Medical Data

Rey B. Villas_____________________________________________ ___________________________

**** *** ***** ***. *****: *********@*****.***

Long Beach, CA 90805

Phone: 707-***-****

June 24, 2011

System Flux, Inc.

Attn: Recruiter

Re: EDI Analyst

Salary Requirements: Open

Dear Sir/Madam:

I am writing to express my interest in the EDI Analyst position in your organization. I am highly skilled in Health claims (auditing, adjudication, and recovery), health claims reporting’s, EDI analysis, and systems health data analysis, conversion, mapping (import/export) as well as in reporting analysis; with emphasis in healthcare claims management applications and clinical systems. My background includes extensive experience in developing, designing, analyzing, and implementing solutions for clients in the healthcare insurance industry.

Conversely, I have recently relocated back to Southern California after completing my MBA degree in Manila, Philippines and at the same time I was taking care of my geriatric mother who is 86 years old which she needed of caregiving and medical attention. As a result of that process, I am actively seeking new employment.

Additionally, I was responsible for the EDI inbound and outbound professional and institutional claims as well as testing the modules including the encounter reporting in the Department of Health of the State of Arizona (Medicaid), United Healthcare, Health Choice Arizona, City of Hope Medical Center, and others. I also maintained the transaction sets of ANSI X12 271, 277/278, 820, 834, 835, and 837.

Lastly, I have already updated my skills from all my previous skills as well as the new trend in the technology applied to the healthcare industry. I am confident that I am the right person for this position who will produce an intelligent, effective systems workflow resulting in increased productivity. Likewise, my expertise in computers systems to evaluate the Quality claims processing and to enhance the productivity of claims auditing in the workplace environment. My knowledgebase in reporting systems from Access, Crystal reports, and other programming/tools as well as testing will be an asset to the organization. My education, training and experience are detailed in the attached resume.

Thank you for your time and consideration.

Sincerely,

___________

Rey B. Villas

Rey B. Villas_____________________________________________ ___________________________

5728 Jay Mills Ave. Email: *********@*****.***

Long Beach, CA 90805

Phone: 707-***-****

PROFILE: - Nineteen years dedicated to healthcare insurance industry

- Demonstrating progression in responsibilities/expertise

- Leadership and management abilities

- Excellent multitasking abilities

- Resourceful problem solver

- Team player

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EXPERTISE: managed care analysis / EDI analysis / program analysis / business analysis / data analysis / claims analysis / reporting analysis / provider networks / reinsurance analysis / cost analysis / contract analysis / compliance / Quality Assurance Claims Audit Analysis / supervision and training

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EXPERIENCE:

University of the East, Philippines (Unemployed) April 2009 – April 2011

Continuing Education – M.B.A

Unemployed / Continued completing of my education.

Graduated in Master Program.

Handled personal issue with my dearest mother medical condition.

United Health Group / Ingenix Division December 2008 – March 2009

Sr. Business Analyst (Clinical Assessment Solution –Contractor/Temp)

Responsible for mapping documents, creation of test plan, test scenarios, test cases of unit, system testing, system integration testing, remediation and configuration of client servers system for HIPAA compliancy.

Performed Risk adjustment assessment from Medicare compliance, Validated HCCs, Extracting Medical Records (MR), Collaborate business objects for web portal development.

Prepared ad hoc reports on tasks productivity based on weekly, monthly, quarterly, and annual.

Performed financial, statistical/variance, utilization and cost information, citing trends and variances for review and further analysis to respond to upper level management.

Q.A test, generates, and translates Electronic records such as Medical Records, and EDI Encounters mapped in loop/segments elements.

Developed program to trapped and performed claims validation in applicable to business claims rules set-up between Secure Horizon products and set business rules for validation audit purposes.

Health Choice Arizona December 2007 – December -2008

EDI Claims/Encounter Analyst (I.S Department)

Developed program audit claims rules, trapped and performed claims validation in applicable to claims rules set-up between AHCCCS and HCA in-house rules for audit purposes.

Performed EDI encounter claims testing in Claredi/TI.

Performed enhancement tasks in the application systems, and QA Audit test system builds, documented tasks lists, and coordinated with application developer. Moving, Test-Staging,-Go Live production on systems modification.

Developed and designed new EDI transactions and enhancements/improvements to existing EDI communication through Encounters claims with AHCCCS (MEDICAID).

Led EDI development team to handle the new EDI program, mapping (1500, UB92, UB04, DENTAL, PHARMACY) and programming the codes/script on VB.

In-charge of ANSI X12 271, 277/278, 820, 834, 835, 837 Transactions sets and responsible for training and testing of transactions sets, Trading partners specification and rules assigned

Troubleshoot issues on State of Arizona Error Pends claims for resubmission.

Validated the claims errors while performing testing in the Test/Staging area for claims data results.

City of Hope December 2004 – December 2007

EDI / Data Analyst (I.S Department)

Lead EDI development team to handle the new EDI program, mapping, and programming the codes/script.

Responsible for ongoing support and new EDI program using EDIDev Framework to write the program codes on VB, Visual Studio environment, MS Access, SLQ Analyzer, Monarch for development and modifications as a tool.

In-charge of ANSI X12 271, 277/278, 835, 837 Transactions sets and responsible for training and testing of transactions sets, Trading partners specification and ANSI 835 Payments posting.

Generates (276, 835, 837) and translated X12 loop/segments elements on X12 997, 277/278, 835, 837.

Responsible for mapping documents, creation of test plan, test scenarios, test cases of unit, system testing, system integration testing, remediation and configuration of client servers system for HIPAA compliancy.

Wrote SQL scripting (SQL Server database) on VB/VB.net and converting data files into EDI transactions.

Performed splitting data files on specific trading partners and review/updates specific set of claims rules.

Performed Q.A test analysis on debugging, test codes scripts, and error trappings based on specific claims of rules and others.

Performed Claredi testing environment and to view their testing status result for outbound files.

Modified programs modem dial-up to secured FTP transfer files.

Developed customized reports using Cognos, Crystal and Access.

Extensive knowledge of Healthcare claims adjudication rules, UB92, RBRVS, RVS, and HCPCS

Performed data analysis to identify the scope of problems, impact to the healthcare business, and provided

Worked on projects where data integrity problems existed requiring the analysis of data contents, business user requirements, user cases, and Functional specs.

Manlink Services/All Wells /INS Overload (Orange Counties/Covina CA) November 2003 – December 2004

Data Analyst - (Contract Assignment – MBC Systems, Pacificare, Prospect/Healthcare, IPA’s Groups)

Extensive experience of Healthcare auditing and processed claims on UB92, HCFA 1500

Knowledge of contract/pricing on hospital contract rates, per diem, case rates, flat rates, RBRVS, and RVS.

Data Analysis: Designed and programmed ac-hoc databases to track aging receivables on Hospital and Professional health claims processed from the Medical Center and seven satellites Outpatient clinics.

Analyzed and coordinated managed care contract compliance of various insurance companies.

Responsible for the business experience of all clients seeking of EDI mapping solution based on contract assignment and handled all QA of EDI Inbound/Outbound.

Contract projects involved on ANSI X12 997, 277, 278, 835, 837 transactions sets and responsible for mapping documents. Wrote program codes for Inbound and Outbound

Performed external web site for Trading Partners to upload test files into their system, and view test status.

CalOPTIMA, Orange, CA November 1999 – August 2002

Program Analyst (Audit/ Compliance/Recovery / Research Department)

Performed audits on provider contract, members’ capitation, and production claims on HCFA 1500/UB-92 on large dollar amount threshold on surgery procedures, inpatient hospitalization (short/long term care)

Extensive knowledge of professional/ hospital contract rates, FFS (Fee for Service – RVS/RBRVS), per diem, case rate, discount rate, threshold, UCR, and Reinsurance (Stoploss) contract rate.

Performed testing pricing on provider contract, claims adjudication/audits/benefits on Facets systems.

Extensive knowledge of professional/ hospital contract rates, FFS (Fee for Service – RVS/RBRVS), per diem, case rate, discount rate, threshold, UCR, and Reinsurance (Stop loss) contract rate.

Developed and programmed to audit/track reinsurance financial stoploss and performed revenue recovery for over $6 million in twelve health network contracted with CalOptima.

CalOPTIMA, Orange, CA (Continuation)

Performed relational databases, data imports/extracting, data scrubbing, and data mapping.

Lead data conversions from the claims systems (QCARE) to Erisco Facets claims systems.

Involved for X12 271, 277, 834, 835, 837 transactions and responsible for mapping documents, test cases, test scenarios, unit testing, system testing, configuration of EDS system for HIPAA compliancy.

Created and performed analysis on business requirements for claims operation, product analysis, task and

workflow, data models/modules, Data Dictionary, and Program/Functional specs on reinsurances, DHS

provider contract rates (Fee Schedules / Hospital rates), benefit products, including all functional data

elements for UB-92 and HCFA 1500 claims.

Benefits Product Development: Building products in Erisco Facets module and lead the process of determining and interpreting the premiums, copayment, deductibles, stop loss, limits (visits and episode) benefits, and services area based on Schedule of Benefits Summary; responsible for the DHS HMO, and Medicare rates.

Developed and customized SQL Ad hoc reporting using MS Access/Crystal reports.

Prepared ad hoc reports on tasks productivity based on weekly, monthly, quarterly, and annual.

Performed financial, statistical/variance, utilization and cost information, citing trends and variances for review and further analysis to respond to upper level management.

MedPartners, Inc. February 1999 – October 1999

Health Analyst Supervisor (Claims and I.S Department - transition)

• As a team leader in-charged of over seven (7) staffs who responsible for claims application & EDI systems.

• Project worked with IDX/EZ-CAP systems and EDI claims (270/271, 276/277, 837, 810) to streamline the electronic claims inbound/outbound information data flows between of trading partners, medical satellite offices, medical billings, and patients to deliver a standard reporting system, analyze distribution of claims effectiveness, and improve data quality under Quality Development audit areas.

Documented business process for Utilization Management, Case Management, in VISIO. Team Lead for ANSI X12 997, 270/271, 276/278, 835, 837 Transactions. Was responsible for training and testing of transactions.

Designed screens and application for 278/835 Business Users. Created Mapping documents, test plan, and Provider Companion Guides.

Collected and organized business requirement documents for the purpose of developing the claims plans.

PacifiCare, Cypress, CA March 1996 –February 1999

Sr. Auditor Analyst (Production Claims -Commercial/Medicare, PPOs, Reinsurance, and EDI)

Managed 8 staffs and responsible for working on multiple projects involving the healthcare claims business operations, compliance/Quality auditing, data quality, claims adjudication, EDI, claims testing, and processed data reporting

Facilitated and prepared reports on utilization, fee schedule information compile the financial recovery reports, quality performance rating, stats reports, citing trends and variances for review.

In-charge of the production health claims auditing, interpretation of utilization and cost information for risk analysis, assisted clinical reviewer, and quality improvement of claims Q.A operations.

Extensive experiences in Revenue code, CPT/HCPCS, ICD-9, and Medi-Cal codes.

Reviewed, adjudicated, and performed Professional/Institutional claims, on all IPAs/physicians contracted, Hospital contracted, reinsurance, FFS (Fee for Service-RVS/RBRVS), per diem, case rate, discount rate, threshold contract, and shared risk pool/capitation (Matrix Responsibility).

Performed EDI auditing logical/physical testing on claims/pricing rules, set of claims code and benefits.

Programmed and designed over 100 database templates reporting - maintained Access database/VB-VBA/SQL.

Experienced in relational databases, data models, data imports, and data mapping.

Developed database reporting and systems analysis design using Access and Crystal. enticed with client servers on NICE/FOCUS/ILIAD/VMX/UNIX systems for all users in claims audit (internal), on-site audit (Compliance), and provider

Lifeguard Healthcare, Milpitas, CA January 1994 – March 1996

Quality Development Supervisor (Q.A Claims/EDI )

Managed 6 employees who performed medical claims auditing, claims recovery, claims auditing, claims processor, and processing of grievances/appeals all under Claims Resolution. Performed medical claims review, EDI claims testing pricing, claims recovery and data entry, Programmed/designed Access databases for quality audit, HCFA, DOC, NCQA and Finance database - created database reports in Access and Crystal Report through ODBC SQL server or stand alone - Maintained Access database front end and SQL back end - Cost analysis and interpretation - supervision/training - compiled/ prepared financial recovery, quality, manual auditing, performance Claims Examiners rating and other statistical reports.

Good Samaritan Medical Foundation, Los Gatos, CA February, 1993 – January 1994

Managed Care Claims Supervisor - Recovery

IPA Group: Managed 12 employees who performed medical claims review, claims recovery, data entry, and processing of grievances/appeals. Prepared database management reports - maintained Access databases - performed audits via auto-audit systems and manual auditing – tested contract pricing – supervision/training.

Heritage Medical Group, San Dimas, CA February, 1989 – December 1992

Medical Billing Supervisor

Managed 5 employees who performed the medical billing and collections – Supervised and trained medical billers/collectors –Performed computer operations regarding account receivable, payable and general ledgers.

Singer Co/Librascope Div., Glendale, CA March, 1982 – July 1988

Lead Production Control Coordinator

Supervised and trained inventory clerks, performed production planning and computer using APICS system.

U.S Navy, U.S.S Kitty Hawk (CV-63) August, 1977 – August 1981

2nd Class Machinist’s Mate (E-5)

Honorable discharge – assigned to the Engineering Department under Propulsion Steam Plants unit.

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EDUCATION:

University of the East (Manila, Philippines) – MBA – Operation and Supply Management – Graduated: April-2011

Azusa Pacific University (Azusa, California) – BS – Management Information Systems – Graduated: May-2002

Honors: Magna Cum Laude

Additional coursework/certificates of completion:

Networking (Novell/NT’s/SQL server); Oracle Developer; Oracle 8i DBA; Client Server Programming; Visual Basic Programming; VB, VB.Net, Visual Studio 2000/2005, ASP, Access; SQL

Application: Healthcare - QCARE, Erisco Facets, HSII, NICE/FOCUS, EZ-CAP, MACESS, IDX, CPU Business – Microsoft Project, Access, Filemaker v5/7, Word, Excel, FrontPage, Filemaker, Crystal Reports writer,

Adobe Photoshop, WordPerfect, Quattro Pro, Paradox, ER/Win and VISIO case tool

HIPAA Skills –

EDI ANSI X12 ANSI documents including NSF, 997, 270/271, 276/277, 278, 834, 835, 837, 810, 815,

HIPAA Compliancy (Privacy information, Security, Fraud, Federal/State rules and regulations)

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REFERENCES: Excellent references furnished upon request

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