Jayne Bacha Email & Phone Number

Houston, Texas, Us

Gathering requirements, documenting specifications, use cases, and work flows.

• Analyze and document the HIPAA 5010 requirements for the Web Portal application and XML transactions

• Analyze .NET application and identify key functionality for building J2EE framework for porting a .NET application to a J2EE-based application• Review application design documents; assisting development team in understanding business requirements• Liaison between development team and clients for technical design changes• Create and document test cases and use cases for the Provider Online Service Center and Member Online Service Center applications• Analyze and document the Professional and Institutional Claims DDE portlet requirements to ensure HIPAA compliance• Support technical team in researching and re-creating defects found during User Acceptance Testing and now in the Production environment

Us

Researching and documenting current business processes of the Centers for Medicare & Medicaid Services (CMS) for redesign of the Medicare Common Working File.

• Analysis of unit test scripts and model office set-up for PowerMHS upgrade.• Developed and implemented the testing process for the HIPAA 837 transactions, both institutional and professional claims.

Analyzed the PowerMHS system for Health Care Finance (HCF), focusing on fee schedules and facility pricing.Conducted team meetings for the MHS pricing conversion.Facilitated the PowerMHS testing of Fee Schedules and Facility Pricing scenarios and verifications for NYLCare conversion.Developed and implemented methods for PowerMHS system knowledge transfer and mentoring for Health Care Finance, Fee Schedules and Facility Pricing.Facilitated the mapping from GEMS to PowerMHS for Fee Schedules.Developed and documented the specific data maps between the GEMS and PowerMHS systems for fee schedules and facility pricing. Identified and documented mapping exceptions and a plan for exception handling. This also included data that needed to be manually keyed.Reviewed and recommended changes to existing provider contracts to improve/increase system efficiencies through automation of file maintenance and claim processing.Analyzed and documented the current provider contracts for the settlement process. Analyzed and documented the current process for claim fund classification. Recommended solutions for improving these processes

Philadelphia, Pa, Us

Developed and documented processes to maintain fee schedules on new system.Trained staff on fee maintenance process using Excel, Access, and PowerMHS.Analyzed claim suspends due to provider pricing and recommending methods for correction.Reviewed and commented on provider contract/fee schedule system modifications.

Developed specifications and business requirements for the PowerMHS segment on the Medical Management Data Warehouse project. Participated in database design, data mapping, and documentation. Tested the requirements using SQL queries to validate the data was mapped correctly.Documented the data source, description, and links for the PowerMHS and ARGUS tables/fields on the Data Warehouse.

Directed the claims and authorization meetings for the IDX to MHC conversion; analyzed policies and procedures; documented conversion issues; and reviewed the mapping process.Represented the Healthsource Managed Care business in the analysis of the Healthsource/CIGNA Provider systems.Supported VisualCACTUS users. On rollouts, set up server connectivity, ODBC drivers, and installed the application. Liaison with CTC on conversions, modifications, and enhancements required by Healthsource. Assisted staff on query and report development.Audited Healthsource, Tennessee's provider contracts. Evaluated current operational procedures and presented recommendations to the HSTN Management Team.Evaluated ChubbHealth credentialing processes and presented recommendations on system and operational workflow to the Regional Operational Center in New Hampshire.Evaluated Healthsource, Indiana provider management, contract set-up, and credentialing operational processes. Documented and presented recommendations to HSIN management staff.Managed the Central Provider Repository Project to ensure corporate objectives were met.Created queries in Microsoft Access (SQL) for

Drafted prototypes/developed specifications for Cost Utilization, Medical Management, and Flash reporting.Developed queries/tables using Access to document and support the analysis of the Medicaid program.Assisted in development of Medicare-Risk Audit criteria for the TPA audit.Conducted an assessment of the operational and system capabilities of identified TPAs to handle Mt. Sinai Medical Center's Medicare Risk claims processing.Developed requirements and conducted an assessment for NYU's operational functions and system setup.

Assisted in the compilation of requirements checklist and workarounds including documentation, as this client considered a system switch mid-implementation.Non-Consulting

Led 10 professional employees in the Provider Services Department.Analyzed and selected a credentialing system for Healthsource, Arkansas.Participated on the Fee Schedule Analysis team, which evaluated and revised fee schedules.Worked with clearing houses and providers to establish EDI procedures.

Provider Relations ManagerLed 28 clerical, professional, and technical employees in the Provider Relations Department.Planned team goals and assisted in setting individual objectives for staff in the following areas: Communication, Financial, Third Party Liability, Internal Auditing, Provider Representatives, and Automated Eligibility Verification and Claims Submission System.Conducted performance appraisals and salary reviews.Coordinated the implementation of systems modifications by utilizing staff in Michigan; and Arkansas.Liaison with the customer for problem resolution and/or development of Medicaid program modifications.Represented EDS in the State Managed Care Workshops.Claims Processing ManagerLed 56 clerical and professional employees in the Claims Processing Department.Assisted supervisors in planning team goals for staff in the Mailroom, Data Entry, and Resolution areas.Reduced Data Entry staff from 32 to 20 without lay offs by utilizing temporary staff.Obtained additional business for the Third Party Liability and Provider Enrollment Departments.Assisted the Medicaid Rhode Island account by developing and delivering the training to the State's Third Party Liability staff.

Led a team of 14 SEDs and Business Relations Analysts.Conducted performance appraisals and salary reviews; help set the individual and team goals.Coordinated the implementation of systems modifications and file conversions.Liaison with the customer for initial design and development of new Medicaid programs and program modifications.Established and updated quality control standards.Backed up manager during proposal process and during manager LOA, assuming complete responsibility for the area.Business Relations AnalystDesigned, tested, walked-through, implemented, and documented system changes for all claims processing sub-systems including HMO enrollment and HMO encounter.DRG implementation team leader. Participated in a successful history conversion. Attended all system walk-throughs to assist both EDS and customer staff on technical questions.Managed and implemented the Medicare Catastrophic Program.Responsible for customer training of the Analysis, Modeling, and Reporting (AMR) subsystem.Additional Positions• TPL Casualty Coordinator• Cash Receiving Account Receivable Clerk• Program Integrity Analyst• Adjustment Unit Leader

Inpatient and outpatient claims examiner for processing commercial insurance lines

Allentown, Pa, Us

• Admissions coordinator (Pre-admission and Emergency departments)• Unit Leader for hospital front office

Amisys Training

Facets Training

Mhs Training