Andrea Marshall
Houston,TX
Summary
Searching for a 100% remote position utilizing Trizetto Platforms in a fast paced environment.
Overview
28
28
years of professional experience
Work History
Business Analyst - Requirements
Wipro
07.2024 - 02.2025
- Facets: Manage workflow and ensure each ticket meets the respective markets State requirements & contractual obligations
- Input the ticket into the Interact system for tracking & to keep the ticket moving to completion
- Attend daily Stakeholder meetings in a SME capacity providing guidance on inquiries related to the project, configuration and any other policies related to Behavioral Health
- Maintain an all inclusive positive work environment for team to remain on track for next steps.
- Processed configuration tickets by validating the information and updating the appropriate tables
Configuration Analyst
VC5 Consultants
04.2024 - 07.2024
- Quick Caps: Medicare Advantage Implementation
- Load Quick Caps platform with all necessary components to welcome new business and process claims through auto adjudication
- Researching edits & Medicare Rules and Regulations, identify areas of opportunity and close gaps that might disrupt workflows, audit the Benefits module to ensure services are assigned to the correct categories & codes
- Worked closely with internal partners to recognize 'no pay' claims and providers without correct Medicare Fee Schedules
- Resolved high priority provider complaints
- Maintain CARC and RARC database
Sr. Associate
Cognizant
08.2022 - 11.2023
- QNXT 6.0-6.1 Translate paper contracts into QNXT system logic
- Build or edit contracts and terms based on negotiations, state requirements & Health Plan directives
- Clam and Provider testing to validate controls outlined by Cognizant or the Client
- Create / update rate sheets used for pricing in NetworX Pricer & mirrors Facets
- Generate various reports such as claim impact, claim status, claims aging & code sets using Microsoft SQL Server 18 and Microsoft Power Automate
- Resolve escalations and/or concerns raised by Providers, Process Specialists and Texas Department of Insurance
- Participate in Client meetings with focus on performance and aging inventory with a recommendation on areas identified as 'Opportunities'
Pricing and Configuration
Impact Consulting
03.2022 - 06.2022
- QNXT: Analyze the request, determine if request is impacting Benefits or contract terms
- Update the QNXT system logic to meet business requirements and satisfy client needs
- Document all aspects of the configuration and steps taken to complete the request as the ticket will be loaded to the Knowledge Bank for new Analysts to reference
Configuration Analyst
Texas Children's Health Plan
05.2019 - 11.2021
- QNXT: Oversee the activities related to complex QNXT configuration, new health plan implementations and conversions within the Configuration Business Operations and Implementation Teams
- Specifically, supported the EPIC/ Tapestry teams to create and map crosswalks between QNXT and EPIC
- Assisted Tapestry team with translating QNXT requirements to Tapestry
- Managed the Service Groups database verifying the codes loaded are still valid codes and mapped appropriately
- Updated rates based on digital files received from the state, updated UHRIP (Hospital Rate Increase) based on the State identifying high-volume vs
- Low-volume Providers
- Updated the QNXT claims system to match contract and other business requirements
- Reviewed and resolved claim edits after researching validity of the edit
- Attached newly built contracts to the Provider files for testing
- Built Provider files in the Provider Module that included demographics, accumulators, contract builds, affiliations and Provider type
- Used MySQL Server to validate system updates or general configuration variances
Configuration /Auditor
United Healthcare
02.2012 - 05.2019
- Configuration and Data maintenance of Integrated CSP Facets 4.7 & 5.2
- Responsible for accuracy and quality of the Integrated CSP Facets systems set up
- Engage in configuration, administration, implementation / installation, troubleshooting & mapping
- Build Provider records in the FACETS Platform provider module, included loading provider type, specialty, attestation with the State of Texas, demographics, affiliations, Provider directory, assign contract(s) to provider files for claim processing
- Define, develop, and document actions
- Quality assurance and testing
- Participate in test development and execution activities with internal and external partners i.e
- Cognizant/ Trizetto
- Initiate effective communication materials that summarize findings and support fact-based recommendations
- Perform root cause analysis and offer solutions for quality improvements
Provider Resolution Analyst
Molina Healthcare
Houston, TX
10.2011 - 06.2012
- Submit updates for QNXT configuration as needed to meet business requirements
- Complex root cause analysis associated with high dollar & high-volume Providers, identify trends and improper system configuration impacting reimbursement
- Provided internal & external provider billing education in regard to Texas guidelines.
- Provider reimbursement and Health Plan revenue were included in process assessment, development, and implementation of Standard Operating Procedures
- Responded to the State (Texas Department of Insurance) in relation to reimbursement and provider complaints
Billing Data Analyst
Memorial Hermann Healthcare
02.2006 - 11.2011
- Developed the Insurance Appeals Team for the SW facility
- Monitored denied claims, determined if Memorial Hermann followed the appropriate procedures to receive reimbursement, if procedure was followed, created the appeal letter and included necessary supporting documents
- Denied claims were reduced 99% for this facility
- Submitted monthly reports indicating reimbursement profit/loss related to denied claims, unpaid claims, and comparisons against other facilities within the Health System
- Use of Pivots & charts were presented to the CFO to present a clear snapshot
- Edit errors from unprocessed and denied claims was another source included in assessment development
- Communicate with management and provide education to staff regarding trend development
- Prepare/ generate various compliance, productivity, and comparison reports
- Audit claims, employees, and vendors for quality assurance
- Work closely with physician’s offices regarding billing and authorization concerns while providing support for reimbursement
- Additionally, provided feedback with supporting data to implement or streamline workflows throughout the facility and present to the partnered physician offices
Service Coordinator
Aetna US Healthcare
05.1997 - 02.2006
- Subrogation/Liability claims, negotiate claim settlements under $5000
- Acted as Gatekeeper for Southwestern Region accepting subpoenas and information gathering for Hospital audits, account reconciliations, Grievance and Appeal processing
- Responded to the Dept
- Of Insurance (TDI) inquiries
- Maintained the Provider Database to ensure updated credentialing & demographics information was available for authorization and claim processing
Education
Some College (No Degree) - MySQL for beginners, MySQL for intermediate learners, Agile fundamentals, Jira for beginners, .Net and Java for beginners
Udemy.com
Online University Some College (No Degree) - Health Administration
Houston Community College
Houston, TXSkills
- Texas Medicaid
- Medicare
- Healthquest
- Pathways
- Interact
- Pluto
- OnBase
- TFS
- Salesforce
- Facets
- QNXT v520001-61002
- NetworX Pricer
- SharePoint
- CACTUS
- Care4
- COSMOS
- Confluence
- EVIPs
- MIDAS
- MACESS
- NDB
- PhyCon
- HIM & PFS Sovera
- Microsoft Teams
- MySQL Server
- CES
- JIRA
- Microsoft Suite
- Intermediate level Excel
- Word
- Visio
- Access
- PowerPoint
Accomplishments
- Memorial Hermann, 2009-2011, Decreased denied dollars by approximately $2 million.
- Memorial Hermann, 2010, Nominated for Memorial Hermann's President's award for multiple projects focused on increasing revenue.
- Memorial Hermann, 2011, Closed the year out with only 3 denied claims for this large Acute care facility.
- Molina Healthcare, 2012, Identified $6 million in underpaid claims.
- Molina Healthcare, 2012, Identified $1.2 million in overpaid claims.
Timeline
Business Analyst - Requirements
Wipro
07.2024 - 02.2025
Configuration Analyst
VC5 Consultants
04.2024 - 07.2024
Sr. Associate
Cognizant
08.2022 - 11.2023
Pricing and Configuration
Impact Consulting
03.2022 - 06.2022
Configuration Analyst
Texas Children's Health Plan
05.2019 - 11.2021
Configuration /Auditor
United Healthcare
02.2012 - 05.2019
Provider Resolution Analyst
Molina Healthcare
10.2011 - 06.2012
Billing Data Analyst
Memorial Hermann Healthcare
02.2006 - 11.2011
Service Coordinator
Aetna US Healthcare
05.1997 - 02.2006
Some College (No Degree) - MySQL for beginners, MySQL for intermediate learners, Agile fundamentals, Jira for beginners, .Net and Java for beginners
Udemy.com
Some College (No Degree) - Health Administration
Houston Community College