Description
Twenty plus years in healthcare management and staff support roles in handling medical, claims encounter and dental claims processing, claims auditing, user acceptance testing, EMS billing, AAPC, DRG coding reimbursement, and configuration of various healthcare payers/providers for Medicare, Medicaid, TPA, and Commercial Managed Care products. Strong understanding of healthcare business operations, with a focus on configuration analyst, implementation, recommendations, business process, gap analysis. Knowledgeable in all line of businesses, whole claim systems, claim processing’s, claim auditing, claim testing, benefits and provider contract logic configuration and implementation. Configuration benefit plans for Medicaid, Medicare, HMO, PPO, POS and HSA all federal exchange procedure and guidelines. 10 years of experience with configuring provider pricing, benefits, authorization, membership, claims, and edi on DIAMOND, XCELYS, QNXT 3.2 Certified, METAVANCE, AS400, NASCO, AMISYS Advance, RIMS, and FACETS claim software systems. 3 months training on IKACLAIMS System. Work on various other software, including OHI CMM2 (UAT testing healthcare - Benefits), ran macro, and SQL queries for testing/root cause analysis. Utilize IDX an analyzing healthcare providers. Created trading partners in software applications, and EDI XML/X12 (837 Professional and Institution outbound files). Utilize enter data in HIP, Ingenix to create 5010 HIPAA compliance files, and set-up trading partners. Analyze data of the EDI XML/X12 837P & 837I files. Work with engineers to re-test defects and document my findings. Analyze, research customer’s business requirements, and root cause analysis all modules, objectives. Support in created test case scenarios, use cases, user story, and user acceptance test data for institutional and professional claims. Initiative in supporting the module office testing configuration, and business implementation efforts. This included all Line of Businesses, Medical, Behavior Health, Dental Claims System, Encounters, Authorization, Benefit, Eligibility, Provider, Vendor contract pricing, and Provider Capitation. Ran macro, SQL server queries and document finding in Quality Center (ALM).
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