Health Care Configuration - Healthcare Resume Search
Health Care Configuration - Healthcare Resume Search
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Health Care Configuration Resume


Desired Industry: Healthcare SpiderID: 76096
Desired Job Location: Las Vegas, Nevada Date Posted: 9/2/2015
Type of Position: Full-Time Permanent Availability Date: Immediately
Desired Wage: 100000
U.S. Work Authorization: Yes
Job Level: Experienced with over 2 years experience Willing to Travel:
Highest Degree Attained: Bachelors Willing to Relocate: Yes


Objective:

Detail-oriented and dedicated
professional with more than 25 years of
proven expertise in end-to-end
configuration, business and

operations analysis, and production
support in the healthcare payor and
medical insurance fields.

Proficiency in end-to-end
implementations including benefits,
providers, contracts, utilization and
medical management and operation

support
Extensive knowledge of health care
products, such as HMO, Indemnity, PPO,
POS, CDH, Medicare, and Medicaid, as
well as reimbursement

methods and CMS rules and regulations
and Healthcare Exchange plans
Go-Live and Operations support to
research and resolve configuration,
payment, and workflow errors
Adept in providing guidance and
leadership to high-caliber teams of
professionals honed from facilitating
training on various claim

systems, policies, and procedures for
internal workflow
Articulate communication and
interpersonal skills in building
positive work relationships with
professionals of all levels
Bilingual fluency in English and Spanish


Experience:

Professional Experience

TriZetto Corporation
Business Rules Configuration – Senior
Configuration Analyst 2014–Present
Provide exceptional support to client’s
production issues related to contracts
and benefits on both QNXT and Facets
Perform comprehensive research on
coverage guidelines and develop design
documents for new and existing benefits
and production updates
Carry out updates for all CMS code sets
including CPT and HCPC, ICD-9, and ICD-
10 on a quarterly and yearly basis
Take charge of configuring and updating
contracts and benefits, as well as in
initiating unit testing for benefits and
contracts
Expertly implement the configuration of
Commercial, Medicaid, and Exchange
Benefit plans

Molina Medicaid Solutions
QNXT Configuration Consultant / Post Go-
Live and Production Support 2013
Handled the configuration of benefits
and contracts for multiple state
Medicaid plans, production support, and
QNXT product management
Executed total claim audit to validate
accuracy of configuration, provider
payments, and claims processing
Offered continuous operations support on
fee schedule updates and CMS codes
Conducted proof-of-concept testing for
DRG and various payment methodologies
Formulated desk-level procedures and
presided over training of multiple
departments

Catalyst Solutions
QNXT Configuration Consultant –
Independent Living Systems 2012–
2013
Conducted data mining to identify
benefit needs for implementation of
Medicare and Medicaid waiver plans for
numerous states
Designed benefit plans, including
benefit coding for multiple state dual
eligible Medicare/Medicaid plans
Created test cases for user acceptance
testing (UAT) and model office for
various lines of business (LOBs)
Trained client staff in Utilization
Management and Benefit systems

Healthcare Information Management
QNXT Client Services Consultant 2007–
2009 | 2010–2012
Leveraged expertise in configuring
benefits for Medicare Advantage, ASO,
PPO, and POS LOBs in QNXT
Exemplified skills in identifying and
documenting benefit code sets, along
with troubleshooting and resolving
errors in claim

processing
Gained distinction for being retained by
clients to perform Medicare APG pricing
verification and research for Request
for Proposal

(RFP) processes
Assumed responsibility in gathering
business requirements, building
processes for new business
implementation, and
Built test scripts and tested different
processing systems and modules
Provided exemplary support in resolving
pending claims related to benefit errors
Rendered effectual support to the
following clients:
Bravo Health, Baltimore, MD
Offered production support to contracts,
benefits, and reference as identified by
client
Health Spring, Nashville, TN
Performed contract data mining, coding,
and configuration for Medicare plans
Created service groups to be utilized in
contract configurations
Facilitated of training for auditors on
QNXT utilization
Conducted annual updates for CMS code
sets
BCBS Montana, Helena, MT
Performed UAT, release, and regression
testing to support system upgrade
initiatives
Sisters of Mercy, Springfield, MO
Performed research and recommended
required changes to resolve system
errors
Adaptis, Seattle, WA
Made use of BPMN to determine and
document workflows for new healthcare
business
Configured Utilization Management System
including, template creation, and
service group development to support
case management
Handled the configuration of sponsor and
membership functions, which entailed
data mapping for membership data
importing and manually

entering new groups and members
Performed as part of the Stabilization
Team in managing critical updates new
business releases, as well as
coordinating with the

Configuration Team in implementing
changes before production roll out
Gem Care, Bakersfield, CA
Provided recommendations on UM workflow,
as well as guidance to users on the QNXT
process differences from legacy system

Comsys – HP
Business Analyst – Cigna Health Care
2010
Worked as part of a remote team in
charge of developing a global pricing
method

UST-Global
Business Analyst – WellPoint, Thousand
Oaks, CA 2009–2010
Developed use cases for technical
requirements and diagram workflows for
developers
Validated technical requirements for
traceability with user requirements
Led focus group discussions on user
interface requirements

BCBS Louisiana/FCG Consultant
Contract for ASO Client
Analysis/Consultant 2006–2007
Drafted comprehensive review of ASO
benefit plans to support standardization
and configuration
Gathered requirements for ASO contract
storage and comparison
Performed feasibility analysis on the
migration of ASO clients from legacy
systems to Facets

Proxicom
BPO Process Design and Implementation
2005–2006
Designed benefit plans and coding for
MetaVance implementation
Provided expert leadership to the
Business Analyst Team in preparing and
running test scripts and plans
Render oversight to data mapping,
requirement assessment, and gap analysis
for healthcare implementation
Took charge of sourcing data for IT
operations, developing benefit packages,
and initiating analysis and
configuration for reference

and controls



Earlier Career

Centene Corporation - St. Louis, MO
Senior Business Analyst – AMISYS
Configuration 2004–2005

DataQuest - Harrisburg, PA
Senior Consultant | AMISYS Configuration
Business Analyst (Contract with Axiom
Systems) 2004
Business Analyst (Contract with Highmark
BCBS) 2002–2003

IBM - Mechanicsburg, PA
Business Analyst – NASCO 2000–
2002

Infotrust - Chicago, IL
Amisys Implementation Consultant
1998–2000

Previous: Claims processing and
management, consulting, analytical,
management roles with various health
care insurance providers such

as InfoTrust, HealthCentral, First
Health, and The Travelers Insurance
Company


Education:

Education and Credentials

Bachelor of Arts in Business
Administration, Minor in Spanish
Westminster College of Salt Lake City -
Salt Lake City, UT

TriZetto Certified QNXT Professional


Affiliations:
-----


Skills:


Areas of Expertise

Configuration Design, Testing, and Error
Resolution ~ Claims Management ~ CPT,
HCPC, ICD-9 AND ICD-10 Coding
Business Process Identification and Flow
Charting ~ User Acceptance, Regression,
and Release Testing
Quality Assurance ~ Process Improvement
Strategies ~ Desk Level Procedures and
Workflows ~ Data Mining
Benefit, Pricing, and Contract
Configuration on Various Systems


Additional Information:

Training

QNXT Training and Certification | Facets |
EZ-Cap |SQL Server Query Writing


Reference:
Available upon request.


Candidate Contact Information:
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