requested the MCEs in Indiana to implement the Gateway to Work Expansion (GTW-E). GTW requires all HIP members to meet specific work, volunteer, or school requirements to eliminate losing their HIP benefits. A member can be exempt if they meet the criteria for an exemption. Also, recently added to the MCE Power Account Reconciliation Project for HIP members.
Work directly with State staff clarifying requirements and processes
Attend all stakeholder meetings with the State.
Creating user stories and feature documents for developers
Creating business process flows
Creating user stories for developers
Prioritizing work for UAT testing
Training of internal staff that will be responsible for this project
Ensure all policy and procedures are being met for compliance
Creating member communication documents
Monitoring the state business and system requirements
Client: State of Indiana Office of Medicaid Policy & Planning (OMPP)
Role: Provider Enrollment Analyst/SME (Jan 2018- July 2018)
Project: Implementation of Provider Credentialing and Enrollment to a new vendor at the State of Indiana
Assignment with the State of Indiana, Office of Medicaid Policy and Planning (OMPP) as a Provider Enrollment Specialist in support of the State’s contract with Conduent/Medversant to process provider enrollment applications and perform provider credentialing for all programs including the Managed Care Entities (MCE).
Work with new vendor creating requirements for approval.
Acting SME for enrollment processes
Reviewing and approving design documents
Assisting vendor with development tools to perform enrollment and credentialing processes to ensure they are within the scope of Medicaid policy and State and Federal laws
Reviewing and approving process flows
Creating policy documents for provider enrollment and credentialing
Other tasks as assigned or needed
Client: State of Indiana Office of Medicaid Policy & Planning (OMPP)
Role: Fraud/Waste/Abuse analyst for Program Integrity at the State of Indiana (May 2017-November 2017)
Project: Implementation of Provider Credentialing and Enrollment to a new vendor
Assignment with the State of Indiana, Office of Medicaid Policy and Planning (OMPP) with Program Integrity Unit as a Program Integrity Analyst.
Worked with the Managed Care Entities on reporting of fraud, waste, and abuse.
Created reporting documents each month for providers on the alert list.
Monitored Scope of Work requirements document for compliance reporting.
Assisted staff with prepay review for fee for service claims processing.
Assisted with the implementation of prepay review functions to a new vendor.
Client: DXC (formerly Hewlett Packard)
Role: Business Analyst (Oct 2012-March 2017)
Project: MMIS Modernization
Replacement of the Medicaid Management Information System (MMIS) for the State of Indiana.
Perform role of Subject Matter Expert (SME).
Define business analysis and requirements.
Engage stakeholder to identify new idea and approach.
Support critical thinking and problem solving.
Develop diagrams/models for process flows.
Facilitate communication between organizational units.
Align the needs of business units with information technology.
Assist in requirements validation for Provider Services/Enrollment with the customer.
Mapping business requirements to system objects and panels.
Provide requirement interpretation and guidance to technical and test teams.
Assist in development of the web based tool for Provider Enrollment processes.
Created process flows, letter templates, and report mock-ups. Review test cases
BUSINESS ANALYST/SUBJECT MATTER EXPERT (SME)
South Carolina Dept. of Health and Human Services (SCDHHS)
Sept 2011-Oct 2012
Replacement of the Medicaid Management Information System (MMIS) for the State of South Carolina.
Assist in the development/formulation and validation of all requirement engineering processes, standards, procedures, and guidelines.
Assist in the requirements management processes, including change control, version control, tracking & status reporting, and traceability.
Providing leadership to requirement teams, serving as a central point of contact through mentoring and motivating other business system analysts in a positive manner.
Guiding both project team members and customers in the development process; providing analysis and solution definitions, to ensure solutions meet customer objectives.
Providing requirement interpretation and guidance to technical and test teams.
Proactively identifying risks, issues, and action items leading to possible solutions.
Interacting with internal and external organizations and persons as deemed appropriate by the Requirements Manager (i.e. vendors, State and Federal government agencies, State providers and beneficiaries, and other stakeholders).
OMPP CONTRACT OVERSIGHT OPERATIONS
State of Indiana, Office of Medicaid Policy & Planning (OMPP)
2006- 2011
Oversight of the fiscal contractor for Medicaid.
Work with medical policy team regarding changes and monitor whether any changes being considered are within existing parameters, rules, and regulations.
Participated in implementing Indiana’s Healthy Indiana Plan (HIP) for uninsured Hoosiers.
Participate and assist with all system changes relating to file interfaces with the Indiana Client Eligibility System (ICES) and the Indiana AIM claims processing system.
Assisted in implementing detailed processes to determine disability aid category for Medicaid with the Medical Review Team (MRT).
Monitor claim processing to ensure accuracy and timeliness.
Perform periodic assessment of vendor claims resolution process to ensure accuracy.
Periodically monitor rates for various procedure codes and specialties.
Collect weekly claims data from vendor and prepare performance matrix.
Perform contract and claims monitoring of EDS. Monitor claims processes and procedures. Review the operational manuals related to claims.
Work on change requests as a part of the CCB and the reference code teams.
Team lead for OMPP on new implementation initiatives related to claims processing and payment.
Serve as a subject matter expert for claims.
Provide bi-weekly status report to manager on activities, open issue and potential problems.
Participate in review of bulletins, newsletters and banners related to claims processing.
OMPP lead on identification of reference code modifications and participate in weekly HICPC meeting.
Actively participate in rate setting decision process.
Participated with State team for the CMS certification process for the MMIS system
Participated in the RFP development for the CMS scope of work
Actively worked with Administration office with writing and reviewing Advance Planning Documents (APD) for CMS funding.
Assisted with creating PowerPoint presentations and standard operating procedures (SOPs).
PROVIDER FIELD CONSULTANT
Electronic Data Systems (EDS)
2002-2006
Indiana Medicaid Staff Position
Training and educating provider community on all aspects of the Medicaid system, guidelines, and the web interchange.
Worked with county Department for Family Resources with eligibility issues relating to denied claims.
Perform quarterly and annual seminars for the provider community.
Waiver program provider representative from January 2003-October 2003.
Perform provider onsite visits in excess of 40 per month.
Perform claims testing for change orders and new Medicaid regulations.
Lead on updating several chapters of the Indiana Medicaid provider manual.
Assist with overseeing 5 provider associations groups.
BILLING MANAGER/SPECIALIST
The McKee Group and Argent Company
1995-2002
Consulting with hospital clients to screen self-pay accounts for Medicaid eligibility
Responsible for billing, training, and revenue for two divisions.
Assisted staff with requirements for determining retro-eligibility for self-pay hospital accounts.
Managed staff of 10 field representatives and 4 billers on eligibility requirements and billing requirements.
Perform Medicaid training sessions for hospital clients.
Assist with developing training manuals for employees and clients.
Assist billing staff with resolving problem claim issues to completion.
Project monthly revenues for the division.
Posting of payments and balance AR in excess of three million average.
Assist client servicing department with implementing new hospitals.
SUPERVISOR OF PROVIDER ASSISTANCE
Electronic Data Systems (EDS)
1991-1995
Supervised call center of 30 + employees
Supervised a staff of 30 telephone representatives for the Medicaid program.
Responsible for training staff on all claim types, which includes, hospital, physician, pharmacy, nursing home, and Medicare/ Medicaid related claims.
Maintained State required quotas on assisting the provider community while assuring.
Improved quality standards.
Assisted in developing provider bulletins on new Medicaid guidelines as mandated by the State Department.
Worked directly with the system engineers on testing of new edits and audits.
Developed in-house training plan to increase quality in all departments to reduce provider calls.
Prior Experience:
PROVIDER CONSULTANT, Blue Cross Blue Shield of Indiana (BCBS)
VARIOUS POSITIONS, Blue Cross Blue Shield of Indiana (BCBS)
Education
1989-1991 Continuing Education, (approximately 30 hours completed), Indiana University/Purdue University of Indianapolis (IUPUI)
1974-1977 High School Diploma, Emmerich Manual High School, Indianapolis, IN
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