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3201 41ST

LUBBOCK, TX 79413
phad430c@westpost.net
405-226-1164

SUMMARY: Results-oriented consultant with over 20 years of healthcare claims an


d information technology experience. Strong skills related to QNXT claims proces
s, auditing, recovery, training, benefits analysis and customer service. Experie
nced with multiple payer applications including AMISYS and FACETS and DIAMOND.

EXPERIENCE:
eHealth Partners, Atlanta, GA-Business Analyst, June 2009-December 2009
* Contractual assignment with eHealth Partners as Business Analyst.
* Provide project support for implementation of fraud prevention software, Blood
hound.
* Analyzed business requirements into functional specifications for IMPACT syste
m.
* Responsibilities included testing and technical consultations as well as proce
ssing of live claims.
* Configured provider contracts and benefits for Horizon Blue Cross on the QNXT
systems.

HP Technologies Inc., Phoenix, AZ-Business Analyst/Tester, February 2007-April 2


009
* AMISYS Quality Assurance Tester at Centene Corporation.
* This project involved several duties including development of test cases, test
plan, test scripts and unit testing.
* Conducted production audits of claims to meet federal mandated guidelines per
taining to National Provider Identification.
* Quality Assurance Management to insure updated NPI product met expectations.
* Performed Business Analyst functions to analyze and validate requirements for
changes to the business processes, policies and information systems.
* EDI formatting and audit analysis of incoming 837 reports.
* Developed benefits matrix for pricing and systems configuration.
* QA testing for Sunshine State Plan implementation.
eHealth Partners, Atlanta, GA-Product Consultant, September 2005- January 2007
.
* Beneficial in the implementation of QNXT for Blue Cross and Blue Shield of Mon
tana.
* Identified inconsistencies between HIPAA X12 834 code sets and QNXT membership
configurations.
* Resolved Blue Card/ITS claim issues for Blue Cross of Montana on the QNXT sy
stem.
* Investigated "problem" claims to determine root cause of configuration issues
with ITS. This involved working on the Host and Home side resolving all SF, D
F and RF edits.
* Responsible for troubleshooting various claim edit issues. This included reso
lving and correcting provider issues in the Provider Module. This required veri
fying that all provider information, including specialty and provider configurat
ion was correct. It also required adding providers if necessary. Also worked i
n the Carrier Module and Claim Code Finance Modules correcting any information t
hat was making a claim pay incorrectly.
* Instrumental in the development of a Claim Recovery Unit for Molina Health Car
e.
* Developed reports using the Report Administration that would be useful in tra
cking overpayments.
* Also trained staff on the different functions available in QNXT to aid in over
payment recovery.
* Developed simple easy to follow work processes for Claims Processing unit.
* Implemented and develop Coordination of Benefits program at Molina Health Care
using QNXT.
* Analyzed and configured plan benefits for Molina Healthcare Plan. This includ
ed verifying provider contracts as well as CMS website to insure correct claim p
ayments.
* Trained supervisors, as well as team members on the system.
United Health Care, Dallas TX, Claims Consultant, January 2005-September 2005
* Identified and recovered claim overpayments.
* Detected patterns of fraud and questionable billing practices.
* Conducted thorough investigation and research on fraudulent claims.
* Corrected system errors which resulted in claim overpayments.
* Provided technical support and identified areas for operational improvement, r
esulting in better, more efficient claim handling.

Perot Systems, Dallas, TX, Insurance Consultant, March 1997-December 2004


* Provided specialized insurance services to major insurance carriers and hospit
al including The Hartford Insurance, Blue Cross Blue Shield of Ohio, Cigna and T
he State of Louisiana..
* Configured group benefits for The Hartford on Pegasystems.
* Handled high dollar hospital and medical claims for The State of Louisiana on
IMPACT system.
* Plan documentation loading that included configuration of providers, contracts
, and pricing on the AMISYS system for Amerigroup.
* Updated and resolved claim projects involving payment issues on AMISYS system
for Amerigroup.
* Provided system support for ITS for and Blue Cross and Blue Shield of Florid
a. Resolving ITS edits. Creating SCCFs when necessary and also sending sirfs o
r inquiry to home or host plans.
* Provider pricing on the FACETS system for Blue Cross of Texas.
* Configured provider set up as well as pricing on the FACETS system for Anthem
Blue Cross of Ohio.
* Configured provider setup and contracts on the DIAMOND System for Blue Cross a
nd Blue Shield of Rhode Island.
* Plan documentation loading that included configuration of providers and contra
cts at Perot Service Center for several different clients including Wellpoint on
the DIAMOND system.

CERTIFICATIONS: QNXT 3.2 and 3.4 upgrade


TECHNICAL
SKILLS: QNXT, AMISYS, FACETS, Perot Diamond, CICS Processing System, LSRP, ITS,
MHS, Power MHS, QMAC, NASCO, MACESS, Microsoft Word, Excel, SQL, Business Objec
t

Education
University of Central Oklahoma, Edmond OK

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