Delfina D Carballo
Pensacola,USA
Summary
Dedicated Sr. Business Analyst bringing more than 10 years of experience in Healthcare Claims, Configuration Testing and Quality Assurance, known for rapidly and effectively translating historical performance figures into actionable data. Able to adapt quickly to change, improving processes and exceeding requirements in team environments. Diligent worker with strong communication and task prioritization skills.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Sr. Business Analyst
UnitedHealthcare
06.2023 - Current
- Testing configuration changes in Cirrus platform such as integration, UI, regression, and functional testing.
- Validating code, design documentation
- Data analysis for claim testing using Excel, Macros and Database simultaneously.
- Facilitated requirement gathering workshops, resulting in clear project objectives and deliverables.
- Improved project efficiency by analyzing business processes and identifying areas for improvement.
- Conducted gap analyses to identify discrepancies between current and desired states, leading to actionable recommendations.
- Collaborated with cross-functional teams, ensuring a cohesive approach to business analysis.
- Implemented Agile methodologies within project teams, increasing overall adaptability and responsiveness.
- Ensured adherence to regulatory requirements by staying abreast of industry standards and best practices.
- Performed gap analysis to identify areas of improvement.
- Collaborated with stakeholders to identify business needs and data sources.
Software Quality Analyst II
Change Healthcare
01.2021 - 05.2023
- Performs integration, UI, regression, and functional testing to validate code and configuration changes in HealthRules Payor (HRP), Facets and various EDI and custom interfaces
- Collaborated with cross-functional teams to ensure seamless integration of new features and functionalities.
- Documented test results meticulously for accurate tracking of issues, facilitating efficient communication between QA and development teams.
- Identified and resolved defects for improved user experience and overall system performance.
- Optimized test coverage by strategically prioritizing high-risk areas based on past defect patterns, industry trends, and customer feedback.
- Supported continuous improvement initiatives by analyzing root causes of recurring defects and recommending preventive measures to reduce future occurrences.
- Ensured compliance with industry standards by validating accessibility, usability, security, privacy, localization, internationalization aspects during the testing process.
- Promoted a culture of continuous learning within the QA team by staying updated on industry trends, emerging technologies, and best practices.
- Documented testing procedures for developers and future testing use.
- Experience with multiple testing strategies such as happy path, negative testing, and functional testing
- Works directly with the project team to ensure quality deliverables are delivered on time
- Developed SQL queries to obtain test data from the HealthRules Data Warehouse
- Manipulated XML files for API testing utilizing SoapUI, Visual Studios and/or other tools for testing
- Performs 837 EDI testing on inbound and outbound files
- Ability to read, analyze and edit EDI files
- Facets and HRP Configuration Testing: Benefit, Provider contracts, limits, pricing (copays, deductible, coins) and yearly New/Exiting Benefit Plan and benefit Testing (new plan enrollment)
- Validating accurate totals using extracted data in Excel reports for Coordination of Benefits (COB) and Explanation of Payment (EOP) audits to validate monthly, YTD payments
- Experience with multiple Diagnosis Related Grouper (DRG) and ClaimsXten (CXT) implementations
- Claim adjudication for Medical (Professional and Institutional), Dental, DME and Pharmacy
- Works across teams with Business Analysts, Config Analysts and Developers to triage issues and drive them to resolution
- Responsible for tracking, analysis, and reporting of defects through resolution in a fast paced, demanding environment with aggressive deadlines
- Documenting test results in DevOps utilizing TDLC test plan and identifying test case scenarios for testing execution
- New/Exiting Benefit Plan Testing (new plan enrollment) (Medical, Dental and Pharmacy).
Quality Assurance Analyst
Change Healthcare
01.2019 - 01.2021
- Performs 837 EDI testing on inbound and outbound files
- Ability to read, analyze and edit EDI files
- Facets and HRP Configuration Testing: Benefit, Provider contracts, pricing (copays, deductible, coins)
- Medical, Hospital and Dental Claim testing, Diagnosis Related Grouper (DRG) and ClaimsXten (CXT) implementations
- Responsible for tracking, analysis, and reporting of defects through resolution in a fast paced, demanding environment with aggressive deadlines
- Documenting test results in DevOps utilizing TDLC (Testing development life cycle) test plan and identifying test case scenarios for testing execution
- Facets and HRP Configuration Testing: Benefit, Provider contracts, limits, pricing (copays, deductible, coins).
Medical Claims Examiner (Facets)
McKesson
01.2016 - 01.2019
- Claim adjudication, Utilization Management, verifying Provider Network, correcting claim errors
- Claim audit for correct pricing
- Ability to train others within Facets applications: Claims testing, Medical Plan, Dental claims, Workflow Config, Prospective UM (Authorizations), letters, entering tickets.
Account Receivable Representative
McKesson
01.2016 - 01.2016
- Managing Account receivables and posting payment into payment systems
- Customer Service: following up with member Balances (collections)
- Claim appeals.
Medical Biller/Auditor
Medical Personnel Management
01.2013 - 01.2016
- NexGen Systems (Benefit, Provider contracts, limits, and pricing (copays, deductibles, and coins)
- Auditing Medical, Dental and Pharmacy claims
- Claim Appeals when needed using the appropriate documentation
- Perform claim audits accurate payment for overpaid or underpaid claims
- Confirmed specific insurance and carrier procedures and processes
- Verified insurance charges and patient billing
- Provided corrections and changes to existing billing errors
- Contacted insurance and followed through with payments for claims.
Education
Business analyst fundamental, Testing strategies, python basics, SQL, Power BI, Excel, Tableau -
Udemy, LinkedIn Learning, Linda.com
05.2024
Medical Billing and Medical Administration -
University of Health & Human Services
Montclair, CA01.2013
Skills
- Healthcare Claims and Benefits Testing
- SQL and Databases
- Quality Assurance
- Agile Methodology
- User Acceptance Testing
- Documentation
- Process Optimization
- Operations Analysis
- Excel(including running macros)
- Tableau Experience
- Gap analysis
- Test case scenarios
- Consulting
- Data and Analytics
Certification
- AAPC certification for Medical Terminology, and more.
- Medical Billing and coding
- QA Manual Testing, Agile
- Business Analysis: Essential Skills: LinkedIn Learning
- Cloud Computing: Core Concepts: LinkedIn Learning
- AWS Intro for Non-Engineers: LinkedIn Learning
- Introduction to Career Skills in Software Development: LinkedIn Learning
- Python for Non-Programmers: LinkedIn Learning
- QA Testing Methodologies – Udemy
- Business Analysis Fundamentals – Udemy
Languages
Spanish
Native or Bilingual
Timeline
Sr. Business Analyst
UnitedHealthcare
06.2023 - Current
Software Quality Analyst II
Change Healthcare
01.2021 - 05.2023
Quality Assurance Analyst
Change Healthcare
01.2019 - 01.2021
Medical Claims Examiner (Facets)
McKesson
01.2016 - 01.2019
Account Receivable Representative
McKesson
01.2016 - 01.2016
Medical Biller/Auditor
Medical Personnel Management
01.2013 - 01.2016
Business analyst fundamental, Testing strategies, python basics, SQL, Power BI, Excel, Tableau -
Udemy, LinkedIn Learning, Linda.com
Medical Billing and Medical Administration -
University of Health & Human Services