Project Customer Service
Resume:
KAY JAMES
Clinton Maryland
email *********@***.***
PROFESSIONAL
SUMMARY
Results driven, With nine years of experience in supporting various complex Projects, to develop Technical Solutions which meet the Organization’s Business needs.
Support SDLC and Project activities, including Blue-e stakeholder identification, Membership Enrollment, Billing, FACETS Systems support, Facets Configuration, Claims, EDI, HIPAA 835/ 837, UAT, and internal/external User Training.
Solid Technical proficiency and hands on experience in FACETS, EDI, HIPAA, CPT coding, UB92 and HCFA 1500 claims, and Medicaid and Medicare Crossovers.
EXPERIENCE
September 2008 Surrex Consulting/CareFirst Blue Cross Blue Shield
Present Title: Sr. Business Analyst
Client Letter Health Care Reform & HIPAA Complaint Project.
Provide ongoing customer support for internal and external users of Client Letter Systems. Resolve system questions and problems, research and analyze moderately complex system problems, Import HIPAA complaint documents into production. Coordinate with other Business Analyst and Legal Contracts and Compliance to ensure quality, while troubleshooting and finding new resolutions to improve production.
Performs system support responsibilities to include but not limited to: system administration and maintenance, production monitoring, review business rules and writing new logics. Test file maintenance such as, creating reports, review and update logs and spread sheets, Write rules and logics to ensure HIPAA compliance is within guidelines of NAIC. Performed data extracts, maintain user training guide.
Participates in the analysis of existing Client Letter processes and systems to recommend process and system enhancements, configuration to improve business process narrow search enhance performance and maximize the effectiveness of available technology.
Participated in the research, analysis, testing, and implementation of system upgrades and enhancements. Provides training to users on changes in software functionality due to system upgrades and enhancements.
Participates in the design, development, and implementation of new software applications, to solve moderately complex problems. Creates documentation, provides guidance and user training on developed software. Maintain the system functionality and data flows between the external internal systems, hosted applications.
Performs team administrative duties including status reporting, team development, self/peer/project assessments, and recruiting. Develops project management analytical skills and increases knowledge of applications.
Manage, track, and monitor the Program Budget, Costs, Resources, and Expenditures, and create appropriate Program and Financial reports, for Senior Management and Project Managers.
Create and monitor the Program Schedules, using MS Project.
April-2001 – Blue Cross Blue Shield
August 2008 Durham, NC
Title EDI Business Analyst
Gathered requirements, documented and analyzed the existing Business processes for all identified departments and functional areas.
Work collaboratively to recommended, identify and design new processes, including opportunities for improvement, working in partnership with EDI Production Support and cross – functional Project Teams.
Provided daily FACETS Systems administration and support.
Gathered, analyzed, and defined Requirements for Systems design, implementation, and User training purposes.
Created and developed Test plans and Test cases, performed Testing and supported UAT processes.
Collaborated with Project resources, to ensure all System design requirements adequately reflect the defined Business processes, and in order to fully meet Business needs.
Process HIPAA Compliant Electronic 835 &837 Claims and Electronic Remittance Advices.
Support the day-to-day activities of the Electronic Services department, including product development, technical support maintenance, as well as Blue-e stakeholder identification, enrollment, billing, and claims issues resolution, and internal/external Customer support
Responsible for the Electronic transmission of 837/835 reports, TA1 and 997, and knowledge of (ISA/IEA). Provided Technical support, to create the new HIPAA EDI Implementation Guide.
Collaborated closely with IT Development, team, Business owners, and Sponsors, to develop Solutions, and support ongoing Business deliverables, in accordance with the Business needs.
Resolved inquires on claims, billing, membership enrollment, practiced and ensured compliance to Government regulations, HIPAA guidelines, Company’s policies & procedures, and CMMI Level 3
Ability to lead in absence of Manager.
Business Analyst & Quality Auditor
Blue Cross Blue Shield Customers of Durham N C
Provided services for Healthcare providers, members, vendors and other external agencies.
Identify CPT codes, HCPCS code, Diagnosis and other coding UB92 and HCFA 1500 claims.
Work Directly with Medicaid and Medicare Crossovers.
Identify trends and opportunities for training and process improvements.
Provided daily Facets Technical support, and supported special Projects.
Resolved inquires on claims, enrollment, billing, policy & appeals.
Helped group administrators with enrollment & payment issues.
Managed and created reports for Customers and the Management staff.
Provided excellent customer service in courteous and professional manner.
1992 – 2001 Department of Health & Human Resources Child Support Enforcement
Researched pays history on computer, research payments, and Case Analyst, for Governor’s Office.
Also Assisted State Senator’s Office of Citizens & Service and other state agencies.
Correspondence received from Custody and non Custodial Parent’s and other Agencies.
Other duties: record reports, for the US Attorney’s General Office,
Child Support Recovery Act of 1992/ Deadbeat Parent Act of 1992.
TECHNICAL
SKILLS
Customer Relations - Strong Presentation Skills - Financial Analysis
Strong Relationships with Customers & Stakeholders Sector
Project Management, Business Process Analysis, Critical Thinking, Analysis, Marketing, SAP, Financial Management, Business Reengineering to lower cost and enhance production.
Operating Systems: Windows NT/2000, 2007, 2010 Solaris 8.0/2.7, HP-UX 11.x and DOS. FACETS, TSO, FileNet, MVS, MS SQL, DB2, Oracle, Rebo, ESL,Client Letter, Power MHS, Maximo, Cubs, Cmid, Anirs, Mobuis, Merck Medco, MS Project, MS Visio, Microsoft Access, MS Excel, MS Word, MS PowerPoint, Outlook, MS Publisher, FMISPC2, Fox Pro, CMS, CTI, Blue Exchange Repository,
Méthodologies: SDLC, JAD, UAT, CMMI, RUP
EDUCATION
CERTIFICATIONS
TRAINING
Prince George Community College
Corllins University
Accounting Seminar- 1990
HIPAA Certification - 2007
MS Access Certification -2006
Medical Termology – 2009
Medical Billing - 2009
Physicians Billing – 2009.
Other information will be provided upon request.
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