yyyyyy x. yyyyyy 0000 xxxxxx xxxx , xxxx , xxxxx 00000
highly effective business professional with experience in medical assistance, hmo business and provider data/reimbursement systems development and analysis seeking a healthcare industry consulting role.
ø many years of experience in business development, regulatory compliance, program development, system analysis and client coordination.
ø strong analytical decision-making, oral/written communications and sldc capabilities.
ø effectively define, develop and execute operations to boost productivity and efficiency.
ø skilled in vendor and supplier coordination, problem resolution and cost control.
ø proficient in advanced business software including microsoft office suite, visio, clearquest, quality center, net meetings and sap.
hewlett-packard 2006 - present
business consultant iii
project lead for provider, pricing, membership and security teams designing metavance claim-based system for large dental client to meet various product requirements in multiple business environments.
ensure methodology satisfies client requirements for benefits, enrollment, contracts and claims.
maximize customer service, web, interactive voice response and document management functions.
effectively train team members on test script development and documentation, and maintain project issue and status logs.
identify/resolve issues to consistently attain project deadlines.
coordinate with programmers and business teams regarding data conversion and configuration.
analyze system capabilities, assist customer with desk-level procedure development and manage defects.
manage/prioritize issue logs and communicate status on project milestones.
immediately inform project manager of any potential delays.
provide enhanced system capabilities/solutions.
facilitate product testing and defect analysis.
ion health, inc. 2002 - 2006
system configuration manager and dpw systems liaison (2005-2006)
assisted director of operations with management of numerous major projects and monitored compliance.
project lead for implementation of drg into pricing system and systems liaison between state and internal staff and vendors.
key contributor in achievement of 837 certification.
initiated, managed and monitored all projects, training meetings and development activities for system configuration department.
spearheaded claims recovery project producing $1.09mm recovery from overpayments.
authored/reviewed business requirements critical to upgrade of system functionality.
- continued -
yyyyyy x. yyyyyy
business analyst i (2003-2005)
participated in development of metavance 2.3, capitation and cob systems, training manuals and compliance policies.
project lead for metavance 2.4 upgrade.
performed basic training for claims and um and assisted staff, customers and vendors.
assumed responsibility for training staff/departments on multiple elements of claims system.
developed provider data and pricing departments including claims system configuration with all training manuals and policies complying with state requirements.
pivotal player in development, testing and implementation of multiple subsystems including capitation and cob.
credentialing manager (2002-2003)
member of staff working with chief medical officer in developing team focused on verifying healthcare professionals credentials in order to operate as a managed care hmo.
established and implemented ncqa-compliant credentialing policies.
trained four personnel and credentialed over 500 providers.
achieved department of health approval for pennsylvania insurance license.
facilitated development of credentialing board committee consisting of local doctors.
led credentialing committee
newalliance health plan, inc. 2000 - 2002
performed ncqa-compliant credentialing process and prepared ncqa audits utilizing med staff application.
trained staff on the credentialing and re-credentialing process.
generated credentialing/provider-related reports from crystal reports, a first for newalliance.
prepared organization for ncqa audit resulting in an excellent accreditation.
prior to 2000, served as managed care support clerk, ashtabula clinic, inc., a newly developed assignment needed due to tac suffering claim denials from lack of provider credentialing/re-credentialing with various insurers. successfully obtained/monitored managed care, cms, and medicaid billing numbers for tac providers required for claims payment. coordinated communication among medical staff and providers ensuring hospital privileges were retained under jcaho regulations.
university of phoenix, associate of arts, information technology, 2010
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