Shelline Pizaro Email and Phone Number

• Analyze contracts for requirements• Create pricing grid• Update NetworX Rate Sheets• Audit of configuration• Create new qualifiers• Create fee schedules in NetworX• Defect troubleshooting via JIRA

• Analyze SPD for requirements• Create benefits grid• Update JAVELINA with new benefit structure• Audit of configuration• Request new code creation• Defect troubleshooting

• Attend Product Sessions to discuss requirements for Benefits and Pricing• Created GAP stories for system enhancements• Created Business Process Documentation• Created BRD’s• Created compensation Grids for Pricing in current system• Attend sessions with system vendors to review and discuss requirements• Created Documentation for Premium Billing• Reviewed Eligibility Requirements

• Create business requirements documents Health Rules BH pricing• Attend HEALTH Rules JAD Sessions• Review claims data to assure claims priced correctly in Health Rules• Configuration on Amisys Advance of updated Provider Contracts• Updating modifiers and modifier Rules per CMS Updates• Create test claims to assure configuration is correct• Create ## groupings for configuration needs• Update Fee Schedules• Attend meetings to ensure configuration can meet client expectations• Troubleshoot claims issues• Behavioral Health Pricing configuration by Provider Specialty• Updated the rates in the Optum Pricer based on updated rate letters

• Review contracts for configuration requirements• Document requirements for configuration team• Review UAT for PASS/FAIL• Correspondence with Health Plans for contract clarification when needed• Audit configuration in Amisys and DST Pricer to assure configuration set up correctly per Pay Class Guide• Review Fee Schedules and submit changes to configuration• Review check run to assure claims are paying correctly• Audit Production to assure configuration move from Test environment moved correctly• Submit updated CR’s for configuration changes and updated P

• Updated core system with Medicare 2019 benefits• Created test plan to assure benefits were configured correctly• Updated Anesthesia Provider to remove suspend• Validated Anesthesia claims were pricing correctly via the Provider Pricing tool• Updated RHC and FQHC per diem rates• Audit claims that converted to new system for payment accuracy• Request system updates to fee schedules when claims priced incorrectly• Created Desk Top Procedure Documents

 Conducted meetings with business users to determine current system functionality and translated into business requirements Reviewed business requirements to determine if the new system meet current business needs Produced Business Requirement Documents for functionalities that the new system currently handle with exception to specific business needs Produced Gap Requirement Documents for items that were not currently in the new system Presented documents to the system software vendor as requirements for enhancements to the existing system Reviewed documents with software vendors  Created System Requirements Documents

 Conducted meetings with business users to determine current system functionality and translated into business requirements Reviewed business requirements to determine if the new system meet current business needs Produced Business Requirement Documents for functionalities that the new system currently handle with exception to specific business needs Produced Gap Requirement Documents for items that were not currently in the new system Presented documents to the system software vendor as requirements for enhancements to the existing system Reviewed documents with software vendors  Created System Requirements Documents for reporting team Review and test reports created by the development staff that was generated in new system to assure the new reports met business needs. Document test results  Update requirement documents with more detailed explanations of requirement Areas of concentration were Enrollment, Sales, Reporting and Claims

 Created SNP electronic application that filtered to the enrollment department once the SNP Sales team entered into SharePoint Review CMS contract language to determine how to process Seamless Enrollment Once process was determined I designed and implemented the process into production Conducted meetings with all necessary departments to get the Seamless Enrollment Process implemented Investigate Medicare/Medicaid changes to contracts and inform internal departments of necessary changes. Reviews claims data to ensure correct payments per Medicaid/Medicare increases/decreases Investigate internal and external questions and respond appropriately Review the state’s system to assure accurate eligibility Reconcile PMPM capitation payments Prepare reports for over and under paid claims Run reports using Eureka reporting system Update Daily eligibility files including COB information Review member history to investigate why capitation payment was not  Received Reviewing configuration of subsystem to assure accuracy for our new Community Living Product Reviewed HMS files to compare COB information to information on file Reviewed HMS claims to assure payments were not Medicare co-insurance and deductibles Reviewed DPW’s system for COB information