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Business Configuration Analyst Resume Example

Resume Score: 90%

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BUSINESS CONFIGURATION ANALYST
Professional Summary
Driven, energetic and hardworking Business Configuration Analyst with over twenty eight years in the healthcare insurance industry.  Experience in claims processing, training and auditing, lead customer service representative, provider relations and contract building.  Well-qualified in all lines of business from TPA, PPO, POS, HMO, Medicare and Medicaid.  Working knowledge of CPT, ICD9, DRG, HCFA and UB92 coding.
Education and Training
Glenpool High School GraduateGlenpool, OK
Skill Highlights
  • Business process improvement
  • Business systems analysis
  • Advanced problem solving abilities
  • Extensive medical terminology knowledge
Skills
Healthcare industry best practices, HIPAA compliance, HMO, indemnity, commercial, Medicare and Medicaid lines of business, policy development and implementation, quality assurance standards, Microsoft Excel, Microsoft Word, contract building, claims review, extensive Xcelys knowledge, team player
Professional Experience
Business Configuration Analyst04/2009 to CurrentKaiser PermanenteEnglewood, COConducts functions of the Business Configuration administration team which includes design, development and testing activities of all components with in the departmental scope of Business Configuration.  Executes and delivers the collection, interpretation, analysis, and organization of information and data necessary to deliver on established organizational and departmental goals within the scope of responsibility.  Participates in cross functional team focused on performance improvements needed in HPSA operations.  Executes on activities to integrate knowledge of business drivers, operations, information technology, change management, strategic and tactical planning in support of key business initiatives.  Developed DLP and workflow for provider contracts within Xcelys.
Claims Trainer11/2008 to 05/2009Kaiser PermanenteEnglewood, COTrained employees to understand and learn the Xcelys claims processing system.  Developed all training materials, in both hard and soft copies, organized and presented hands on activities, drafted job aids for the claims adjudicator department
Claims Examiner/Senior Claims Consultant09/2005 to 10/2008Employee Benefit Management Services/Mountain States AdministrationAurora, COProcess medical, dental and vision insurance claims adhering to contractual language and negotiations.  Review medical records to determine medical necessity based on standards of care.  Respond to customer inquiries regarding claim status and verification of contractual language.
Customer Service Representative12/2004 to 03/2005Admin OneTulsa, OKResponsible for answering a high volume of calls from enrollees and providers regarding plan benefits,  HRA accounts, and claim payment inquiries.  Analyzed and resolved issues or concerns regarding claims processing.
Claims Trainer/Auditor07/2004 to 12/2004Community Care HMO of OklahomaTulsa, OKDeveloped and maintained an aggressive training program for new and established employees in a department of thirty associates.  Analyzed documentation to determine where additional training was needed.  Provide answers to all claims related questions from all associates.  Performed auditing of claims auditors.  Conducted software quality testing.
Provider Relations Representative08/2001 to 02/2004Schaller Anderson of Oklahoma LLCTulsa, OKResponsible for developing, contracting, maintaining, and strengthening the provider network in accordance with the plans' requirements.  Provided onsite training and education to physicians, facilities, and office personnel.  Worked closely with providers to resolve claim and contractual issues.  Responsible for monitoring provider and vendor compliance on access, quality and member satisfaction.  Interact with other departments to resolve problems for physicians and facilities.  Prepare monthly reports regarding provider network, specified needs, and trends in complaints, denials and utilization monitoring.  Researched and negotiated financial analysis for contractual evaluation.  Created correspondence to disseminate information and address specific issues and problems.
Reciprocity Claims Specialist05/2001 to 06/2001Blue Cross Blue Shield of OklahomaTulsa, OKAdministered benefits for multiple lines of business in a production environment.  Closely monitored performance group claims to meet contractual requirements, minimizing penalties imposed upon plan.  Maintained less than 5% in non-conformance.  Undertook special projects to assist management.  Accountable for claims adjustments, problem analysis and communication with other plans regarding claims issues and payments.
Claims Trainer/Auditor02/2008 to 05/2001Blue Cross Blue Shield of OklahomaTulsa, OKTrained associates to achieve effective and efficient claims processing.  Maintained and reported daily audits and performance audits.  Implemented and evaluated documentation to help provide accurate, current claims adjudication guidelines.  Addressed associates' inquiries.
Customer Service Representative08/1996 to 02/1998Blue Cross Blue Shield of OklahomaTulsa, OKResponsible for answering high call volume phone lines to provide assistance for enrollees and providers.  Addressed benefit coverage, claims payment inquiries and provider information.  Analyzed and resolved issues or concerns regarding provider network or claims processing.  Responded to written inquiries submitted by providers and members.  Promoted to group leader representative based on the ability to resolve complex and problematic issues.  Dealt with group's Human Resource representative to maintain customer service satisfaction.
Claims Examiner01/1995 to 08/1996Blue Cross Blue Shield of OklahomaTulsa, OKResponsible for claims adjudication for multiple lines of business in a production environment.
Chiropractic Assistant/Office Manager06/1989 to 06/1994Dr. Howard J Boos, D.C.Tulsa, OKResponsible for the smooth and successful operation of the physician's office.  Accountable for taking and developing X-Rays.  Maintained medical records including but not limited to insurance billing.  Managed both accounts receivable and accounts payable.  Interacted with insurance companies, attorneys, and patients.  Trained new employees.  Oversaw front office including scheduling appointments.  Produced daily reports of financial analysis.  Attended multiple job related seminars.
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Resume Overview

Companies Worked For:

  • Kaiser Permanente
  • Employee Benefit Management Services/Mountain States Administration
  • Admin One
  • Community Care HMO of Oklahoma
  • Schaller Anderson of Oklahoma LLC
  • Blue Cross Blue Shield of Oklahoma
  • Dr. Howard J Boos, D.C.

School Attended

  • Glenpool High School Graduate

Job Titles Held:

  • Business Configuration Analyst
  • Claims Trainer
  • Claims Examiner/Senior Claims Consultant
  • Customer Service Representative
  • Claims Trainer/Auditor
  • Provider Relations Representative
  • Reciprocity Claims Specialist
  • Claims Examiner
  • Chiropractic Assistant/Office Manager

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