Business Analyst/QA

PATRICIA STRICKLAND

****-* ***** ** **********, NC 27410 Phone: 336-***-**** ********.**********@****.***

BUSINESS ANALYST, QA TESTER, EDI X12-5010, CLAIMS PROCESSING (837) and PAYMENT PROCESSING (835), ICD-10

FOCUS: HEALTHCARE SECTOR

Primary focus: EDI X12 5010 and ICD 10 analysis and testing. In depth understanding of the health care business processes, resulted in well-defined workflows attained through the process of gathering, and applying complex analysis to the found results. Executed well designed Business Requirements and Test Scripts at the SIT and UAT levels. As a core member of a project, my ultimate focus was preventing negative impact to existing revenue flow.

Expertise Highlights

Develop Detailed Gap Analysis

Strategic Workflow Analysis

and Re-design Planning

Data Flow & Process Mapping

As Is-To Be Documenting;

Use Case Design

Strong Billing Requirement Analysis

Post-live Support and Analysis

Team Lead & Mentor Strong Risk Analysis Approach

QA SIT UAT Testing w/ Scripting and Tracking

Major Software/Systems Implementation

Holistic Approach to Project Plan Balancing Payer Requirements with Application Functionality

Strong Complex Analysis

Analysis Conclusion Based on Supporting Facts

SME EDI X12 & Regulatory Requirements

Strong Coordination Plans with All Key Players

Professional Experience

NOVANT HEALTH APRIL 2011 – CURRENT

Contractor through TekSystems for 5010 Project

Sr. Business Analyst

Project responsibility the conversion of 14 applications and 47 business facilities from 4010 to 5010 namely, Cerner – Hospice facility (1); GE-Centricity – ASC (1) and Imaging (33) facilities; Hyland Papers - 835 payment processing for 12 varied A/R applications. The project scope was to conform to the regulatory compliance related to X12 837 (I/P) and 835, and enable readiness for the next phase of regulatory change ICD-9 to IDC-10.

Key Results:

Coordinated with Business Owner, Application Vendor, Business Project Teams, Payers and Clearinghouses to bring all processes to a level of execution to mitigate any impact to current revenue flow under the 5010 compliancy requirements

Produced for transaction sets 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy,

Validated that the system claim scrubber included editing based on the CEM published edits to ensure a positive 999 and 277CA transaction.

Designed the Business Requirements for the 5010 Project.

Designed robust 5010 testing and 4010 regression SIT and UAT Testing Scripts for the 5010 Project. Scripts were written on an application level and subset by payer resulting in over 600 combined scripts with a maximum of 70 testing scripts steps per script.

Analyzed the testing results to ensure that the results were in accordance with the Gap Analysis expected results for 5010 compliance.

Documented workflows and executed comprehensive testing and training plans to ensure the new acknowledgement results demonstrated in the 999 and 277CA were properly interpreted and managed to ensure Payer acceptance of the 837 files.

Mitigated impact to revenue flow by analyzing results shown in the 277CA transaction. Took action in the process flow to prevent rejected claims from falling into “limbo”.

Mitigated claim denial increase through a complete analysis of the application “Claims Scrubber” to ensure 277CA accepted claims would not result in an increase in Denials at the payer adjudication level.

Ensured “Claim Scrubber” was aligned with payer billing requirements based on TOB.

Ensured the corporate level 835 files were correctly split using the Hyland EDI Splitter tool.

Analyzed the split files to ensure the file remained compliant in format, and that all the splits from the original file balanced back to the original file.

Validated the receiving A/R applications (up to 12 recipient applications) received the correct split file and the application was able to correctly post the 5010 compliant 835 file.

Tracked all required resolutions required that were identified as needed from Vendors or Payers based on testing results.

Identified all risks associated with the project and gave suggestions for mitigating the impact the identified risk posed to the business.

BROWARD HEALTH – JAN 2011 – APRIL 2011

Contractor through Avant for 5010 project

Sr. Business Analyst

Project responsibility was the conversion of multiple applications and for varied business facilities from 4010 to 5010 namely, Invison – Acute facilities (5); Signature – Professional Offices; Proprietary Claim Scrubber - Managed claims processing for the entire enterprise. The project scope was to conform to the regulatory compliance related to X12 837 (I/P) and 835, and enable readiness for the next phase of regulatory change ICD-9 to IDC-10.

As a member of the ICD-10 Steering Committee, the focus was to produce a RFP for the execution of the ICD-10 program for the enterprise. Identifying every department and level within a department that would be effected by the conversion to ICD 10 and what needs the departments were anticipating to embrace the required change. RFP was completed and issued end of March 2011 to potential contractors in accordance with the FL state requirements.

Key Results:

Produced for transaction sets 835 and 837 (I/P) a full gap analysis 4010 vs. 5010 against the documented application 5010 enhancements ensuring the upgraded application included the required changes and additions for 5010 compliancy.

Identified the master file changes and builds needed to enable the 5010 format to be utilized.

Conducted Business Requirement and Business Process (As Is/To Be)) sessions with various department directors and staff to ensure the Testing Plan and Test Approach would meet the identified Business Requirements, and the Training Program covered all identified new and changed processes.

SIEMENS HEALTH 1996 – 2008

Level 5 Application Support Analyst

During the 12 years with Siemens varied responsibilities included: 6 years supporting the Diamond application utilized by various Invision clients for management of Medicare C and Medicaid “At Risk” programs, and 6 years involved from the inception of Soarian Financials with responsibilities associated to release of a new application including and not limited to QA, identifying the supportable requirements for application and user documentation oversight focused on accuracy and ease of usability by business staff.

Key Results:

Supported Soarian Financial (HIS) Application

o In summary, supporting the Soarian Financial application in the infancy stages required extreme flexibility and the strong analysis ability to view the issues present from the unit level, and the integrated level to ensure all affected areas were considered in the solution. My strong abilities in complex analysis tagged me as a primary support member on the team. Below at a high level some my involvement and accomplishments on the Soarian project are presented as relates to the phases of Initial Design, Beta, Live and Post-Live.

o Key member of the application design support team involved with QA, and analysis of functional design and test as the functional design was associated to the specific business process expectation.

o Assisted in the user application documentation approach to ensure the attributes of being user friendly and an easy “to the point” functional document related to each function in the workflow process.

o Assisted in the requirements to attain a supportable application. This included consideration of utilities to be design for support purposes, help documentation on varied expected issues.

o Supported the Beta installation on site during application build and testing, go-live and post-live focusing on the claims process functions and outcomes. Measured the level of clean claims and analyzed cause of claims classified as “not-payer-compliant” and presented action plans to correct the findings including the changes associated to master file set-up, processing rule designs and form design.

o Identified and presented application design modifications required to meet payer and/or business requirements.

o Transitioned from application design support through Beta to application support of post live clients.

o As the client’s base of the application was building, supported the Project Implementation teams in their efforts related to application build and testing in preparation to bring application live in production.

o Designed and facilitated various “Ask the Expert” presentations as needed based on analysis of the incoming support calls.

o Based on support call analysis engaged in developing varied presentations to the Implementation Teams on “lessons learned” and identified changes and/or more education focus in areas that showed weakness based on post live client support required.

o Involved with attaining UAT when application upgrade versions were released. Reviewed issues reported from the UAT efforts and analyzed for root cause and took action based on findings.

Supporting Diamond Payer Managed Care Application included

o Analyzed and validated the key components of the implementation plan related to Line of Business focusing on proper contract set up and processing of membership files, claims adjudication and payment to provider in accordance with LOB contract not limited to capitation, DRG, APC, and/or fee for service.

o Assisted in the design of contract details associated with varied Lines of Business. Ensured the associated rules were correctly built for the LOB to enable correct adjudication of claims and provider payment.

o Assisted in ensuring timely management of the membership file to enable providers of service to manage their responsibilities to members, and enabled the members to be empowered on the details of elected plan.

o Requirements analysis review and coordination with development to ensure the system was compliant from a regulatory prospective, and the application had the flexibility within various modular to meet the ongoing creative business contract design needs.

o Post live support addressing all issues, with a focus on claim adjudication to ensure a high percentage of “clean” claims in take to enable complete and accurate adjudication.

o Specialized in working on the more complex level issues associated with all modular of the application---Identified cause and designed temporary and permanent solutions working closely with technical programming staff members.

Education

IMMACUATE CONCEPTION JR COLLEGE now/ LODI UNIVERSITY– LODI, NJ

Major- Education

Technology Summary

Applications: Soarian Financial (HIS), Diamond Managed Care, EDI X-12 5010 transactions 837, 835, 999, 277CA and more, HL7, Microsoft SQL, Microsoft Project, Microsoft Visio, Microsoft Office

Systems platforms: Windows, UNIX, Java, ASP Desktop.

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