Claudia Nickerson
Humble,TX
Summary
More than 10 years’ experience as a Claims Manager/Business Systems Analyst/ Business Analyst in the HealthCare Insurance Industry. Experience with SQL and SQL server databases, Data Warehouses. Experienced in conducting requirement analysis, user case design, designing test plans and developed database schemes based on the logical models. Expert in requirement gathering and documenting the requirements in business requirement documents. Experience working as Facets Benefits/Pricing Configuration Analyst, Benefit Implementation Specialist, Research Specialist, Coding Specialist, Reimbursement Analyst, Health Rules/Health Edge Business Analyst. Stakeholder Specialist, Technical or Business Problem Solver. Specialist at creating Test Scenarios and tracking defects and manage solutions to resolve. Ability to Manage Multiple Projects. Loading Instructions Specialist. Facets Application more than 10 years experience. Claims Test Pro. Published Rate Fee Schedule Specialist. Provider Contract Expert. All positions required an Expert focus on Infrastructure and Analytics. Extensively worked on many systems such as, HRP, FACETS, Amisys, MHS Power and Macess, Allterx. Worked extensively with CMS and their different markets. Expert with Published Rate Updates. Excellent interpersonal and communication skills, technically competent and goal-oriented with problem solving skills and ability to work independently and use sound judgment. Functional knowledge of various modules of insurance like channel management, policy servicing, claims management, underwriting, reinsurance, pricing, and finance. Extensive Claim Testing and Triaging. Preparer of functional, system and program specifications using CASE (Computer-Aided Software Engineering). Agile Scrum Methodology expert. Product Owner Agile. Scrum Master Agile. Developer. Service Ticket expertise and Jira. Systems Integration Specialist. Data Mining Experience with Transference of output to Data Visualization Tools such as Jira and TFS. Design Document Creator Specialist. Very skilled at IT Governance and creating BRD’s as a translation and transparency tool. Specialist in Medicare and Medicaid Disputes and creating processes for those disputes. Power MHS Developer Healthcare.
Overview
20
20
years of professional experience
Work History
Solutions Architect
Justified Solutions
10.2022 - Current
- MHS Power Developer, Ticket and Story Triage, Set up rate sheets in Networx for multiple Medicaid Implementations, Assist Analyst and Developers with Solutions for their defects, Dbeaver Sql scripts, Move and extract Big data from Wearhouse
Business Systems Analyst-Configuration, Healthcare Pricing Analyst-Medicare/Medicaid
Talent Software
03.2021 - 09.2022
- HealthRules Payor experience, Created more than 1500 Design Document for HRP implementation, More than 10 years’ experience in Health Insurance and delivery with a working knowledge in one or more operational areas including Claims, Used Modeler for all pricing and contract configuration to broadcast into Networx, Experience in a data management and/or analytic environment is required with the ability to gather, document, test and implement business requirements, Tested benefits and Networx pricing configuration and provided findings, Benefit Configuration, Provider Contract Pricing Configuration
UAT Testing Specialist, Healthcare End to End Testing Facets
The Jacobson Group
10.2021 - 07.2022
- Main focus on UAT testing, including reviewing requirements, writing test cases in detail, and executing the test cases, Created more than 1800 Design Documents for HRP implementation, Implemented contract into HRP based on Design Document creations, Management of the BSA’s opened defects, from creation to close, working with development teams, Review, analyzes, and evaluates information technology systems operations, Tested benefits and Networx pricing configuration and provided findings along with quantified data results of over/underpayments, Set up rate sheets with Optum Pricer for third-party pricing and edits, Determines user needs and requirements and recommends ways to improve systems, Facets Claims Test Pro Specialist, Served as primary point of contact between users and engineering/development staff, Identify, document, report and track system issues through Jira, Developer
UAT Testing Specialist, Healthcare Pricing Analyst-Medicare/Commercial
The Jacobson Group
03.2021 - 08.2021
- Collaborate with other departments to ensure smooth functioning of processes surrounding re-pricing and pricing scenario requests, Analyze the data from paid claims to ensure the proper re-adjudication of adjustment claims, Request refunds for previously overpaid claims based on provider resubmission of corrected claims, Void claims and recoup the monies from claims that should never have been submitted, while keeping up with the financial data from these claims, Reprice/ Adjust and re-adjudicate COB claims, Test Claim scenarios for correct Pricing and Benefits
Claims Manager
Energy Transport LLC
07.2019 - 03.2021
- Develop and maintain understanding of customer workflows and business needs for the transportation industry, Deliver precise functional specifications to include functional hierarchy, workflow, business rules, interface design and definitions, outstanding issues, data analysis, and data mapping to clients and development staff for a fairly young transportation company, Be responsible for direct interaction with clients including, but not limited to, eliciting comprehensive business requirements and use cases and recommending appropriate solutions, Created rate sheets in Networx for new Medicaid Implementation, Gather requirements and help build and document specifications for development, Work with Technical team to develop high level labor estimates to develop and deploy functionality, Conduct gap analysis between application and stated customer requirements and collaborate with Architects and Developers to estimate project impact, Work with Development, QA, and Production Support teams to communicate, verify, and test the desired functionality changes, Helping to develop a path to integrate systems, Work with the clients to demonstrate the changes to the system to ensure all relevant business needs are addressed, Develop training materials and provide training in one-on-one or classroom environment, Manage multiple competing priorities through effective organization and communication, Recommend and institute BA best practice and methodology and tools, Perform QA of BA team deliverables, Responsible for BA Team development, performance goal setting, management, and evaluation reviews
Health Care Solutions Architect/Business Systems Analyst / Product Owner/ Scrum Master
Justified Solutions
07.2017 - 07.2019
- Provide business analysis services at a local, institutional or enterprise level, Understanding and considering both the business and the technical needs of all customers with the goal of providing a quality product or process that meets the business objectives, Exam costs, benefits and risks associated with the proposed investment/project and recommend alternatives for solutions throughout the business life cycle, Collaborate with stakeholders and users to synthesize, articulate, and document business objectives and requirements by applying system and analytical thinking methodology and discipline, Proficient understanding of business strategy and business planning principles and applies to project work, Contribute to project charter and plans, work assignments, target dates, and other aspects of assigned projects, Apply systems engineering methodologies and discipline throughout the project lifecycle, Performs data analysis, define and documents business requirements, supports translation to functional specifications early in the development cycle, and concludes with design synthesis and system validation while considering the complete system, Assist project leaders in coordinating deployment of deliverables, Demonstrate system and analytical thinking capability, Progressive knowledge and demonstrated use of business analysis methodologies and tools, Understanding of Facets and its workflow and assisted with the implementation of HRP from Facets
Sr. Business Analyst
SpectraForce , BCBSNC- Remote
09.2016 - 07.2019
- Facets Configuration Triaging, including triaging claims for proper ICD 10 coding and testing, Interpreting provider agreements and translating them into facets configuration, Review, analyze, and evaluate business systems and user needs, Utilized Networx to build new agreements and maintain existing ones within the Medical Agreement Configurator, Supervise the Integration of systems, Document requirements, define scope and objectives and formulate systems to parallel overall business strategies, Utilized Networx to export, import, and edit fee schedule tables, Analyzed data to ensure the proper execution and payment based on provider agreement and product details, Triaging PRIOR-AUTHORIZATION RECLAMATIONS, Triage Configuration Issues, Resolve Service-related Tickets opened by users of various modules or Applications, Drill down on root causes of integration issues, Familiar with all modules of Facets Production, Familiarized my Team with the Agile Scrum Methodology, Extensive Claims testing after system upgrades or patches, Data Mining and Transfer of Output to Data Visualization Tools such as Jira and TFS, IT Governance and creating BRD’s as a translation and transparency tool, Expert at writing Test Scripts, Prepare functional, system and program specifications using CASE (Computer-Aided Software Engineering), Specialist in Medicaid Remediation and Medicare Remediation
Healthcare and Insurance Claims Operations Supervisor
Dell/NTT Data
08.2013 - 04.2017
- Technical Skill Rank (Expert/Average/Below Average) Rating out of 10 Last used year Years of Experience Primary Skills Healthcare Expert 9 Current 30+ years Healthcare Payer Expert 9 Current 25+ years HRP (HealthRule Payor) Expert 9 Current 7+ years Claims Expert 9 Current 30+ years Facets Expert 9 Current 10+ years Agile Expert 9 Current 12+ years Secondary Skills Project Management Expert 9 Current 12+ years Configuration Expert 9 Current 20+ years HealthEdge Expert 9 Current 7+ years Communication Expert 9 30+ years
Sr. Benefits Business Analyst
First Care Health Plans
08.2015 - 09.2016
- Resolved data discrepancies and validation report errors, HRP Configuration, Asissted with the move from Amisys to HRP, Retained accountability for successful implementation projects, Backup to Implementation Project Manager, Solutions Architect for Billing, Membership and Enrolment exceptions, Complete job-related training courses and/or seminars, as may be required for the job and/or assigned by Manager, Benefit Configuration, Implemented extensive process re-engineering improvements, Implemented Healthcare Software, Optum Editing Systems, Interpreted provider agreements by product and translated the agreements into Health Rules Payor Configuration, Tested the HR configuration for accuracy and move from Configuration to Live Production, Expert in EDI transactions, HRL Syntax Specialist, Encoder Pro Specialist, Worked with implementing the Agile Scrum Methodology, Prepare functional, system and program specifications using CASE (Computer-Aided Software Engineering), Data mining and transfer from Business Objects and IBI Tool (Query) Specialist, also Tableau and Access, Resident Re-Insurance/Stop Loss Specialist, Systems Integration Specialist, Assisted with the implementation and Testing of ICD 10 conversion, Extensive Claims Testing after upgrades and fixes, Design Document Creation, Microsoft dynamics CRM, Created Test Scripts and BRD’s, Drill Down on Pricing Discrepancies, which included interpreting provider contracts and creating fee schedules
Sr. Business System Analyst /Product Owner/ Scrum Master
The Walker Group
06.2011 - 08.2015
- Client Listing: WellCare 2yrs, Excellus BC/BS of NY 2 yrs., Regence of Oregon 1YR, FL Blues and NC/SC Blues 2Yrs and Cook Children’s Health Plan- Remote, FirstCare Health Plans-Remote, Proactive, Analytical and Self-directed Sr
- Business Analyst with strong technical academic background complemented with comprehensive years of experience in Medicare/Medicaid business technology solutions and client management, Offering over 10 years of experience with Top Consulting majors, in the Insurance IT industry with expertise in business analysis, client delivery management and project management, Facets Testing and Configuration, Health Rules Payor, Analyzed business and user needs, Document all requirements, build out the system, provide unit testing and move into Live production, Participated in application implementations and testing end user processes, Product Owner, Scrum Master, UAT Testing Team Lead, HRL Syntax specialist, Minimizing system errors and pended claims through analysis, and solution development, configuration and testing, communications, and documentation of reactive and proactive corrective actions, Researching and completing root cause analysis of customer service intakes and claim errors, Expertise in EDI Transactions, Support Corporate Operations by participating and leading projects associated with identifying and/or solving system-related problems, development of new products or services, and business processes, Ensuring compliance with all State and Federal mandates and regulations by a thorough understanding of required documentation critical to claims processing, Specialized in configuring qualifier Groups in Trizetto Facets Networx and DRG Related groupers, Ensuring the dissemination of all information to all Operations Units in a timely manner by maintaining a complete and current understanding of new and revised Technologies and processes, Responsible for assisting management with Reporting and making sure all daily, weekly, monthly reports are completed, Also researching and reporting issues that arise with the reporting data base for timely fixes, Gathers Information and supports Corporate Operations with all audits, Managed the Integration from an older system to a newer system, Billing, Membership and Enrollment Solutions also Architect Medicare and Medicaid Solutions, Went through several implementations of Agile Scrum and Jira and TFS with several BA teams, Extensive Testing of Data after change request implementation, Prepare functional, system and program specifications using CASE (Computer-Aided Software Engineering), Advanced Data Mining Experience, Design Document Creation Specialist, Claims Configuration Specialist/Testing, HIPAA Compliance Specialist, Medicare/Medicaid Reimbursement Specialist, Healthcare Database Developer, Training and Implementation, Translate Provider Contracts into System Configuration based on Product, Specialized in configuring agreements in Trizetto Facets Networx, Created fee schedules in Networx Pricing, Created Alternate rules for UM Edits, Configure Providers in Facets, Drill down on exceptions to correct them, Process re-engineering specialist, Healthcare Software Implementation Specialist, Design Document Creation Specialist, Expert at writing Test Scripts and BRD’s
Education
High School Diploma -
Oliver Perry Walker High School
New Orleans, LA06.1984
Skills
- MS Visio
- Share Point
- Rational Suite (Rose, Requisite Pro, ClearCase, ClearQuest)
- JIRA
- QC
- Test Director
- FISS
- QTP
- PLSQL
- SQL Server or Oracle
- SQL Server 2014 Management Studio (T-SQL)
- WinRunner
- Load Runner
- MP
- Erwin
- Oracle
- SQL
- Microsoft Office
- SOA
- MS Project
- NUnit
- HP Quality Center
- QNXT
- Agile Scrum
- Jira and TFS
- Microsoft dynamics CRM
- WinCVS
- Web Services
- Waterfall Model
- Agile Methodology (SCRUM)
- Rational Unified Process (RUP)
- Windows Server 2014
- GMP and CGMP
- Trizetto FACETS
- Rims
- ITS
- Diamond
- Xcelys
- Fast Track
- COSMOS
- Group Insurance
- Erisco
- RIMS
- WEBSTRAT
- Group Claims
- BI Tool (Business Intelligence)
- Business Objects
- Web Intelligence
Timeline
Solutions Architect
Justified Solutions
10.2022 - Current
UAT Testing Specialist, Healthcare End to End Testing Facets
The Jacobson Group
10.2021 - 07.2022
Business Systems Analyst-Configuration, Healthcare Pricing Analyst-Medicare/Medicaid
Talent Software
03.2021 - 09.2022
UAT Testing Specialist, Healthcare Pricing Analyst-Medicare/Commercial
The Jacobson Group
03.2021 - 08.2021
Claims Manager
Energy Transport LLC
07.2019 - 03.2021
Health Care Solutions Architect/Business Systems Analyst / Product Owner/ Scrum Master
Justified Solutions
07.2017 - 07.2019
Sr. Business Analyst
SpectraForce , BCBSNC- Remote
09.2016 - 07.2019
Sr. Benefits Business Analyst
First Care Health Plans
08.2015 - 09.2016
Healthcare and Insurance Claims Operations Supervisor
Dell/NTT Data
08.2013 - 04.2017
Sr. Business System Analyst /Product Owner/ Scrum Master
The Walker Group
06.2011 - 08.2015
High School Diploma -
Oliver Perry Walker High School
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