Sr Network Business Analyst Resume Example

• Project Management (June 2010 - April 2014)

Maintained approximately 15 large delegated NY hospitals delegated and non-delegated provider groups to tracked information and compiled data to improve efficiency and ensuring accurate provider linkage, and contract configuration. Developed and fostered strong business relationships to promote positive working relationship through communications with all groups via phone and/or email, bi/weekly/monthly meeting, which include group tracker of all submissions, external and inter-departmental inquiries and/or request.

Responsibilities:

• Provider roster audit via Examiner, Business Object & UHN Reporting
• Maintained current group rosters ensuring system platform are up to date for all Lines of Business
• Root cause analysis and problem solving for claims projects, which can include recoupment, while reined in project costs while meeting key milestones
• Physician Network Contractor (May 2009 - June 2010)

Developed operational methods to and grow competitive, stable physician network that achieved unit cost and trend management in an effort to provide affordable products to customers and business partners by fostering strong working relationship with vendors to promote positive working environment. Interpreted needs, utilizing effective communication and identifying solutions by analyzing problems problems and developing appropriate course of actions in project cost while meeting key milestones

Responsibilities:

• Serviced approximately 30 special deal groups, ensuring annual escalators, and new provider linkages updated, while fostering strong business relationships through personal attention to vendor inquiries and concerns
• Tracked vendor information and compiling data to improve efficiency ensuring that system platforms are up to date for al Lines of Business
• Established and contracted Brooklyn territory for all lines of business
• Completed SRs, ORs, AmeriChoice Tracker Items (Web mails) in timely manner to meet key milestones

• Sr Strategic Business Team Lead, Physician/Hospital Contracting (December 2006 - May 2009)

Created queries, analyzed and interpreted statistical data to conduct analytic projects; maintained network provider count by region for all lines of business, performed disruption analysis and network accessibility analysis and mapping as requested by Sales to support RFP; Created representative fee schedule for physician and hospital contracting, and managed provider deficiency based on DOH guidelines

Responsibilities:

• Created and maintained provider database and reports (HMO/PPO provider files, Ancillary/Facility and Rented Network), for corporate wide distribution
• Performed queries for extraction of monthly mainframe download and dataset queries, reports and statistical tests to meet contracting objectives
• Conducted complex analysis for interpretation of network and membership data to ensure appropriate reports for decision making are generated accurately and as scheduled
• Support Corporate Communication website files, working closely with IT, Provider Operation and Credentialing Departments to develop functional specification on required enhancements and improvements in network reporting, data collection, procedures and guidelines based on data findings including website initiatives
• Performed disruption analysis in support of RFI and RFP process, in development of new target network in strategic geographic location and assisted with preparation of network accessibility analysis and mapping; generating presentation quality tables and graphics for senior management and prospective clients while managing provider deficiency based on DOH guidelines
• Prepared claims utilization reports for providers to resolve claims payment issues based on contract error, mass adjustment and contract renegotiation
• Created representative fee schedule for use in hospital and physician contracting
• Fostered relationships with vendors to obtain information for competitive comparison network studies
• Collaborated with business users in use of databases and maintaining statistics, research methods and interpreting measurement findings
• Sr Supervisor, Adjustment (August 2002 - December 2006)

Prepared and maintain inventory cycle time report and production statistics; Created departmental operational guidelines and initiating coaching and feedback training program to facilitate production accuracy; Developed functional specification on system enhancement specification for system enhancements such as customer service intake system to standardize communication to providers and subscriber as well as inter-departmental stakeholders

Responsibilities:

• Supervised workflow of Approvers ensuring timely completion of product line to corporate goals
• Prepared and maintained daily, weekly and monthly inventory cycle time reports, production statics reports, attendance and payroll
• Created departmental operational guidelines and initiated coaching and feedback training program to facilitate accuracy and production enhancement based on corporate policies, procedures and initiatives.
• Outlined work plans implementation initiative to enhance to provider/ subscriber intake environment from Corpprod to Siebel in effort to standardize communication with clients including interdepartmental stakeholders. Collaborated with IT and vendor on font-end user experience and UAT testing.
• Created and oversee training program designed to utilized enhance intake environment, Siebel, to repurpose staff position responsibilities to resolve open provider/subscriber inquiry to support production standards and reporting
• Sr Auditor, Compliance (September 1996 - July 2002)

Perform regulatory and compliance audit for internal departments and vendors, prepared root cause analysis and created workable corrective action plan for training and quality assurance

Responsibilities:

• Performed operation, compliance and regulatory audits on claims, providers and vendors
• Performed pre-payment & Post post payment audit of claims coding, payments and high dollar check releases
• Prepared monthly & annual reports and root cause analysis on errors identified during audits and created workable corrective action plan for training and quality assurance
• Closely collaborated with project members in addressing Prompt payment violations. Developing project plans and managed project scope in tracking and prioritizing violations to identifying and quickly resolving issues to mitigate fees where possible