|Desired Industry: Healthcare
|Desired Job Location: Nashville, Tennessee
||Date Posted: 7/12/2017
|Type of Position: Contractor
||Availability Date: 1 week
||U.S. Work Authorization: Yes
|Job Level: Experienced with over 2 years experience
||Willing to Travel: Yes, 50-75%
|Highest Degree Attained:
||Willing to Relocate: Yes
7 years of experience on projects related to Health Information Exchange (HIE), Interoperability, Medicare, Medicaid, EDI transactions (inbound and outbound: 837, 820, 834 etc.,) HL7, Eligibility and Benefit systems, ICD-10, HCPCS, CPT, HIPAA 4010 and 5010,Claims Adjudication and expert in Affordable Care Act( ACA), aka Healthcare Reform (HCR).
Experience in all the Latest BI Tools Tableau, Qlikview Dashboard Design, and Spotfire
Having extensive domain knowledge ¬in MMIS, EPIC, EDI X12, HL7, HIPAA, ICD-10, System, Medicare and Medicaid, CMS Compliances/Regulations.
Development of 820, 834, 837 Claim billing, 276 Status, 834 Enrollment, 835 Claim Payments, 829, 270-278 and many other healthcare maps.
Understanding of EDI business practice and the ability to understand the client's needs.
Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.
HIPAA related EDI development for 837, EDPS, 835 and other EDI processes using Pervasive EDI translator.
Worked on different EDI healthcare transactions like 834-Benefit Enrollment and Maintenance and 820-Payment Order/Remittance Advice.
Also 5010 Upgrade mapping for new B2B and existing B2B clients.
Involved in Facet Implementation and conversion of 4.21 and also in TriZetto Facets and TriZetto HIPAA Gateway 4.11.
Conducted internal audits and prepares audits reports to ensure compliance with Medicare, Medicaid and other institutions.
Knowledgeable for gap analysis in changing old MMIS and Involved in testing new MMIS.
Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR(continuity of Care Record), CCD(Continuity of Care Document),NCPDP Script 8.1, ELINCS, and CDA, HHS, CMS, RHIO's, IHDN's.
Expertise in Membership Enrollment, Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
Proficient in conducting Business process modeling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis. .
Designed and developed normalized, relational databases in MySQL.
SQL application management, (added users, created backup and recovery plans, ran SQL scripts).
Thorough knowledge of ICD-9, ICD-10 codes and CPT codes for both Mental and Medical Health.
Experience in Performance Tuning of SQL and Stored Procedures.
Exceptional knowledge in testing phases with state HIX projects.
Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
Involved in Facets Output generation, Interface development and Facets Migration Projects.
Excellent experience in developing and executing Test Procedures, Test Cases, Test Scripts, Test Plans, performing Functional Testing, Compatibility Testing, Usability Testing, Stress Testing, UAT.
Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall, Scrum and Agile
State of Maryland Health Department, Saint Charles-MD October 2015 Present
EDI Analyst/Business Analyst
Focusing on Medicaid and Medicare and provides managed care services exclusively for government-sponsored healthcare programs. Currently working on the HIX implementation for ACA and As a Business Analyst I was responsible to utilize ICD 10 within the healthcare claim process and modify all the impacted systems to adhere to the requirements.
Built an Information Security Risk Assessment (ISRA) for the secure exchange of health insurance data as part of the Affordable Care Act (ACA).
Responsible for implementing payers onto the Health Care Exchange (HIX) for the Affordable Care Act.
Strong working knowledge of the 834, 837 & 835 EDI Healthcare files and Transactions.
Thorough knowledge of ICD-10 codes and CPT codes for both Mental and Medical Health and worked extensively with Inbound and outbound 834 Transactions processing systems.
Compile, validate and report system-wide metrics to attest meaningful use of EHR to the Centers for Medicare and Medicaid Services.
Created, altered and implemented T-SQL Stored Procedures for the use of processing consumer data and developing new web delivered tools.
Collaborate with federal clients (CMS, NIH, ONC) and standards development organizations such asHL7 to develop
Responsible for UAT project planning like creating testing scenario, test plans, and test scripts.
Assisted JAD sessions to identify the business flows and determine whether any current or proposed systems are impacted by the EDI x12 Transaction, Code set and Identifier aspects of HIPAA.
Gathered the Requirements for Medicare Systems as part of Patient Protection Affordable Care Act (ACA).
Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
Performed Regression, UAT, Integration, User Interface, GUI, and Usability Testing and wrote test cases and test scripts, execute test scripts and analyzed outcomes.
Generated and maintained SQL Scripts to perform back-end testing on the oracle database.
Produced customer functions, complicate SQL commands in Business Object Enterprise XIR2 and Oracle 10g, Crystal Reports XI environments.
Assist clients in resolving billing issues for Medicare, Medicaid, and private insurance.
Involved in creating sample mappings for the conversion of EDI x12 transactions code sets.
Acted as an SME on various subject areas including state reporting, death benefits, Medicare, Bill review and RX eligibility.
Troubleshooting utilizing CPT4 & ICD-10 codes and Managed HL7 interfaces for PM/EHR software and Lab computers and performed requirements gathering, business process mapping and re-engineering as a part of health exchange readiness efforts for leading public health plan entering state HIX market.
Involved in HIPAA/EDI Medical claims analysis, design, implementation and documentation.
Developed various test cases for testing HIPAA 8371/P/D 834/835 and 276/277.
Ensured that the Pre-UAT activity is performed accurately and efficiently.
Wrote test plans and tested individual transactions for Medicare / Medicaid transactions (835 and 834).
Environment: SQL Advantage, MS Visio, MS Word, Clear Case, Clear Quest, Agile. Tableau, Qlikview Dashboard Design, and Spotfire
UML Tools Rational Rose / Microsoft Visio / Enterprise Architect 4.0/Provision
Requirements Management Rational Clear Case, Requisite Pro, SharePoint, Use cases, User stories
Databases Mainframe, Oracle, DB2, MS Access, SQL Server,
Methodology Waterfall, RUP, SDLC, UML, Agile, JAD,
Web Design HTML, DHTML, XML, CSS, XSLT, Tableau
Front end tools Microsoft Project, MS Visio
MS Office Tools MS Outlook, MS Word, Ms Excel, MS Access, MS PowerPoint
Operating Systems Windows 95&2007, Windows 98/2000/XP/Vista/7, Mac OSX, LINUX, DOS
Project Management MS Project (Gantt charts), Excel spread sheets
Change Management Stakeholder Analysis, Change Classification, Prioritization & Implementation
Candidate Contact Information:
|JobSpider.com has chosen not to make contact information available on this page.
Click "Contact Candidate" to send this candidate a response.