Loraine W. Brown

Summary

Health Care Claims Conﬁguration and Business Analyst with over 20 years of managed care payer and provider expertise relating to plan beneﬁts, provider implementation and member enrollment. Key areas of focus are data analysis, business process improvement, requirements gathering and documentation, claims conﬁguration, claim compliance and audit review, full suite testing, user acceptance / system integration / regression using the business systems Facets, QXNT, HRP (HealthRules). Additional aspects of conﬁguration include provider pricing utilizing Network and DST Pricer for 5 years and Beneﬁts auditing for both Commercial group sales and Medicare Advantage plans.

Overview

13

years of professional experience

Work History

Product Manager

Aetna

10.2021 - 08.2025

Participated in front end claims edit processes to align existing business processes to future state platform implementation based on vendors requirements.
Ensuring that all requirements gathered from Product owners were simplified and present to business stakeholders for easy translation before adding epic/features/user stories and backlog prioritization.
Investigate and resolve configuration related provider, member, claim processing and clinical operations issues and assist other departments in understanding configuration rules.
Provided configuration set-up for provider’s contracts, configuration using Networx pricer. Ran QA testing for assigned plans both Regression and UAT testing. Created SQL and V lookup formulas to help with UAT testing. Testing was completed for both Medicare and Medicaid claims. Utilized both HRP platform and QXXT for this company.

Business Analyst – Government program Configurations

CareSource

02.2021 - 10.2021

Contracted with CareSource to provide business analysis to resolve configuration issues with several governmental programs.
Engaged with assigned product owners and business stakeholders to research and document all current state operational processes spanning pre-claims, adjudication, post payment operations, and payment reconciliation within Facets.
Participated in front end claims edit processes to align existing business processes to future state platform implementation based on vendor capabilities. Familiarity with CMS rules and regulations was a requirement that I had ensure that all guidelines were being met. This also was important to ensure that all state guidelines were also being met for state plans (Medicaid).
Worked within the department to co-write and streamline the SOP for all new business analysts.
Worked with the Configuration team and MSO regarding issues with Configuration with NetworX Pricer on Facets and QXNT system.

Program Analyst / Business System Lead – Government program Claims and Enrollment Billing and Reconciliation

Atos Syntel

Norfolk, USA

12.2019 - 04.2020

Contracted with Atos Syntel to provide claims operation and enrollment business analysis and documentation development within the Facets system for Anthem BCBS’s enterprise roadmap initiative for claims modernization and enrollment / reconciliation improvement initiatives spanning for all impacted government programs both internal and BPO services while implementing an additional PEGA system.
Engaged with assigned product owners and business stakeholders to research and document all current state operational processes spanning pre-claims, eligibility, adjudication, post payment operations, enrollment, membership billing and payment reconciliation within Facets.
Participated in PEGA Smart Claims Engine v8.3 training for front end claims edit processes to align existing business processes to future state platform implementation based on vendor capabilities. Provided Enterprise Architects and Product Manager with existing business requirements, technical requirements along with rationale to validate platform capabilities for out of the box vendor solutions vs. in-house product builds utilizing developers and systems engineers.
Ensuring that all requirements gathered from Product owners were simplified and presented to business stakeholders for easy translation before adding to epic/features/user stories and backlog prioritization.
Developed Visio Flowcharts including platforms and processes integration (hand-off points) with call outs of file payloads and data points (EDI T837 de-batch, parsing, 834 / transaction reply to reports E/DE/CT TRC)

System/ Business Analyst

United HealthCare

03.2012 - 10.2019

Investigate and resolve configuration related provider, member, claim processing and clinical operations issues and assist other departments in understanding configuration rules.
Design, configure, test, implement, and maintain configuration payor pricing membership, claims and/or benefit configuration rules and clinical operations. (Care management and Utilization management).
Configured and worked in Facets and QXNT systems depending on claim and plan product using such program as NetworX also using Data mapping for configuration.
Performed all Facets assigned membership and division configuration set-up and operations maintenance.
Provided business requirements and compliance regulations for system upgrade from River Valley to Facets.
Provided configuration support for all new Facets software changes/updates by providing various levels of testing and quality assurance to ensure that software features are performing as expected. Performed User acceptance / system integration /regression testing for all 27X EDI files. Use Jira system to help control the work intake and the responsibilities of the analysts.
Provided extensive side by side training of new hires inclusive to supervision of basic and complex comprehension of fundamentals of provider pricing configuration.
Ensured that new contracted providers / facilities were correctly reviewed, configured and tested based on documentation from Federal / State guidance.
Worked with claim workflow using the Jira methodology.
Performed standard benefits, provider pricing configuration using the BPA tables and NetworX pricing tool.
Implementation and configuration of Health Edge business system with being able to interpret the coding tables, workflow analysis, Utilization and benefits analysis and maintaining customer relationship.
Successfully converted a health plan from River Valley to Facets.

Education

Some College (No Degree) - Human Biology

Francis Marion University, Florence, SC

Skills

Business Analysis
Technical Analysis
Implementation
Agile/Jira Methodology
Configuration both Benefit and Pricing
Deep Dive

Data mapping
Requirements Documentation
Systems Testing
Staff coaching
Mentoring
SQL/Microsoft Access reports

Websites

http://www.linkedin.com/in/loraine-brown-19198b52

References

Available upon request

Career Accomplishments

Successful in the Facets conversion of Iowa Medicaid product from River Valley platform to Facets.
Successful in working on the project introduction into Health edge and Health Rules payor system.
Successful in the implementation of adding ICD-10 codes into the Facet benefit table.
Successful in leading a 2-year project by overhauling the EPAL (authorization and coverage) table.
Completed training and initiated training for Jira methodology. Helped with the distribution of work and stories.
Successfully documented the end-to-end 87/enrollment operations for Wipro 360 enrollment solution including workflows, processes and CMS requirements for Medicare Advantage, Special Needs Plan and MMP.

Work Preference

Job Search Status

Open to work

Work Type

Contract Work

Location Preference

HybridOn-SiteRemote

Salary Range

$96000/yr - $200000/yr

Timeline

Product Manager - Aetna

10.2021 - 08.2025

Business Analyst – Government program Configurations - CareSource