Experience

Simply Healthcare Plans

• United States
• Insurance
• 200 - 300 Employee

• Configuration Auditor

  • Jan 2014 - Present

  Analyze, and configured provider contracts and benefits. Maintain quality in accordance to state and CMS policies and processors. Control of quality/configures to provider contracts. Insure the accuracy between provider and business contracts. Managed changes to addendums/adjustments in accordance to effective dates. Interpret terms of agreement set forth in addendums/adjustments. Insure consistent with term for members needs and Primary Care agreements. Assist in provider compensation under certain benefit plans set by Government Agencies. Quality assurance of configuration, for Specialty providers and Faculties in accordance to agreement/contract specifications. Show less



Harvard Pilgrim Health Care

• United States
• Wellness and Fitness Services
• 700 & Above Employee

• Configuration Analyst

  • Jan 2013 - Oct 2013

  OHI(ORACLE)/AMISYS Analyze, develop/design configuration requirements/specifications, configures/implements, and maintain in accordance with the customer needs. Develop and maintain system configuration in accordance with providers, employer contracts, and customer needs. Interact with quality checks, and tests new/existing system configuration, software changes, and new releases/upgrades to ensure the accuracy, completeness, and compatibility of changes. Interacting with vendors and leadership to determine acceptable technical solutions to business issues. Provided consultative services by actively participating on numerous cross-functional teams and projects, as well as troubleshooting inquiries and issues from other departments. Resolved software and data issues and investigating accuracy of user transactions and their effects on the system. Administering the data that resides on the system. Configuring and ongoing maintenance of system parameters, system configuration, and data or links. Developing, maintaining, and disseminating internal and external configuration documentation, including status updates; prepared procedural and customer documentation when required. Researched complex problems to ascertain possible solutions. Design and implement solutions to support key business objectives, including developing design requirements and technical specifications Show less



Royale Class Tech.

• United States
• IT Services and IT Consulting
• 1 - 100 Employee

• Testing/Configuration BA

  • Dec 2012 - Jun 2013

  FACETS 4.8 Created benefit grid design document templates from group contract matrix benefit information. Lines of business included PPO/PFFS, HMO, Medicare Advantage, and managed care. Benefit grid design creation involved locating the most current contract version which included any updates. Benefit grid design templates were built for the following providers of service according to contracted benefits, Inpatient/Outpatient facility services, outpatient ambulatory surgery services, home health care vendors, outpatient laboratory and radiology facilities, DME vendors, Skilled nursing facilities specialty providers and PCP’s, Inpatient/Outpatient rehabilitation services and outpatient hospital ancillary services. Benefit grids included all pertinent information such as deductibles co-pays restricted allowances and any ala carte benefits. Show less