Consultant Role Analyzing Infrastructure Resume Profile, USA

Reference Id: 70165     Posted on Thursday 30th July 2015      Healthcare Technologies

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Consultant role analyzing infrastructure Resume Profile, USA


  • Over 18 years of experience with various types of Healthcare organizations Insurance plans payers hospital administration Medicaid MCO and healthcare consulting firm
  • Certificate in Fundamentals of Business Analysis from Boston University Strong knowledge of SDLC and demonstrated experience with several IT projects
  • Over 8 years of experience in Business analysis in different settings methodologies and organizations working on IT projects
  • Strong understanding of system flows integration of various parts that impact a system from a business perspective
  • Strong experience with documentation of requirements business process flows and creating test cases
  • Two years of experience as Claims SME for implementation of Claims Management system a web based Service Oriented Architecture NewMMIS for the State of MA
  • Collaborated with business process owners to identify opportunities defined or gathered business requirements and design and implement solutions designed to maximize efficiency and productivity
Confidential April 2011 November 2011
Consultant role analyzing infrastructure and revenue cycle management of Local Health Departments LHDs of New York State Analysis of compliance aligned with revenue cycle to maximize revenue and reduce costs

  • Prepared business requirements narrative report for client New York State health Department
  • Analyzed business processes compliance Claims and revenue cycle of six local health departments of New York State
  • Identified obstacles and challenges to efficient billing practices and offered recommendations
  • Created a sample workflow based on requirements best practices and recommendations
  • Compiled reports for each site summarizing findings and recommendations for each county This allowed them to make immediate changes
  • Prepared SWOT analysis based on findings and recommendations of on site assessments
  • Researched information on Compliance of NYSDOH rules and regulations and best practice methods for infrastructure and operations of a health clinic
  • Conducted research on industry practices defining business requirements planning and writing documentation for Client performing analysis and offering solutions for existing processes
Claims SME role in implementation of a web based SOA Claims processing system New MMIS New Medicaid Management Information system developed by EDS

  • Created test cases based on business knowledge of claims cycle and claims operations and integrating system requirements
  • Integrated business and technical knowledge of different subsystems into Claims adjudication This resulted in more comprehensive testing and accurate claims adjudication
  • Applied business knowledge and business rules service limitations payment policies of DHCFP and reduced errors of claims processing
  • Consulted with business users developers and created and executed functional regression and smoke test cases and ensured accurate claims adjudication and system function

Sr Contract Analyst Reimbursement and Contract Administration
Key role in configuring provider contracts into claims processing system for Medicaid MCO Key role in configuring Benefit plans business rules payment rules and limitations into implementation of new system HealthTrio

  • Managed Payment Policy Project plan to ensure compliance with governmental regulations DHCFP and aligned provider billing practices with Network Health s payment methods This communication resulted in increased accuracy of claims billing and payments and improved provider relationships
  • Provided guidelines of system capabilities and limitations with Contracting department for better alignment of contract terms i e carve outs and accurate claim payments Reduced provider complaints by 50 and reduced manual intervention of claims adjudication
  • Audited and tested claims activity to ensure assimilation of contract terms
  • Increased membership from implementation of Commonwealth care product by ensuring efficient implementation of fee schedules and reducing claim payment errors
  • Lead role in documenting of new configuration processes resulting in reduced errors by 80

Business Analyst International Operations
Managed and analyzed patient demographic and financial information for Confidential Mass General and Brigham and Women s Hospitals created this area to market and manage hospital services to International patients of VIP status

  • Analyzed International patient data and revenue for profit and market analysis resulting in expansion of new markets and increased revenue
  • Audited claims activity by diagnosis treatments and patient demographics for analytics reporting
  • Reduced data collection and merging efforts by 50 from two disparate hospital databases resulting in more accurate financial reporting of revenue of International program

Project Manager Product Implementation
Lead role in new product implementation that reconciled and recovered capitation non payments or partial payments to various medical groups Leadership role in all aspects understanding the application from technical and business point of view product enhancement building and enhancing processes team building managing client relationships documentation of a new business unit built around a product developed by Terahealth

  • Audited Claims activity of several clients for capitation overpayments and recovered 60 000
  • Identified and assisted with software enhancements resulting in increased efficiencies of analytics reporting by 30 Managed automation of data processing and reduced system run times by 90
  • Developed a team to create analytics and reporting for senior management

Business Systems Analyst
Analyzed business requirements for GUI application development for efficient monitoring licensing and registration of associates that replaced a manual process

  • Created and executed test cases for LARS Licensing and Registration based on functionality analysis resulting in reduced errors and improved functionality

Project Coordinator
Managed internal projects for senior management

  • Created an office management infrastructure to monitor profitability and develop income projection matrixes by analyzing and performing data and workflow analysis
  • Created matrix of employee skill sets and availability resulting in simplified assessment of PRT s ability to bid on and deliver projects that reduced effort time by 90

Business Analyst / Team Leader
Led new products/functions from inception to maintenance stage defined processes analyzed their applicability and enhanced them to meet anticipated needs resulting in time and money savings Lead a Team of National Account Geographic Specialists in analyzing and producing reports for RFPs and offered assistance to the team leader of the middle market and small market units

  • Acted as liaison between managed care customers and technical staff on post merger product overlaps and identification of disruption in service that assisted in retaining customers
  • Translated technical information in business terms for clients to assist them in developing a better marketing strategy that resulted in increased sales
  • Redesigned a provider database after extensive data analysis data mapping process mapping and work flow analysis
  • Revamped reporting methods to evolve with the product and remain competitive that increased sales
  • Increased report accuracy rate by 50 decreased annual costs by 60 000
  • Improved efficiency by streamlining processes that increased profit margin for managed care sales
  • Key role in the implementation of a new product / new business GIS application GeoAccess an analysis tool for managed care products
o Analyzed data prototyped processes and built documentation
o Identified product limitations and developed creative workarounds
o Developed requirements template that reduced effort time by 70
o Coached customers on concepts and applicability of managed care information analysis
Technical skills
Microsoft Office Microsoft ACCESS MS Visio Windows environments mainframe and midrange systems Oracle SQL SOA Claims processing systems

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