As a subject matter expert in health care domain, I have a vast amount of experience working in projects in enrollment and claims processing. My core expertise is in Health Exchange Marketplace Enrollment for individuals and their family members. I also have a working knowledge on encounters, reporting, correspondence applications.
I possess the ability to analyze systems and develop business process models to showcase areas where process efficiencies can be achieved and identify processes that create waste and eliminate them. I am also very efficient in root cause analysis of issues and identify the changes or enhancements required for issue correction, taking into consideration the business scope and impact.
I have gained substantial knowledge in the business rules and processes that are involved in building a system to enroll ACA members. I was involved in reading through the implementation and companion guides to understand the Federal and individual State rules to develop requirements, business process flows and business rules. This is my current project and I have been involved very closely in the technical design of the system. For more details about my experience in this project click below.
As part of a project that involved the re-write of a client's Medicare Enrollment Application, I have obtained a great amount of knowledge about the eligibility rules, and enrollment rules regarding Medicare. I have also received certification from ahip.org for completing their online course on Medicare Primer.
This is a re-engineering project where I was involved in the analysis of the existing system and understanding the different rules that were applied on the claims that were received and determining the correct member, provider and vendor for the claim. I identified the rules and business process for the new system and developed business process flow for the end to end processing of the claims intake. In this project I was also involved with testing the system by comparing the outputs from the existing system and the the new system and analyzing the reason for the differences and creating enhancements as needed to fill in any gaps in the system.