Resume of EDI BA/PM Consultant

Title
EDI BA/PM Consultant

Primary Skills
EDI, HIPAA, BA, PM

Location
US-TN-Nashville (will consider relocating)

Posted
Nov-28-07


OBJECTIVE: EDI Business Analysis, Project Management, EDI projects, Healthcare, Insurance Market.

(Six Sigma, EDI project specifications (X12, HIPAA, etc.), Business Requirements, Use Cases, Validation, EDI Trouble Shooting; Trading Partner / Vendor management); Database Mapping; MCC / MCO EDI Management.

SKILLS:

• Business Analysis: Project Management of EDI staff and business processes, responsibility for formal project specifications and project status reporting, personnel work assignments. Assist with system design overview and database requirements. Work with and between trading partners, clients, management, technical and non-technical personnel to define issues and identify solutions. HIPAA EDI resource person (segments, elements, loops, etc.), negotiate with Trading Partners, work on legal issues with corp. attorneys, perform vendor selection.
• Six Sigma: Utilize Six Sigma's DMAIC approach to data-driven project analysis. (Recognize, Define, Measure, Analyze, Improve, Control, Realize). Apply six sigma principals to project, including analysis, reporting, and performance matrix.
• EDI Validation: Personally responsible for attaining HIPAA EDI validation from Medicare, Medicaid, and other payers or government carriers. Developed HIPAA EDI Transmissions for both government carriers and commercial entities. Work includes complete business cycle management and hands-on production as well. Create EDI Testing process, documentation, and performance matrices.
• HIPAA Resource: Completed several HIPAA Projects, leading a number of HIPAA projects for Medicaid Plans, large insurance companies, clearinghouses, and healthcare providers. Companion Guides, legacy system integration, HIPAA code set resolution and payment posting projects, including Claims, Eligibility, Claim Status, Remittance, COB, Explanation Of Benefits (EOB or EOP) and other healthcare IT projects. Work with government carriers and payers to support the provider community, including Institutional, Professional, Dental, and specialty work such as Encounter transmissions, Secondary Payers, and Cross-Over billing. Includes Medicaid MCC / MCO and Medicaid Management Information System ( MMIS ) work: 837 and 824 system design.
• EDI Department Designs. For this type of work the following skills have been utilized: Project Scope determination; Corporate interviews to determine the scope of project. Work Flow, WBS (Work Break Down Structure); Trading Partner Selection: Hardware, software, and vendor services are determined after appropriate interviews. Development of Job descriptions, documented in detail, including skills needs, desired experience, and a general description of costs. Production phases are documented as well as a test plan for deployment.
• Trading Partner / Vendor Management: Manage the requirements and selection for Trading Partners and Vendors. Schedule conferences, JAD sessions, participate in negotiations, set/create/resolve EDI TP issues and create legal draft points for corporate attorneys.
• Gap analysis and Market Research: Trading partner assessment was performed as well as corporate readiness for EDI production. Industry knowledge was shared to assist in long-term goals. Gap analysis was performed to identify changes (as-is and to-be status for six sigma), which was kept within the corp. objectives both financially and objectively.
• Technical Specification Creation for EDI. Schedule meetings with technical personnel to determine technical parameters for EDI and other related processes, including communication, security, and privacy. Create transaction sets requirements, usually with Microsoft Excel, for transactions such as: HIPAA 270/271, 276/277, 835, 837-(I,P, &D), 835 Remittances and others. Resource for UB92 and HCFA1500 billing formats, transaction sets requirements, EDI development and Design, X12 protocols through Version 4010A1 and newer, conversion needs and understanding of legacy EDI formats, such as UB92 Versions 4, 5, 6 and NSF.
• Communications and Security knowledge: Work with vendors to set up electronic communications and clearinghouse communications, including protocols such as Frame Relay, FTP, Dial-up, and others. Encryption software was also selected and tested, including SSL, PGP, and encryption keys, both public and private.
• Use cases, test plan creation and Companion Guide development: Development or oversee others in developing EDI Specifications, Test plans and/or companion guides for the 837 Institutional, 837 Professional, 837 Dental, 835, 270/271, 276/277, others. Test plan design, from stage to production, including both internal and external requirements. Companion guides and crosswalks were developed using Excel. Insurance and clearinghouse entities were consulted to insure proper integration and compliance, research done on segments and elements as needed. Mapping staff were instructed on EDI issues and management was made aware of systems issues, status, and progress.
• Research and Reporting (for upper-level management): Interview stakeholders, create and maintain reporting and milestones for upper management. Participate in corporate meetings to resolve issues and present solutions. Identify resources needed for special projects.
• RUP, Rational Unified Process: Inception phase-define scope; elaboration phase-analyze needs; construction phase-create product/source code; transition phase-delivery, installation and user sign offs.
• Disaster recovery plans. Create Disaster Recover plans, including hot and cold off-site Recovery Procedures and validation processes. Design problem escalation parameters. Work with third party vendors to arrange appropriate communication and data transfer for operation set-up in the event of a disaster.

Management Tools / Skills:
Microsoft Project, Microsoft Office, MS Word, MS Excel, Power Point, Visio, Access, custom Project Management tools, Validation Testing tools such as CLAREDI, Disaster Recovery Planning and trouble ticket software, SAP version 4.6, meetings and conferences (speaker), client and employee training.

Use of the following management methodologies: PMM: Project Management Methodologies, Six Sigma methodologies (DMAIC). Work with Sarbanes-Oxley requirements (SOX) to resolve regulatory requirements. Registered with PMI, preparing to take newest PMBOK 3rd edition PMP Certification test.
Project Management has been a regular requirement of resent and past projects.

Programming Languages: Visual Basic, C.

Database work: Microsoft Access, Table File Design, Data importing for Databases, SQL commands to access the databases.

Project work performed in conjunction with EDI tools:
EDIFECS SpecBuilder 6.1, Mercator Event Server, Mercator Message Manager, Sterling Software Gentran, custom EDI transmission development in Visual Basic, EDI testing with CLAREDI, St. Paul's Software, Advantis and other VANS.



EXPERIENCE:

Fox Systems, Phoenix, AZ (in Nashville, TN) January 2007-present
EDI Business Analyst and DB Consultant for NPI Project.

• CLIENT: TennCare (Medicaid TN, 2007)
• PROJECT: NPI
• Work Description: Design and create NPI de-duping process. Responsible for MCC/MCO flat file validation and testing. Define 837 I/P/D errors for all MCC / MCO entities. Develop data importing processes for EDI files. Maintain NPI database. Produce EDI Testing environments for HIPAA EDI transactions. Produce and maintain all vendor performance matrices, including details numerical analysis. Create project documentation. Define and suggest needed improvements to management and perform a key role in execution of those roles, including reporting and custom applications for analyzing flat files as well as HIPAA EDI files.



Remora Software, Inc., Fillmore, IN July 1996-December 2006
EDI PM / BA Consultant

• EDI CLIENTS: TMHP(Medicaid TX, 2006); WellPoint (BCBS/CA, 2005); ACS (Medicaid Hawaii, 2004); AFLAC (2003); Blue Cross Blue Shield (BCBS/GA), Magellan Behavior Health, and EDI systems for several health care providers or carriers, nationwide.
• BA work for HIPAA TCS: Develop Mapping rules, Design specifications, and Test Case / Use Cases for the HIPAA 837i/p/d; 270/271, 276/277, 835, 824, 275 and others. Worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277). Create EOB systems (835). While “in-house”, help with development. While on-site, work as a business analyst. These projects span several Insurance Payers, Carriers, and providers, working with and for each of these, typically in an EDI Business Analyst roll.
• MMIS work for Medicaid Carrier: Created the complete 824 to 837 indexing system for ACS in Hawaii. Worked as an EDI Coordinator, working with Trading Partners / Providers. Worked on and initiated changes to Medicaid EDI rules, specifically the Coordination of Benefits processes. Worked on the MMIS system, doing EDI claim testing and EDI processing functions.
• SAP 4.6, Inventory and Disaster Recovery for ROCHE; SAP EDI work for Merisel (CA).
• Business Designs for EDI Departments: Consulting work included corporate interviews to determine the scope of project. Existing legacy systems were examined and personnel with ownership responsibilities were interviewed. A design of how the newly created EDI department would function was put together in Visio type flow charting. Job description and skills needed were documented separately. Launch plan created with appropriate stage and production plans was documented. Reviews and corporate meetings were held to discuss issues.
• Responsibility/accountability: On consulting projects, generally manage or lead 3-8 technical or business personnel. On in-house projects, responsible for HIPAA EDI from start to finish. Participate in both pre and post client interface to insure projects roll out smoothly. Serve as a representative and contact person.
• Technical Tools: EDI and Billing Systems were created with Visual Basic, Sterling Software, Microsoft C. Some Gentran and Mercator work. Windows and user-level Unix operating systems. SQL commands were used to manipulate databases. Used EDISM while working 6-month contract with Magellan, for specifications only.
• Accreditations: HIPAA-approved (by carrier) status was attained for proprietary Medical EDI systems. Received letters of validation from both Medicare and Medicaid. Listed on the Federal Government's list of approved & validated Medicare Vendors list. Sat on the Blue Cross Blue Shield Association's committee for launching the 837 (while working for BCBS/GA).
• Common EDI work performed: X12 specifications were developed, issues were addressed (EDI, security, HIPAA, NPI), X12 version design. Some automation tools and/or scripts were created. EDI systems were evaluated. EDI setup work was performed for Client site, administrative tasks, including personnel and cost estimates were created. Transaction sets included UB92 Versions 4, 5 and 6; X12 270/271, 276/277, 278, 837 (I,P & D), 810's, 850's, 864's, and 997's. More recent work includes UB04 and review of upcoming 5010 EDI versions.
• Internet work: Internet Domains and HTML and Java Script were developed. Internet software included Microsoft's Front Page. Communication protocols were suggested, including FTP, modem, Frame Relay, Virtual Private Networks, Internet. Encryption options were also evaluated and/or setup, including PGP, SSL, and others.
• Security work: Create processes to protect PHI (Protected Health Information) for HIPAA compliance. NPP (Notice of Privacy Practices) was researched and protocols were created for sending NPP's to patients and users of PHI.
• Outbound and Vendor work: Remittance automation has also been performed. Multiple Trading Partners were set up as well. Vendors were assisted in EDI interfaces.
• Project Scopes: EDI systems were created for both large and small critical medical and/or insurance corporations. Projects also have included Billers, Payers, and both institutional and professional providers.
• Roles: HIPAA EDI specialist, HIPAA EDI Business Analyst, EDI Project Leader, systems designer and developer, Client Representative, Conference Speaker, corp. technical trainer.
• Data Conversions and Computer Interfacing: Legacy System integration conversions were created. Imports were created to take data from existing systems and convert & import data to new systems.
• Visual Basis work: Custom reports were done in Visual Basic. Visual Basic functions used included data grids, VB modules for customized functions, and direct file I/O for custom VB functions.
• Database and file format work: Database systems were developed using Visual Basic and Access with SQL commands to access the Tables in the database. XML software was created to produce XML documents for information distribution. XML standards were defined. Clients have used a wide variety of databases, including Oracle, SQL Server, Access and others.
• Classes taken: 2001: IBM classes were taken in UNIX basics and Korn Shell scripting. Mercator Event Server and Message Manager classes were taken in 2001 as well.


Quantum Health Resources, Indianapolis, IN March 1996 -- November 1996
Project leader.

EDI transmissions were created in both Microsoft C and other EDI transmissions were created in Sterling Software's Gentran product. Both were used in production and maintained. Worked with Trading Partners and flew out to site for installation. Determined parameters for best up-time for the EDI for this home-infusion health company.

J.F. Malloy, Inc., Indianapolis, IN August 1995 -- February 1996
DP manager

Note: Nationwide Care went through a buy-out or merger process that laid off technical personnel; J.F. Malloy was an “interim” solution until re-employment with the same Vice President that had moved from Nationwide Care to Quantum Health Resources, who tendered the offer.
Conversion programs and hardware work. Set up telecommunication software and hardware for telecommuting (work at home) employees. Worked with virus control software to protect systems. Ordered hardware systems and updates to maintain corporate systems. Helped to resolve Windows issues.

Nationwide Care, Indianapolis, IN November 1994 -- July 1995
Software Engineer

Cross-Platform Conversion programs for Multi-platform software. This company was a Nationwide Nursing Home acquisition company. Systems conversions were written in C to convert and or automate the production flow of data.

Michigan School System, Lansing, MI September 1994
Software professor

Taught the Macintosh operating system for students In Michigan Public School system - this was a Special short-term interim course. Daily projects and assignments as well as course objectives were set. Students were assisted in various stages of their work assignments.

BLUE CROSS AND BLUE SHIELD OF GEORGIA. July 1992 -- August 1994
Lead Programmer

• Paperless billing software was created and maintained. C programming, Supervising, Research and Development were performed.
• Key problem resolution for Data Importing from all platforms for the EDI Medical Billing products and services.
• Hardware included mainly micro computers; also used were Xenix, and RISC 6000. Files were interfaced from Mainframes, Mini's, and Micro computers.
• Communication scripts were written in ProComm Plus and PC anywhere.
• Mainframe upload software was also written.
• Medical paperless billing software was the main focus.
• This involved all client hospitals and physicians and their UB92 and HCFA1500 billing forms.

Blue Cross of Western Pennsylvania, Indianapolis, IN September 1985 -- July 1992
Programmer Analyst

• C programming and training was done for staff and 12 other client Blue Cross and Blue Shield plans.
• Work orders were created for the programming staff. Cost estimates were created.
• Quality control, check lists, and manuals were created and maintained.
• Software research, process automation, and documentation were created. Data Importing was programmed for these EDI Healthcare Billing Systems.
• Computer programming for hospital billing was performed using Microsoft C.
• Hardware used included IBM compatibles and LAN networks such as Novell and Corvus.
• Database used: Rbase. Utilities: Norton Utilities, Brief.
• Job cost estimates and purchase orders were coordinated for billing.
• Technical support was maintained. Production was coordinated with Blue Cross plans throughout the United States.


EDUCATION: Olivet Nazarene University (ONU),
Ball State University (BSU),
Indiana University Purdue University at Indianapolis (IUPUI)
Bachelor of Science degree in Computer Science
Minor in Economics

Certifications
Validated Federal EDI Vendor (personally)
Validated State EDI Vendor (personally)
Validated Encounters EDI Vendor (personally)
Validated Commercial EDI Vendor (personally)


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