Profile of Claudine Elizaga EDI, HIPAA implementation, QNXT upgrad/implementation

Claudine Elizaga ( Available )

Palm Harbor, FL - 34685 USA

Expertise :	EDI, HIPAA implementation, QNXT upgrad/implementation
Status :	Citizen
Job Type :	All -
Position :

Resume

Summary

Over 17 years of experience in operations and information systems, in a variety of health care fields, both in the provider and managed care sectors, : Home Health Care, Internal Medicine, Emergency Medicine and Commercial, Medicare and Medicaid Health Plans. Specific areas of experience include but are not limited to the following : Business analysis, Process improvement and documentation, Application documentation and training, Medicare, Medicaid and Commercial insurance, System design, upgrades and implementation, IT production support

Employment

January, 2008 - December, 2008
Senior Business Analyst, Consultant

Mercy Health Plans, Inc

Prepare, write and update the mapping documents, business requirement documents and technical specification documents for the inbound and outbound EDI processes for both HIPAA compliant files and proprietary files for various Trading Partners for the implementation of the QNXT system.
Design screen flows, data process flows and functionality.
Coordinate with developers, architects and the business in the implementation of the system and process workflow for the inbound and outbound EDI processes.
Write the documentation for the necessary processes and procedures for the various trading partners.
Coordinate and update the documentations required for Texas CHIP s Readiness Review.
Manage and coordinate the QA and UAT testing of the inbound enrollment process for different Trading Partners and the QA testing for outbound encounter process.
Created test scenarios for integration testing and worked with the customer to develop user acceptance test criteria.
Coordinate and provide updates to the CORE Team on issues and changes in requirements for the EDI processes.
Support the developers and QA team on the development and testing of the outbound encounter and inbound enrollment and online enrollments for different Trading Partners.
Facilitate open and effective communication in and between the development team and the business.
Foster and maintain good working relationships with customers and colleagues to meet expected deliverables.
Provide production support and troubleshoot production issues on different Trading Partners for the enrollment processes.

September, 2006 - January, 2008
Supervisor, IT Operations

Wellcare Health Plans, Inc.

Interact with healthcare providers, executives and staff to implement and operate compliant EDI solutions.
Experienced in the use of EDI tools, HIPAA Implementation Guides and analytical tools.

Coordinate with Provider Relations, Health Services, Operations, Legal Services and other business Areas to ensure that providers have sufficient contact and education to exchange electronic transactions.

Assist Provider Relations in promoting EDI to the provider community to achieve strategic corporate objectives related to increased transaction volume.

Organize, prioritize, coordinate and administer the day-to-day activities and workload of the IT EDI Operations team, like : Ensure that the daily proprietary and HIPAA compliant professional and institutional files for the EDI Load process meet the SLA and perform EDI Load reposts for the Claims Department
Monitor the AutoSys Scheduler for job failures and issues and escalate to the necessary IT or business owners via e-mail and Magic tickets for resolutions
Kick off jobs in the AutoSys Scheduler as requested by the business
Enter new jobs via job turnover form in the AutoSys Scheduler as requested by the business

Support production processes like membership listing, eligibility file extracts and loads, RAPS process, TRR for PDP and MAPD processes, 837 encounter file extracts and loads, 820 file loads, etc.
Perform EDI file transfers/transmissions as requested by the business
Update the daily, weekly and monthly reports for upper management s review
Monitor BizTalk and escalate BizTalk issues as needed
Perform the Check Run and CAP Run processes for all lines of business for the Finance Department
Extract, analyze and transmit 835 files to the vendor
Provide change control management support via deployments of approved programs.

Provide operational oversight and administration to ensure that the delivery of information systems solutions meets or exceeds the expected business requirements and work is completed and delivered on time and in budget
Analyze, write and update business requirements for automation of manual processes
Update the Sarbanes Oxley audit reports for the encounter files to maintain compliance
Write/update the documentations on all the necessary EDI processes and procedures for the IT EDI Operations team

Monitor and report to IS, business and customer management on the status and progress of project efforts, anticipating and identifying issues that could inhibit achieving the project goals and objectives and implementing corrective actions and mitigation strategies.
Provide first level support, troubleshoot and maintain production systems to optimize performance, resolve problems and provide timely follow-up on identified issues.
Facilitate open and effective communication in and between the development team, the business and external customers.
Foster and maintain good working relationships with customers and colleagues to meet expected service levels.
Motivate, mentor, train and lead the operations team to achieve high productivity, high quality and develop effective business solutions.
Conduct annual employee performance reviews.

Assist with technical training and user education as needed.

February, 2006 - September, 2006
Business Analyst

Wellpoint, Inc

Wellpoint, Inc Membership and Data Analysis Group, State Sponsored Business
Business Analyst II
Manage the eligibility and encounter file production for the State of California and encounter file production for the States of Virginia and West Virginia.
Write the documentations/job aids of all the necessary eligibility and encounter file processes and procedures for each state.
Prepare and write business requirement documents for a variety of existing eligibility and encounter processes and for new business acquisitions and their Readiness Review.
Review the existing logs and develop new logs and audit the documentation of processes.
Develop and modify existing management reports.
Update the Sarbanes Oxley audit reports for the encounter files to maintain compliance.
Execute, monitor, do quality check and troubleshoot on the existing and future automated programs and processes but not limited to the import and loading of the eligibility files ; generation and transfer of outgoing encounter files ; import the eligibility files and export the encounter files electronically.
Provide support to the users of the applications related to the processes or related areas. Do data analysis of the rejected 997 s and error reports received from the state, correct the issues and resubmit the files.

Coordinate with programmers, other departments and vendors to request enhancements or bug fixes in programs used by the processes.
Map the state s proprietary and HIPAA compliant file formats to Wellpoint s WGS 2.0 or Peradigm s file formats
Manage and coordinate the testing of the encounter file extract process for Wellpoint, various Vendors and the State of Ohio.

December, 2004 - February, 2006
Operations Analyst

Molina Healthcare, Inc.

Manage the eligibility, claim and encounter file processing for the States of Michigan and Indiana.
Coordinate with programmers, claims department and vendors to request enhancements or bug fixes in programs used by the processes.
Update the Sarbanes Oxley audit reports for claims and eligibility files to maintain compliance.
Write the documentation on all the necessary eligibility, claims and encounter file processes and procedures for each state.
Review the existing logs and develop new logs and audit the documentation of processes.
Develop and modify existing management reports.
Gather requirements for future processes and implementation.
Execute, monitor, do quality check and troubleshoot on the existing and future batch programs and processes but not limited to the import and loading of the MI and IN eligibility, encounter and claim files ; generation and transfer of outgoing encounter submission files ; import and export the eligibility/encounter files electronically ; and do mass adjudication.
Provide support to the users of the applications related to the processes or related areas.
Provide back-up coverage for the eligibility, claim and encounter file processing for the States of Washington and Ohio.

May, 2002 - December, 2004
Supervisor, Emergency Medicine Billing Office

UCLA Physician Support Services

Manage the professional billing office of UCLA Emergency Medicine.
Supervise staff with daily operations.

Provide proper training to ensure maximal efficiency and effectiveness.

Delegate work to staff, provide direction and review as needed.

Manage all aspects of the daily operations from the collection of ER charts, submission of charge documents, ensure the use of the correct CPT and ICD-9 coding, charge entries, to the monitoring of collection activities. Review daily production reports of staff ; determine problem areas ; meet with individual employees to discuss resolution.
Provide disciplinary counseling to staff, as necessary.
Assist the Director, Assistant Director and Chief Financial Officer on various special projects.

Develop office procedures, reference materials and training programs for staff members to expedite the billing and collection of account receivables.
Review, troubleshoot and resolve complex account problems with staff.
Conduct daily correspondence reviews.
Propose or recommend solutions to the operational areas, where there are difficulties and processing problems ; implement procedures that allow staff to be shifted to areas with heavy inventory demands.

Coordinate and correspond with clients, physicians, coding company, insurance representatives and other UCLA departments for accurate medical and insurance information and grievances, verbally or in writing.
Exercise excellent customer service. Facilitate and conduct staff meetings to resolve issues on compliance and proper workflow.

Prepare weekly, monthly, quarterly and annual summary reports for the UCLA Emergency Medicine.
Provide insurance companies, DHS and Medicare with completed provider application forms to update the credentials of UCLA Emergency Medicine physicians.

June, 2001 - May, 2002
Patient Biller III

UCLA Physician Support Services

Manage accounts receivables for the Department of Primary Care Network with a focus in Internal Medicine and Managed Care.
Prepare, correct and bill professional claims for all payer sources.

Coordinate and correspond with clients, physicians, clinic and office staff and insurance representatives for accurate medical and eligibility information and claims status to expedite billing and reimbursement of claims. Analyze/solve complex claim issues.
Exercise good customer service.
Exceed daily production quota and provide management with production reports.

November, 1994 - June, 2001
Patient Biller III

UCLA Medical Center Home Health

June, 1991 - November, 1994
Biller and Collector

Foremost Healthcare, Inc

Audit patients charts for pre-billing, coding ICD-9 codes and CPT codes, proper documentation and compliance issues.
Manage accounts receivables.
Prepare, correct and bill home health claims for all payer sources.
Coordinate and correspond with clients, insurance representatives, case managers and care providers for accurate eligibility information, proper authorizations and reimbursements.

Assess training needs for the billing department.

Develop and implement appropriate training programs and systems to expedite billing and reimbursement of claims.
Analyze/solve complex claim issues.
Assist upper management with account determination and statistical reports.
Post all payments to the proper accounts.
Facilitate and conduct staff meetings to resolve issues on compliance and proper workflow. Write minutes during staff meetings.

COMPUTER KNOWLEDGE :
QNXT
SQL
Peradigm/Diamond
WGS 2.0
Tibco
Autosys Scheduler
EDIFECS SpecBuilder
Version 1
Microsoft Excel
Microsoft Power Point
Microsoft Access
Microsoft Word
Microsoft Visio
Microsoft Project
Mercury Quality Control
Adobe Photoshop
Adobe Illustrator
Macromedia Director
Macromedia Flash
Macromedia Dreamweaver
Corel Bryce
Macromedia Fireworks
QuarkXpress
HTML
Adobe After Effects
Adobe Premiere
Final Cut Pro

Education

University of the Philippines

Diliman, Quezon City, Philippines

June 1986 to March 1992

Bachelor of Science in Clothing Technology

Skills

QNXT 3.4

Peradigm/Diamond

WGS 2.0

Tibco

AutoSys Scheduler

EDIFECS SpecBuilder

Version One

Microsoft Excel

Microsoft Power Point

Microsoft Access

Microsoft Word

Microsoft Visio

Microsoft Project

Mercury Quality Control

Adobe Photoshop

Adobe Illustrator

Macromedia Director

Macromedia Flash

Macromedia Dreamweaver

Corel Bryce

Macromedia Fireworks

QuarkXpress

HTML

Adobe After Effects

Adobe Premiere

Final Cut Pro