Maria Gonzalez
Rialto,CA
Summary
Experience in Project Management, Office Administrator, Marketing, Data Analytics, which includes Electronic Data Interchange (EDI) experience, Project Implementations, HIPAA compliance.
Overview
12
12
years of professional experience
Work History
Business Analyst Sr./Consultant III
Kaiser Permanente
06.2015 - Current
- Business Project Management on moderate- to high-complexity project implementation of New or Change transactions.
- Facilitate internal company and external meetings
- Drive completion of user (UAT) acceptance end-to-end testing including.
- Liaison with external trading partners
- Collaborate with internal Kaiser cross-functional teams to identify and resolve root causes of issues that impact encounters and identify improvements to operational performance
- Claim rejection analysis and error management
- Create all project documentations for implementation – Test Plans and Test Summary
- Maintain and coordinate our validation system on custom edits, instream validation updates & crosswalk table updates, portal updates, Tibco Communications, and system performance Issues
- Operational Metrics Reporting via Excel: Maintain SharePoint intake database, Claims metrics reporting by using Splunk query reports, Validation system reporting, Run Service Now portal reports
- Support our validation implementation release team in staying on track for deployments and other activities that stabilized and improve performance
- Participate in releases and maintenance
- Provide support to Medicare Advantage Encounter Data rejection analysis to the Error Management team
- Research and data analyze Inbound/Outbound HRR Claim Files
- Assist Kaiser internal auditors and regional business for resolution of external audits for line of business Medicare Sr Advantage claims
- Provide support to claim file/claim rejection analysis when requested
- Infrastructure: Business Project Management support to IT KPEG system team to ensure all upgrades and implementations are completed.
Contract Position
Kaiser Permanente
06.2014 - 06.2015
- Region Claim Submissions – MAEDS (Medicare Advantage) Encounters – Track claim submissions from Regions to CMS
- Track claim submissions from regions
- Manage SOX controls for complete and accurate audit reports of data submission for auditors
- Error Management – trouble shooting and resolution, coordinating with internal and region business
- Data analytics reporting
EDI Processor/Eligibility Coordinator II
OPTUM NAMM
06.2013 - 06.2014
- Health Plan file data downloads (BlueShield, BlueCross, Aetna, United, Health Net, Cigna)
- Data analyzing, Parse data, map providers and benefits, submit plan codes for configuration
- Review, process and post to Xcelys
- Process NE request through NAMM system
- Support responses to physician office and internal customer Service submit request for verification of member eligibility
- Internal and external customer support to physicians office and internal Customer Service
- Verify via Health Plan websites and contact Health Plans and verify member eligibility
- Verify and update member records in Xcelys on received PHI forms
- Reconciliation discrepancy reports – review assigned IPAs and update Xcelys with findings
- Analyze Demographic issues: DOB, Name, Not in System, Copay, PCP, IPA changes or add
- Coordinate members updates with Capitation, Configuration, internal Customer Service, Claims Team
- Train temps.
Contract Position
Kaiser Permanente
07.2012 - 05.2013
- Executive Admin II
- Support all Administrative and operations of the department
- Centers for Medicare and Medicaid Services (CMS) support
- EDI transmission tracking - Excel Error logs
- Triage encounter data communications on KPEG Error resolution with Regions/Business PM/IT PM (internal and external claims)
- Research and data analyze Inbound/Outbound HRR Claim Files
- Entry and maintenance of MS Access database for error tracking
- Change request of edit codes for CMS
- Remedy Work Order entry and follow-up
- Control Tower and other CMS support meetings
- Infrastructure Claims Support
- Production support process to CMS
- Foresight code table updates
- Health Insurance Portability and Accountability Act (HIPAA) Guideline updates
- KPEG Custom edit maintenance
- KPEG Instream Validation Sheet
- Maintain and update Foresight Master Sheet for validations
- Attend meetings as required from Regions and Claims.
Education
Bachelor of Science, Business Administration -
Southern New Hampshire University
Associates of Arts, Management Information Systems -
San Bernardino Valley College
Certificate of Achievement, Microcomputer Programming Specialist -
East Lost Angeles College
Skills
- Data Analysis
- Requirements Gathering
- Microsoft Office Suite
- Project Management
- User Acceptance Testing
- Business process improvement
- Test case scenarios
- Operations Management
- Operations Analysis
Languages
Spanish
Professional Working
Timeline
Business Analyst Sr./Consultant III
Kaiser Permanente
06.2015 - Current
Contract Position
Kaiser Permanente
06.2014 - 06.2015
EDI Processor/Eligibility Coordinator II
OPTUM NAMM
06.2013 - 06.2014
Contract Position
Kaiser Permanente
07.2012 - 05.2013
Bachelor of Science, Business Administration -
Southern New Hampshire University
Associates of Arts, Management Information Systems -
San Bernardino Valley College
Certificate of Achievement, Microcomputer Programming Specialist -
East Lost Angeles College