Electronic Data Interchange

Health care policy and Electronic Data Interchange (EDI) analyst and consultant with more than fifteen years experience in health care claims and claims processing including more than ten years in an EDI environment.  Subject matter expert for the Health Insurance Portability and Accountability Act (HIPAA); developed and implemented HIPAA security regulations and concepts in both a provider and payer environment.  Developed and implemented an effective national EDI standard using both ANSI X12 and HL7 standards.  Adept at employing Total Quality Environment (TQE) tools to focus individuals within a group work environment in order to solve significant problems.  Highly focused individual with excellent communication and team building skills.  Outstanding track record for on-time project completion.

PROFESSIONAL EXPERIENCE

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BRAVO by ELDER HEALTH; City, State

EDI Supervisor: January 2007 – Present

·         Supervise all EDI operations for Medicare/Medicaid plan, including three developers, one tester, and one data entry analyst.

·         Managed all HIPAA transactions, including assigning to developers, liaising with clearing houses, developing test protocols, and working with testers to ensure accurate and detailed implementation.

·         Implemented process of scanning paper claims to electronic format with Imagenet software; validated accuracy and HIPAA compliance of EDI claims from clearing houses prior to importation to operating systems.

·         Participated in the Bravo by Elder Health transition team, driving changeover of claims processing operations from legacy EZCAP system to QNXT system, enabling processing without intervention.  System to fully implement in April 2008.

 

LOCKHEED MARTIN; City, State

Project Manager:  April 2006 – September 2006 (contracted through Apex Systems, Inc.)

·         Lead project team of four senior analysts and three junior analysts in implementing an innovative Electronic Wage Reporting (EWR) System for the Social Security Administration (SSA).  Directed all work assignments for team of analysts, reviewing output as necessary and allocating time and house on a per project basis.

·         Documented all specifications per SSA; utilized superior communication skills to deliver written and oral presentations at various project milestones.

·         Prepared and monitored project timeline to ensure successful project conclusion to elevate the percentage of all wage reports submitted electronically from less than 25% to at least 75% by 2008.

·         Oversaw validation of Electronic Wage Reporting System through testing of three thousand wage reports over a forty-five day period in an online environment; successfully testing allowed program validation within designated contract period.

 

NORTHROP GRUMMAN MISSION CONTROL SYSTEMS; City, State

Project Task Manager: October 2004 – August 2005

·         Managed development and implementation process for the ANSI X12N 270/271 HIPAA Eligibility Request and Response system for the Centers for Medicare & Medicaid Services (CMS).  The 270/271 Eligibility Project technology specifications included MQ software, WBI Broker and WAS technology.

·         Supervised team of system developers, testers, requirement developers and technical writers to ensure all products and deliverables were conveyed to CMS within the established timeline.  Deliverables included Business/System Requirements, System Design Documents, and Internal Operational Readiness Reviews.

·         Successfully lead project to conclusion by September 2005, allowing health care providers to request eligibility information and receive responses rapidly as a part of the Medicare Modernization Act (MMA) and CMS Modernization Architecture.
MAXIM HEALTHCARE; City, State

Title: May 2003 – July 2003

·         Developed ANSI X12N formatting and coding for all ANSI X12N 837 transactions, including Provider, Intermediary and Dental, in support of Maxim Healthcare’s Home Health operations.

·         Provided programming, testing, program validation, and implementation expertise to execute ANSI X12N at one hundred Home Health locations within a two month timeframe.

 

LEXINGTON CATHOLIC HOSPITAL; Lexington, KY

Title: July 2002 – August 2002

·         Performed HIPAA 837I and 837P transaction coding evaluation, responsible for reviewing coding completed by internal hospital staff in order to validate the accuracy and completeness of coding performed by LCH developers.

·         Successfully identified all errors and inconsistencies in coding to developers, enabling that both 837I and 837P transactions were completed according to the implementation timeline.

·         Developed implementation schedule for future-slated HIPAA transaction implementations; composed an estimate of work and cost savings for implementation of all future HIPAA transactions.

 

PRICE WATERHOUSE COOPERS; City, State

Senior HIPAA Consultant, Mid-Atlantic Region: June 2001 – April 2002

·         Directed team of consultants who performed HIPAA assessments and developed specific tools to determine HIPAA compliance, including security and privacy compliance.

·         Conducted HIPAA assessments, system implementations and training on all HIPAA regulations for Magellan Health Care, Value Options Health Care, Met-Life, Sharon Regional Health Center and the New York State Department of Health.

·         Provided high level training for HIPAA senior staff at PWC centers of operations in New York and Boston; presented HIPAA training to staff personnel at a variety of health care facilities.

·         Developed implementation tools for HIPAA ANSI transactions including 837I, 837P, 837D and 835 to more readily identify data elements and requirements for payers and providers.

 

FIRST CONSULTING GROUP; City, State

Senior Consultant: April 2000 – June 2001

·         Conducted HIPAA assessment at Harvard Pilgrim Insurance Company including a complete evaluation of all current transaction gaps to be addressed to achieve HIPAA compliance; prepared written evaluation for presentation to CEO.

·         Developed HIPAA training tool for Blue Cross/Blue Shield for all HIPAA transactions, code sets and identifiers that allowed for training to be provided by teleconference for all participating Blue Cross and Blue Shield plan personnel.

·         Provided HIPAA assessment for the Veterans Administration, which identified gaps in current processing in order to achieve HIPAA compliance; delivered oral and written presentations delineating assessment deficiencies.

 

ACI GROUP CONSULTING; City, State

Senior Consultant: January 2000 – April 2000

·         Produced HIPAA transaction training materials for awareness and detailed training sessions; delivered three-day HIPAA interactive training sessions to federal Medicare Regional Office personnel at 10 regional offices.

·         Developed ANSI mapping exercises to build basic awareness for trainees in how to map HIPAA transactions.

 

HEALTH CARE FINANCE ADMINISTRATION; City, State

Project Officer: 1986-2000

·         Developed and implemented national health care standards under HIPAA for supplemental information or attachments to support claims transactions.

·         Began work with HIPAA legislation in 1996, instrumental in developing two sets of transactions that became standardized and universally accepted in health care claims transactions.

·         Developed and tested ANSI X12N 276/277 Request/Response for Claims Status; published implementation guides for ANSI X12 transactions.  Modified existing ANSI X12 instructions for incorporation into Medicare contractor requirements.

·         Developed evaluation and testing criteria for providers, health plans and vendors for 276/277 Request/Response for Claims Status transaction; produced Medicare instructions manual for 276/277 Request/Response implementations.

·         Initiated all data maintenance requests for ANSI X12N transactions including 276/277, 278, 837 and 275.

·         Conducted on-site evaluations of utilization of ANSI X12N transactions by Medicare contractors.

·         Delivered presentations to various organizations on topics including a high level overview of HIPAA, its impact and its projected effect on the health care industry, as well as information on the automation of attachment.  Organizations touched included the Workgroup for Electronic Data Interchange (WEDI), the National Uniform Billing Committee (NUBC), the National Uniform Claim Committee (NUCC), the National Association of Health Data Organizations (NAHDO), the Blue Cross and Blue Shield Association (BCBSA), the Health Insurance Association of America (HIAA), Michigan Data EDI and the American Medical Association (AMA).

·         Delivered HIPAA tutorial presentations at HL7 meetings, giving an industry overview of HIPAA, its impact and drawing a picture of work to be accomplished prepare for HIPAA implementations.

·         Presented testimony on scope of Attachment Project using dual ANSI standards (X12 and HL7) within one transaction to the National Committee on Vital and Health Statistics (NCVHS) in Washington, D.C.

·         Wrote evaluation paper for utilization of ANSI X12 276/277 Claims Status and ANSI X12 275/277 with HL7 Attachments transactions for utilization within the national health care community.

·         Served as Facilitator for Total Quality Environment (TQE) within the Health Care Finance Administration; trained six Medicare regions on TQE and problem-solving using this strategy.

 

TECHNICAL PROFICIENCIES

Highly proficient in Lotus 1-2-3, Word Perfect, Microsoft Word, Microsoft Project, Microsoft PowerPoint and other Microsoft Office programs.

 

EDUCATION

Bachelor of Arts in Business Management; University of Baltimore; Baltimore, MD.

Bachelor of Arts in Health Management; Towson University; Baltimore, MD.

 

References available upon request.

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