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Jessica Claire
, , 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary

Experienced Senior Business Analyst highly organized, methodical and skilled at overseeing daily milestones along with meeting stringent deadlines to promote corporate initiatives. Ability to multi task from successfully taking a project from the initial stages to completion. Comprehensive experience in identifying and analyzing areas of potential risk including, but not limited to identifying unusual variations and assessing the impact of changes; Excellent quantitative and critical thinking abilities paired with basic knowledge of rational database to effectively synthesize data from multiple sources into sound business decisions with accuracy; Can work independently with limited or no supervision. Strong work ethics and leadership skills in relationship building and project management, foster a working environment that is accountable and transparent through communication. Ability to leverage technology

Skills

MS-Excel and rational databases/SQL Server, MS-Access, Business Objects, GeoNetwork, Siebel, InfoMaker, and other MS Software, CPT-4/ICD-9/HCPCS, Health Connect (Network Comparison), NDB, Diamond, Orbit, Health Care Economics (Cognos), Yoda/Pulse, Lotus Notes, Examiner, Phycon, Emptoris, MCO, PHIL (AlphaCare Creation), Care Compass, Cactus, Mosaic, Facets, PUMA, Integrated Provider Database (IPD)

Work History
04/2014 to Current
Sr Network Business Analyst Sevan Multi-Site Solutions Las Vegas, NV,

Working within a high degree of independence, having strong technical capabilities in production data loading, querying and monitoring, oversee its validation and organization in support of Network Management and Operations. Continuously support quality improvement, network adequacy standard, and compliance with regulatory requirement for NYSDOH, CMS, ACHA, DMAS and other reporting for Network Adequacy Standards for SOX and HEDIS). Process improvement, P&P and desktop guidelines development

Responsibilities:

  • Responsible for weekly, monthly and quarterly report to support network adequacy and claims reporting, including responding to any deficiencies received from state (PNV, NSRM, PNDS, MLTC, FIDA & MMP products); participating in audits regarding quality management in supplying data and corresponding document to supporting SOX and HEDIS audits
  • Create and writes SQL queries to extract required data mining task for extracts for Network Management, including but not limited to support for PNV, online Provider Directory (POD) and other Ad-Hoc reports
  • Updating fee schedule rate changes for both providers and facilities, including new code add; code termination, IC code update, NPI updates, New facility add/termination and FQHC and RHC updates in support of claims and Network Management and other operational platforms, insuring quality and accuracy for configuration
  • Uploading monthly delegated rosters to to MCO system via PHIL (Provider Health Information Loader) application
  • Create weekly report from Cactus to support loading of newly credentialed provider (true paperless loading)
  • Develop P&P, Process Improvement and Desktop guidelines to facilitate department with functional workflow and guidelines to support quality audit on provider loads and configuration and credentialing
  • Configuration audit for accuracy and completion for capitation, fee for service, APC, DRG and bill above codes
  • Department management in absence of Director
05/2009 to 04/2014
Project Manager United Healthcare, UHG City, STATE,
  • 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
09/1996 to 05/2009
Sr Strategic Business Team Lead, Physician/Hospital Group Health Incorporated/Emblem Health City, STATE,
  • 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
Education
Expected in 2013
: Green Belt Certification
UHG Training - New York, NY,
GPA:

The Six Sigma Green Belt operates in support of or under the supervision of a Six Sigma Black Belt, analyzes and solves quality problems and is involved in quality improvement projects

  • Completed professional Certification in Six Sigma Green Belt
Expected in 1996
: Computer Operator
Resource Enterprises Computer Training - Brooklyn, NY,
GPA:

Completed professional development in Windows, Lotus 1-2-3, Excel, WordPerfect6.1, Word6

Expected in 1995
Bachelor of Arts: Politics Philosophy & Law
Binghamton University - Binghamton, NY,
GPA:

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School Attended

  • UHG Training
  • Resource Enterprises Computer Training
  • Binghamton University

Job Titles Held:

  • Sr Network Business Analyst
  • Project Manager
  • Sr Strategic Business Team Lead, Physician/Hospital

Degrees

  • Bachelor of Arts

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