Billing integrity system creation and payor EDI management

• Created, optimized, and maintained all .x12 EDI systems between the State of Colorado (HCPF) and QNXT hosted environment used by COA. Main business objects were Membership (834), Claims (837), and Payments (820)• Created training modules and instructed several COA departments on QNXT technical items customized to their needs.• Created several internal solutions for various business purposes: CARC/RARC, Claims Dashboard, EDW interfaces, .x12 interfaces, and QNXT plandata and planintegration reporting• Trained software development team members on COA tools and business solutions• Created internal process documentation to promote and maintain systems• Estimated time and tasks for new project requests

• Provided business and technical EDI support for a new Medicare line of business using QNXT 5.2.• Managed project deliverables, leading meetings, and delivering QNXT EDI export solutions focusing on 835 and other provider payment transactions• Consulted on several other EDI .x12 transaction sets (837, 270, 271, 276, 277)• Guided technical team on how to use QXI SOAP calls• Trained both business and technical teams on QNXT databases/tables, BizTalk Event Viewer, QConnect, QNXT UI Payment Manger, and QNXT UI EDI Manager• Created specialized reports from QNXT PlanData and PlanIntegration using SQL Server Management Studio 2012

• Fixed and enhanced EDI Membership Preprocessor add-in logic to import membership related files (834 and DTRR). Logic focused on properly updating enrollment related tables in QNXT 5.1, as well as government related factor and condition PlanData.• Provided detailed analysis of current membership data and processes to drive business requirements• Created technical requirements for the updated Preprocessor• Mentored development team to properly code new Preprocessor requirements• Performed unit testing on new Preprocessor logic• Created several ad-hoc reports from QNXT PlanIntegration, QNXT Plandata, and in-house preprocessor tables

Helped payers implement and integrate QNXT into existing systems.

Created 837 test claim files and used QNXT Connect to help determine proper QNXT configurationCompleted research on QNXT Connect log tables focused on claim importationCreated executive summaries and presented directly to CIOCreated 837 institutional and professional companion guides used by providers sending Medicaid claim data Created business and technical requirement documentation templatesUsed Florida Medicaid provided Ramp Manager to verify .x12 formatting

Day to day production critical issue resolution - X12 Claim data (837)- X12 Member data (834)- Worked with team to fix other related critical production QNXT anomaliesTeam Subject Matter Expert for QNXT and Plan Data- Core team member to configure and implement QNXT at ILS, and integrate into local ILS systems and vendors- Answered questions from team members related to: - EDI (X12, proprietary vendor data feeds, internal ILS data feeds) - database - vendor data - workflows - internal interfaces with QNXTData Extracts- Wrote many critical ad-hoc QNXT plan data extracts for provider, member, claim, and authorization data- COO Claims Dashboard Report- NY State Provider Network Data System Files- Provider Affiliation Data Feed- Provider Enrollment Broker Data- Provider QNXT to eCare enhancementsBusiness requirements and technical solution documents for QNXT and eCare Interfaces- Provider Web Portal- eCare 834 Data Validation- EVV Authorization and claim processing- Several EDI interfaces for QNXT go liveVendor Interface Management - Determined root causes with TriZetto and help resolve many QNXT issue tickets related to claim and member processing- Determined root causes with Smart Data Solutions to resolve claim and member file issues- Developed and tested EVV solution with ContinuLink and DialNDocumentSetup and Configuration- Set up high priority demos for immediate use- Configured QNXT Connect for X12 import transactions into QNXT- Determined limitations of QNXT Connect, and wrote business requirements and technical solutions for all X12 import add-in code- Estimated cost and researched third party solutions for several necessary software tools: - 27x series data management - Claredi .x12 validation - Desktop data manipulation tools - .x12 documentationData Migration- Created solutions for migrating member and provider data from existing ILS systems into QNXT.

Provided X12 EDI, reporting and database expertise for Medicaid businessGained experience in AMISYS Advance 5.0 UI and database structureCreated design documentation for several Medicaid subsystems: - Electronic Remittance Voucher (ERV) Reconciliation - Payment (820) Reconciliation- Enrollment (834) file processing- Claim (837) file processingCreated design documents for several Reports required by Medicaid:- Provider Network File- Provider Termination and New Provider Notification Report- Complaints, Grievances, and Appeals Report- Claims Aging ReportWorked with client to create mappings from Medicaid subsystems and reports to AMISYS Advance, VisualCACTUS and internal Access Databases

• Led business and technical meetings to create and gain final approval for requirements in the fol-lowing system areas:o 5010 X12 EDI interfaces: 834, 835, 837, 820, 270/271, 276/277o Hard Copy Claimso Proprietary membership fileso Claim export files from QNXT to Centers for Medicare & Medicaid Services• Used QNXT 4.8 UI and databases• Performed analysis on legacy and QNXT systems by:o reviewing 4010 and 5010 X12 data using implementation and companion guideso configuring the QNXT EDI Manager Utility for all trading partnerso examining the QNXT Process Log Browser and Plan Integration database for QNXT Con-nect issueso troubleshooting and correcting HIPAA errors using the Microsoft System Event Viewer generated from X12 BizTalk processing• Created test cases and test data for 5010 X12 interface units, and proprietary membership files• Facilitated testing of pre and post QNXT Connect add-in code by creating appropriate claims from the UI, adjudicating, paying, creating checks, and running appropriate export processes• Created detailed reports of X12 EDI data imported and exported by both legacy and QNXT systems at the element level to find possible HIPAA compliance issues, and to flag any gaps between systems• Determined impact on 4010-5010 differences for X12 EDI files.• Configured EDI client data by setting trading partner information, rules and translation values within the QNXT EDI Manager Utility for subsequent use by the Connect utility• Led technical discovery meetings to capture current EDI system designs• Led transition meetings with overseas developers to explain business and technical requirements for EDI deliverables• Reviewed resumes and provided direction for hiring new technical analysts

• Led business user meetings to create scope, requirement, and design documentation for several QNXT interface projects• Worked with most QNXT interface systems including 837 Claim Routing, 835 Remittance, payment, ARGUS Drug Claim Processing, EFT to Provider, Reports to Members and Providers, Check Sta-tus, and 834 Membership• Defined, analyzed, designed, created, tested and maintained several systems to interface with QNXT health care management software• Worked with QNXT 4.7 to troubleshoot membership anomalies• Managed development team located in India assuring requirements were communicated correctly, and that software solutions are delivered on time• Performed cost benefit research on membership projects to determine ease of data portability into current membership systems and how to potentially remove the need for third party software• Completed project to estimate difficulty and size of mainframe data cleanup tasks to export data to a third party drug claim system• Wrote requirements and designed a system to generate group data membership files to be sent to third party systems• Facilitated third party gMax membership data file discussions to gather completed requirements• Leader of system test and production technical support for the automated membership project, and performed the following items: triaged system test items, reported on latest updates to open defects, coordinated system test file flow, answered any EA technical questions from the team, and triaged new defects for production problems• Reported on a regular basis to CIO and management team on high severity production issues• Performed system test cases and created defect reports • Provided estimates for deliverables of the automated membership project using Benefitfocus third party software.• Created EA Configuration tool which controlled membership on-boarding.• Created data models with database administrators• Performed production data fixes to correct anomalies