Summary
Overview
Work History
Education
Skills
Timeline
Generic

Paula Peak

Senior EDI Analyst
Tamarac,USA

Summary

Experienced Senior EDI Analyst skilled at analyzing and solving complex problems. Identifies inefficiencies and implements effective solutions to enhance operational performance. Proficient in leveraging data analytics and possesses strong communication abilities to drive strategic initiatives. Demonstrates a proven track record of success in improving processes and achieving organizational goals.

Overview

25
25
years of professional experience

Work History

Sr. EDI Applications Design Analyst

Gainwell Technologies
08.2021 - Current
  • Integration of MMIS for the State of OH, KY, MT, MI
  • Understanding current state requirements and performing systems operations jobs duties to prepare for operational readiness
  • Collect requirements regarding system enhancements or new system implementation and prepare details of specifications needed; prioritize and implement requested changes to the system
  • Investigate standardization and process improvement opportunities while making build decisions
  • Troubleshoot, identify root cause, and document problems of simple to medium complexity for assigned applications and systems
  • Analyze and manage systems or third-party vendors/service providers to ensure service level agreements are met
  • Assist Senior Manager leading the DDI and System Operations transition and have a team of developers and infrastructure personnel to support
  • Assist in planning, architecture, analysis, and design of enterprise technology solutions that satisfy business requirements for large complex systems in the Medicaid/MMIS or health insurance claims and pricing space
  • Prepare and participate in Change Control Board meetings
  • Development (enhancement and maintenance) of enterprise technology solutions that satisfy business requirements for Medicaid and CHIP claims, enrollment, rates, providers
  • Attend walkthrough reviews, verify test case completion, participate, and assure results are posted
  • Plan and monitor release results against established timelines, deliverables, tasks, dependencies, and associated technical specifications
  • Perform Batch, Realtime and interface operations including FTP, scheduling, and error handling within specified SLAs

Senior Systems EDI Analyst

Pulse8 Inc/Allscripts
07.2019 - 07.2021
  • Support encounter data reporting processes for EDPS, RAPS and the EDGE server, including tracking, reporting, and resolving rejections
  • Perform ACA and MA Submissions for Clients
  • Monitor CMS data submission deadlines for both MA and ACA lines of business
  • Review and understand periodic CMS software releases which impacts both the ACA and MA submissions
  • Understand RAPS and EDPS filtering logic which CMS uses for Risk Adjustment and/or Risk Score calculations
  • Conduct gap analysis and data validation, identifying possible issues in data submission and determining financial impact
  • Analyze and reconcile claims and encounter data which will include 837 EDI encounter files for EDPS, RAPS and Edge Server submission files
  • Perform research in the encounter management system (Edifecs) and liaison with the CSSC Helpdesk for exception resolution
  • Comfortable with raw data files in their native format and accessing these through various servers
  • Provide technical support to enterprise clients related to technical and operational aspects of the products
  • Partner with Product Support Engineers and development teams as necessary
  • Assist development team with performance analysis and testing during release cycles for service packs, hot fixes etc
  • Respond to client inquiries regarding file issues
  • Collaborate in virtual teamwork with other Product Support staff
  • Host online troubleshooting and investigation sessions on customer’s production environments
  • Deliver a consistent, responsive and satisfying customer experience with each contact
  • Successfully reproduce customer issues in a controlled test environment
  • Follow standard operational procedures for case management
  • Continuously improve troubleshooting skills, product expertise, and knowledge on related technical topics
  • Update knowledge base / create reusable documents, originating from patterns observed during customer issue troubleshooting
  • Understand and keep track of CMS model changes which details about eligible Risk Adjustment codes (diagnosis, CPT, HCPCS, etc.,) for submissions

Systems Analyst Advisor (Supervisory Role)

Simply Healthcare Plans an Anthem Company
03.2018 - 07.2021
  • Managing client expectations and eliciting requirements from end user
  • Analyze business requirements/needs and translate into functional and or technical specifications
  • Deliver requirements, perform analysis and evaluate downstream system, process and/or organizational impacts
  • Plan and assist with oversight of test planning and execution including defect identification and resolution, including BETA testing as needed
  • Provides subject matter expert support to internal business partners by quickly triaging and responding to business partner inquiries
  • Work closely with Business Partners, Developers and Quality Assurance Analysts to ensure requirements and design are completely understood
  • Communicate design to all stakeholders and varying levels of the organization
  • Act as the liaison between Business Partners, Developers and Project management groups
  • Work closely with business teams to strategize solutions that support long-term business objectives
  • Ensure IT deliverables align with business requirements with measurable results
  • Collaborate with QA team to ensure testing efforts align with system deliveries and business processes
  • Lead and mentor other Systems Analysts
  • In depth knowledge of tools utilized
  • Develop estimates for application functionality enhancements

EDI Systems Analyst II

Simply Healthcare Plans an Anthem Company
12.2015 - 03.2018
  • Responsible for supporting encounter submission environment (specifically Medicare and Medicaid – CMS & AHCA)
  • Analyze EDI files from Carriers and Vendors and identify the root cause for EDI file rejections
  • Review and assess the quality and accuracy of SHP’s current HIPAA Companion Guides for healthcare x12 transaction sets to include 834, 837, 835 and 999, 270/271, 276/277
  • Manage current EDM applications to ensure EDI files are scrubbed of errors
  • Add Edits as necessary in Stored Procedure DataBase
  • Test files in QA and Production environment
  • Recommend and draft specific updates to Companion Guides and submit for review by EDI Manager and key business stakeholders
  • Perform Daily inbound and outbound EDI process workflow and accuracy analyses; ensure processes are completed correctly on time; perform necessary quality assurance; assess and communicate any issues related to these processes with internal/external entities when necessary
  • Identify data anomalies and gaps; troubleshoot data in/outbound processing errors and propose solutions
  • Create Reports using SQL to validate Data and track paid, pending or denied encounters

Lead EDI Business Systems Analyst (Consultant)

Centers for Medicare/Medicaid Services-FFM
10.2014 - 10.2015
  • Work with the Federal Government on the Healthcare Exchange
  • Analyze FFM (Federally-Facilitated Marketplace) records as part of the ER&R (Enrollment Resolution and Reconciliation) project based on 834 transaction files received for Baseline enrollment
  • Main liaison between trading partners nationwide as well as state Medicaid organizations on all EDI related issues or conversions
  • Perform root cause analysis
  • Perform testing and thoroughly document issues
  • Review documented training material for accuracy and assist in end user training and support
  • Data Mining and Peer Review of completed cases
  • Guide and Mentor Team members on new Processes and Policy updates
  • Work with Stake Holders and Project Managers on new initiatives
  • Lead EDI projects converting and implementing X12 transactions involving but not limited to 834,835,837, and 277
  • Responsible for troubleshooting and resolving errors in 834 and 820 transactions for health insurance exchanges
  • Support all phases of the design, development, and implementation of the Enrollment Resolution and Reconciliation Process for health insurance exchanges
  • Advised on changes for the system design, methods, procedures, workflows and policies that effected the Medicare/Medicaid claims processing in compliance to government procedures such as HIPAA and EDI formats as well as ANSI

Senior EDI Business Systems Analyst (Consultant)

Univita Health
06.2014 - 08.2014
  • Working knowledge of ANSI X12 healthcare EDI specifically 837 (Professional & Institutional), 276/277 and 835 file formats
  • Technical skills include MS Project, MS Office Tools, MS Visio, UltraEdit, SharePoint, basic SQL query and TFS
  • HIPAA Standard Transactions, Implementation Guide, Specifications and HIPAA X12, Changes and Implementation
  • Perform for UAT Testers with Healthcare Claims UAT testing
  • Understands 835, 837, ICD 9, ICD 10, HCPC, CPT
  • Assist the development team in identifying and correcting errors and issues identified by internal and external customers
  • Set up and create Plan file Layout and Mapping documents as part of ACHA/MMA Implementation
  • Work closely with the Business Analyst and Development team in creating Encounters for 3rd Party billing to State Agencies (i.e
  • Medicare/Medicaid)
  • Determine error correction based on the encounter rejections and track encounter submission to the payers
  • Interpret Implementation and Companion guide documents such as (837, 835, 834 and 276/277) to create processes to resolve rejections and streamline operation
  • Also advance knowledge of the EDI Guide and Overview, Claims EDI, Medical EDI and claim related transactions such as EDI 834, EDI 835, EDI 837, EDI 277 CA /EDI 277 U, EDI 997
  • Responsible for individual project management and gap analysis
  • Proactively communicate and collaborate with external and internal customers to analyze information needs and functional requirements in identifying (business scope, business requirement documents, process workflows, etc.)
  • Test new or revised systems requirements against business requirements and participate in the debugging and implementation of new processes

Senior EDI Analyst

Emblem Health
08.2008 - 05.2014
  • Facilitate the 4010A to 5010A conversion process with active Trading Partners and Providers
  • Working with 837I, 837P, 997, 997R, 834 Enrollment Files
  • Maintain EDI Integrity and maintain EDI Mapping rules for HIPAA Validation software
  • Managing all EDI-related activities for the business that include 837 Institutional and Professional claims from all Insurance Carriers, Medicare and Medicaid
  • Monitoring the daily receipts and processing of claim files from Medicare contractors along with troubleshooting and resolving data transmission or content problems
  • Use of EDI data translators and validation support, i.e., Gentran and Faciledi
  • Set up and maintain trading partner profiles and transaction mappings, as well as maintaining the EDI Inquiry Problem database including evaluation of problems or issues through to resolution
  • Conduct regular audits of EDI transactions to determine accuracy and areas for improvement; and maintain EDI maps and business rules for HIPAA validation software
  • Monitor the daily receipt and processing of claim files from Medicare contractors and troubleshoot and resolve data transmission or content problems
  • Perform analysis based on claim crossover inquiries related to eligibility files and billing
  • Interface with and/or lead management and technical application teams and both internal and external business partners to define project specifications, timelines, and deliverables
  • Attend client meetings for ongoing and prospective projects
  • Involved in implementation of Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007
  • Train customers and internal employees on the data exchange processes available and the data exchange systems

Risk Reconciliation Supervisor

Vista Health Plan/Coventry Health Plans
04.2007 - 08.2008
  • Oversee daily functions of the Billing Department
  • Responsible for probationary and annual reviews for Department employees
  • Maintain accurate payroll information on department staff
  • Develop and implement department policies and procedures
  • Responsible for the reconciling and reporting of membership payments from governmental agencies i.e
  • Medicare and Medicaid
  • Determine the accuracy of risk data to validate risk scores
  • Run Queries using SQL and other data base for a comparison of financial information received
  • Interact with the internal departments such as Enrollment and IT/IS and Finance for reporting purposes
  • Transmit member information electronically to CMS and maintain accurate log of information sent and received through Argus

Lead Reimbursement Specialist

Nationwide Laboratory
09.1999 - 04.2007
  • Oversee the day-to-day productivity of Intake Coordinators and Reimbursement Specialists
  • Provide guidance and assistance to Intake Coordinators and Reimbursement Specialists
  • Work with management on system reports, accounts payable and insurance issues
  • Interact with salesmen, Field Service Representatives, trainers and/ or processors to set up billing system and maintain current patient roster
  • Inform Managers of all Deficiencies and concerns associated with assigned Regions
  • Reconciled payment discrepancies
  • Resolve Client billing and eligibility issues

Education

Diploma - General Education Curriculum

NORTH WESTERN SENIOR HIGH
06.1993

Skills

  • EDI 837I
  • EDI 837P
  • EDI 837D
  • EDI 834
  • EDI 835
  • EDI 820
  • EDI 270/271
  • EDI 2076/277
  • 820 Edifecs
  • XEServer
  • Specbuilder
  • XEngine
  • XEConnect
  • EAM server
  • Config Tools
  • MEVS config
  • XML
  • JMS
  • Webservices
  • SoapUI
  • FACETS
  • Azure DevOps
  • Response files 277CA
  • Response files 999
  • Response files TA1
  • Response files MAO-001
  • Response files MAO-002
  • Response files MAO-004
  • SQL
  • QNXT
  • EDM
  • Transaction Manager
  • ALM
  • TFS
  • SNOW
  • JIRA
  • MedTrac
  • CERRS
  • SharePoint
  • TSO
  • 4010 and 5010 GAP Analysis
  • Agile methodology
  • IDX
  • PeopleSoft
  • Excel
  • EHDL
  • Medical Manager
  • Microsoft Office
  • Medicare Billing
  • Medicaid Billing
  • Hospital Rev codes knowledge
  • Basic CPT Codes
  • ICD-10 Codes
  • Collections
  • Basic medical terminology
  • Microsoft office
  • System troubleshooting
  • Database design
  • Conflict resolution
  • Cross-functional collaboration
  • Team leadership & development
  • Client relationships

Timeline

Sr. EDI Applications Design Analyst

Gainwell Technologies
08.2021 - Current

Senior Systems EDI Analyst

Pulse8 Inc/Allscripts
07.2019 - 07.2021

Systems Analyst Advisor (Supervisory Role)

Simply Healthcare Plans an Anthem Company
03.2018 - 07.2021

EDI Systems Analyst II

Simply Healthcare Plans an Anthem Company
12.2015 - 03.2018

Lead EDI Business Systems Analyst (Consultant)

Centers for Medicare/Medicaid Services-FFM
10.2014 - 10.2015

Senior EDI Business Systems Analyst (Consultant)

Univita Health
06.2014 - 08.2014

Senior EDI Analyst

Emblem Health
08.2008 - 05.2014

Risk Reconciliation Supervisor

Vista Health Plan/Coventry Health Plans
04.2007 - 08.2008

Lead Reimbursement Specialist

Nationwide Laboratory
09.1999 - 04.2007

Diploma - General Education Curriculum

NORTH WESTERN SENIOR HIGH

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Paula PeakSenior EDI Analyst