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Click here or scroll down to respond to this candidate Candidate's Name
Street Address Alveston Dr./Atlanta, GA/Candidate's Name @msn.com / PHONE NUMBER AVAILABLE
B U S I N E S S A N A LY S T / S Y S T E M C O N F I G U R AT I O N /T E S T I N G / A U D I T
Accomplished and results driven professional recognized for professionalism, commitment to
excellence, and demonstrated ability to communicate and work with senior management,
associates, and customers. Has an excellent interpersonal skill, able to collaborate effectively
with co-workers at all levels. Self-motivated and can work independently or in a team. Broad
based qualifications include:
Technical Qualification/Skills List:
Knowledge of Procedure and DRG related impacts for ICD-9 & 10
7 years of experience working with SQL on various projects
12 years of experience with Data Profiling/Data Modeling with configuration
Experience using PTC Windchill Life Cycle Management tool for migration and
iterations
Experience using Apex extraction tools.
Experience in HP, ALM tool to resolve UAT defects. Identified medical coding (ICD-
9/10 gaps, CPT)
Utilizing Rally Agile and Scrum Life Cycle Management tool for system configuration
and updates.
Experience in benefit configuration, claims processing, unit, UAT on NASCO, Q-Blue
(QMACS), MCS, QNXT, FACETS, ITS, QCARE, Metavance, Epic/Tapestry, and legacy
systems.
Adjudicated in EEC. Used HRBK in Nasco to make updates to the Benefit File.
Used the RBRVS (Resource-Based Relative Value Scale) for Benefit codes for group
plans under Medicare, NASCO and commercial providers.
Assignment of Employer and Provider Group plan codes, CPT, HCPCS II, ICD-9, ICD-
10, DSM-IV coding. Claims processing in real-time. Tested Benefit Specification Codes
and Medical Codes in Testing Environment prior to Migration to the Production region.
Queried claims in test and reported any errors. Submit claims in RTCP for actual
processing
AS-400, NASCO, ITS, QNXT Benefit and Provider Pricing File, QBLUE, QCARE,
GenC, NCN, METAVANCE, MCS, MHS, NetworX, and AMYSIS
Facets configuration for benefits, claims, membership and enrollment for new
implementation and enhancements.
Facets claim processing for benefit validation and defect management.
Edited and Entered DRG rates, global rates, outliers, outpatient groupers and ER rates
according to provider contracts. Revenue code assignment into fee schedules. Inpatient
Billing.
Worked Problem Logs (P-Logs). Used the ODL onto the EEC Worksheet and OLRX
Application.
Adjudicated and process claims in EFDE, HEHK, and HEUK (EEC). Used the Message
File (MI) to enter internal notes.
Edited and entered provider contract codes on various software. Used HINQ in Nasco.
Processed HMO, PPO, POS, ASO, self-funded, Cafeteria plans, Capitation, and EPO
claims.
Entered CMS fee schedule tables on contract files and benefit file plan summaries.
Billed secondary and Tertiary insurance carriers. Followed up/Collected on Self-pay,
Medicare/Medicaid and Commercial Insurances using HBOC Stars and HANS system.
Processed secondary insurance claims. Processed claims using Medicare, CMS 1500 and
CMS-1450 Claim forms.
Experience with EDI 835/837, 834, 270/271, 276/277 and accumulators, HIPPA 4010 and
5010.
National Claims processing through various In and Out of State providers. ITS and
BlueCard
Interpretation of Claim edits for adjudication. Utilized McKesson Claim Check for
correct coding.
A/R functions utilizing Lawson. Posting payments, claim adjustments and creating
account receivables to recover and track overpayments.
HR functions using Lawson and Vanguard for open enrollment and new hires.
PROFESSIONAL EXPERIENCE
Sr. Business Analyst/Testing/System Configuration/Claim Processing
Kaiser Permanente Remote Aug 2014-Dec. 2015
Unit Testing for Component Group (CMG) system updates
Validated System Configuration
Validate ICD-9 and ICD-10 codes Crosswalk for system compliance
Create Test Scenarios Validate ICD-9, ICD-10, CPT and HCPC codes
Audit Benefit Plans and Benefit Component Groups
Execute Test Claims using EPIC
Running SQL queries to validate benefit configuration
Benefit Configuration using Excel and Benefit Enhancement Tracking System (BETS)
Updated configuration of limits and accumulator rules.
Defect Management and UAT using HP/ALM
Claim processing utilizing test data.
Quality Analyst/ Defect Management/System Configuration/Claims Processing
Harvard Pilgrim Healthcare Quincy, Mass. Mar 2013-Sept 2014
Audit customized medical, dental, and vision product builds to validate accuracy of benefit
specifications prior to migrating to the systems testing region.
Tracking Build schedule to delegate Quality Control Audits.
Advised builders of the errors in configuration that required corrections.
Validated configuration to ensure accuracy for migration.
System configuration by coding benefit specifications in Oracle Health Insurance (OHI)
development region.
Validate UAT test case scenarios.
Evaluated defects identified by UAT team members using HP/ALM
Research and resolution of defects by either disputing defect or updating configuration using
HP ALM tool.
Manage Product Builds using Rally Agile tool and PCT WindChill.
Systems utilized were AMYSIS and OHI this involves complete knowledge of AMYSIS
claim adjudication for conversion to OHI.
Claims processing
Validated plan benefits, limits, and accumulators configured correctly to insure correct claim
adjudication and customer service operations.
Business Analyst/Claims
BCBSMA Remote Jan 2011-Aug 2012
Prepared and wrote Conceptual Specific Design (CSD) documents for Large Scale
Implementation (LSI) from local system for migration to NASCO.
Served as a liaison for IBM/Cognizant and BCBSMA.
Facilitated stakeholder meetings for JAD sessions, gathering and writing requirements,
Technical Design Review (TDR) walkthroughs that included 837 mapping, MDE
transactions.
Worked with Membership Business Analysts, HP and IBM Technical Teams on Metavance
Members Edge for Customer Requests on Claims, Finance, Plans and Reporting.
Created and monitored statuses of Customer Service Requests (CSR) from inception until
completion.
Researched Systems Specifications (Spec-View) in order to assist the Plan in determining
which new functionality was required.
Tested Professional and Facility medical claims using Nasco system.
Identified defects and errors on claims to allow adjudication.
Gathered requirements and ensured that expected results were obtained to successfully
finalize claims.
Monitored CSRs to update and watch progression to insure time lines were met. (SDLC)
methodology.
Triaged and monitored Defects after system updates were made Model Office (testing region)
using HP/Quality Center.
Aided in training team members on LSI procedures in PDM, CSR, Defects and CSD.
Performed Impact Analysis of ICD-10 Coding and Reporting Regions to system change
scheduled for deployment.
Utilized NShare to access resource materials and documentation.
Benefit Configuration/Benefit/UAT/Claims Processing
WellPoint/Anthem BC/BS Remote Jan 2010-Dec
2010
Used HRUK in Nasco System Configuration to update benefit strings and create Ded/Max
files for new and existing groups.
Executed a Gap Analysis between NCN, NASCO CSR, and BTRD for non-par provider
discount program.
Handled claims processing using EFDE and EEC in NASCO and FACETS
Reported inconsistencies between business/technical requirements for implementation team.
Update Plan configuration to insure member and family accumulators and limits reflect sales
contracts documents.
Created test scripts and scenarios.
Tested and validated claims for ded/max, accums, and lifetime max, coinsurance, and other
out of pocket expenses for GenC and Membership project using Metavance.
Reviewed and audited of E.O.B. to validate accumulations, payment and provider checks.
UAT testing and Regression testing on Nasco. QNXT and Facets claims processing and
provider pricing for small group products line of business.
Created benefit grid design test scripts for template involving researching the most current
provider contracts for accuracy. This process involved creating test cases for all eligible
providers of service.
Execution of test cases documenting expected and actual results and the recommended issue
resolution for any defects resulting from the execution of the test.
All line of business that included PPO/PFFS, HMO, Capitation, Medicare
Advantage/Medicaid, and Medicaid, Managed Care.
Validate Limits and Accumulators for correct claim processing and adjustments.
Review and update accumulators to plans that were configured incorrectly.
Test execution for all providers of service included inpatient and outpatient providers, PCP
providers of service, independent laboratory and radiology providers, ambulatory service
providers, DME service providers, and Skilled nursing home services provided by VNAs
such as physical therapy etc.
Clean up claims backlog processing and adjustments in Facets
Business Analyst/Medical Coder/Benefit Configuration/Claims Processing
Horizon BC/BS of NJ and BC/BS of MI Remote/Southfield, MI Sept 2007-Dec
2009
Updated group benefit files for Mental Health and Substance Abuse as mandated by the
Federal Government.
Tested mental health and substance abuse claims to insure that same guidelines as
Medical/Surgical.
Processed and Adjusted live claims for backlog.
Applied experience in mental health and substance abuse claims as well as knowledge in
DSM IV coding
Tested Claims using NASCO for dedicated groups.
Used HRBK in Nasco System Configuration to make changes to Benefit File. Accumulated
benefit codes in benefit file to calculate correct benefit services.
Utilized extensive knowledge of benefit grids, summaries, group booklets, contracts and
benefit group coding.
Analyzed Nasco benefits by group, package, and section.
Uploaded benefit codes to repository and tracked benefit codes in test environment after
loading to repository.
Derived accumulation rules from uploaded PDF. Files and from management.
Tested benefit codes in queries. Converted to benefit Mnemonics.
Reported information to project managers and software configuration department.
Benefit Coding P-logs for National and Corporate Groups.
Updated Benefit, Limit and Accum Strings.
Review Benefit Tables and NAEGS.
Knowledge of Benefit File Mnemonics, Grids and Booklets.
Successfully completed Analysis of Medical Coding and Prior Authorization Requirements
within the Q-Blue System (QNXT) and Nasco Database for all lines of business.
Completed Comparisons of the for the NJ Future, DOBI, Contract, and Systems lists.
Identified the inconsistency in Coding and Reports for all PPO, POS, HMO, Medicare, and
Indemnity Products on Q-Blue, QNXT, NetworX, and Blue2.
Prepared Reports for all POS, PPO State, and Direct Access and Fully Insured groups on
Nasco.
Identified and prepared all required coding updates for all products for IT for both Nasco and
Q-blue systems.
Updated Project Tracker with findings and completion Prepared Weekly Status reports for
management.
Successfully met all deadlines and updates as requested.
Implementation UAT Testing/Claims Processing
EDS Oklahoma City, OK Mar 2009-Jun 2009
Tested and Processed Professional, Facility and dental claims for client using Metavance.
Processed live medical claims, facility and dental using Metavance 2.8. meeting all
production standards.
Gathered dental benefit documentation and requirements.
Distinguished accidental dental, medical dental and dental Codes.
Corrected dental codes and reported systems errors.
Made recommendations for system upgrades and enhancements to IT staff.
Created test scenario templates for UAT test execution on the Metavance system for lines
of business that included PPO, HMO, Medicare Advantage/Medicaid.
Execution of test process included full documentation for expected and actual results and
issue resolution for defects found.
Utilized Medicare CMS for fee schedules and trailblazer and also, provider contracted
specific and ala carte benefits.
Provider of services included all facility services, specialty providers and PCPs.
Psychiatric Claims Specialist/Audit
Magellan, Columbia, MD Dec 2006-Sept
2007
Responsible for coding, audit and adjudicating psychiatric claims using QNXT, Nasco, and
AS-400.
Claims processing meeting all production and quality standards.
Processed backlog of claims for outstanding receipt dates.
Managed audit of contract benefits for limits, pre-authorization requirements.
Handled processing and adjustment of claims for Horizon BC/BS.
Loaded and updated pre-authorizations for NJ State employees.
Validated provider credentials.
Priced and reviewed benefit maximums
HMO, POS and PPO mental claims adjudication.
Successfully completed assignment meeting all required production standards.
Successfully met all DOI deadlines for 1st submission receipt dates.
Group Membership/Recovery Analyst/UAT/Claims Processing
BC/BS of NC/Cahaba GBA Feb 2005-Dec 2006
Responsible for membership conversions from legacy system to Power MHS and AMYSIS
for specific product lines of business.
Accounted for system configuration for New Group membership, benefits, and enrollment.
Processed unsolicited and solicited recovery of over payments from providers and
subscribers.
Posted payments, claims research and adjustments on MCS, Facets, Nasco, and Power
MHS
Created, posted and tracked A/Rs utilizing Lawson for overpaid claims.
Managed COB with BC/BS and Medicare, MVA, W.C., and other commercial carriers.
Audited claims for coding reimbursement accuracy. Benefit Coding.
Researched/investigated and documented expected results and actual results regarding
system functionality when a claim is processed and an error resulted against current and
newly implemented benefit configurations using Amysis.
Researched provider contracts and benefits for accurate pricing and benefit information
pertaining to the specific procedure code and type of service.
Validation and/ or updating of accumulators in benefits plan configuration.
Review of claim history to determine if limits and accumulators were calculating within
the system correctly.
Review of year end carry over deductibles for accurate accounting.
Claim testing/auditing, research and investigation of benefit grid design.
Documented results via Project tracking tools (Access and Excel).
Tested current CPT codes, ICD 9 codes along with HCPC codes.
Ensuring correct payment allowance for services.
Benefits Specialist
Crawford and Company Atlanta, GA Dec 2004-Feb
2005
Processed medical and life insurance 401k enrollment applications using Lawson and
Vanguard
Reviewed member eligibility, billed premiums, and setting payments schedules for payroll
department utilizing Lawson.
Handled heavy phone contact with employees and new hires regarding benefits,
compliance and underwriting regulations.
Notifying payroll for deduction changes for open enrollment and new hires medical, life
and 401k plans.
Reverse adjustments to notify payroll for deductions made in error.
Benefit Coding and Underwriting Part-Time
AIG Alpharetta, GA Nov 2004-Feb 2005
Performed claim review, audit, suspense edits and adjudication.
Forwarded claims for nurses review.
Handled facility and professional coding.
Processed Workers Comp claims.
Met all requirements.
Medicare Recovery Analyst MCS
BC/BS of AR Little Rock, AR/Trailblazer Dallas, TX Nov 2003-
Nov 2004
Handled disability, ESRD, and liability claims.
Posted solicited and unsolicited over-payments.
Set up A/Rs and Research Medicare Part B claims.
Handled adjustment and processed suspense claims.
Audited VA, W.C., MVA, Set up A/Rs against overpaid providers and beneficiaries.
Identified fraudulent claims and prepared written correspondence to recover thousands of
overpaid claims.
Reduced A/R considerably by posting payments timely and accurately, claim adjustments
and claims processing.
Senior Claims Rep. /Provider Network Specialist
BC/BS of GA Atlanta, GA Feb 1999-Jun 2003
Reviewed, processed and adjusted Managed Care Claims including PCP Capitation.
Assisted co-workers with medical policy coding issues.
Specialized in high-dollar cancer claims and chiropractic claims in excess of over
$100,000.00 monthly with 100% accuracy.
Processed Facility claims and validated pricing.
Monitored that claims were paid according to contract limits.
Ensured that deductible and out of pockets expenses were calculated accurately.
Claim audits and troubleshoot for provider contract updates. Bulk Claim adjustments.
Accounted for monthly reports and spreadsheets to Department Director and senior staff.
Trained staff on operations and database.
EDUCATION
BA Healthcare Information Systems
Ashford University Anticipation Graduation 2018
Professional Medical Coding:
Natl Medical Coding Institute, Atlanta, GA 2002
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