Bertram Pampanin

• Providing Benefit, Contract, Fee Schedule and all general configuration support for QNXT Medicaid, Medicare, MediCal and Commercial clients

• Successfully led the complete configuration implementations of newly acquired markets and several market

expansions

• Gathered and reviewed client business requirements to develop, test and document the most

effective configuration

• Performing in-depth root-cause analysis of claim defects to efficiently identify and remediate

configuration defects

· Implemented and maintained custom, RBRVS and Medicaid UCR Fee tables

· Trained health plan and claims department personnel on QMACS/QNXT functionality

· Configuration of QNXT to interact with the MicroDyn pricing system and other extended pricing systems to properly meet Medicare/Medicaid payment and processing requirements

· Configuring system to meet prompt payment claims requirements including interest payment based upon each health plan’s specific guidelines

· Implemented QNXT version upgrades from QNXT up to and including v identifying new functionality between versions as necessary

· Maximized the automation potential of the QNXT claims adjudication operating system by ensuring that it is accurately and effectively configured, documented and maintained

· Served as integral QNXT liaison between client and several state Medicaid health plans, as well as various commercially-based lines of business

· Configured contracts and benefits as required by self-funded plan’s business needs

· Tasked with assisting in the development and documentation of procedures related to the updated Javelina system ‘SIE’ and ‘DC Tran’ data conversion processes and procedures

· Worked with El Dorado client to facilitate the import of 834 membership data records and 837 claims data records. This includes all necessary Javelina configuration. This also includes generating the necessary edi records. Also, tasked with review and resolution of errors returned once the edi records are processed in Javelina.

· Assisted data conversion team with the conversion of data from a mainframe, ‘flat file’ system to the ‘relational’ Javelina healthcare claims administration enterprise system. The type of data converted included Physician, Facility, Connector, Network, Enrollment (Employee and Dependents), Notes, Master File Maintenance, Images, Authorizations/Referrals and Claims data

· Once data was successfully converted, assisted in quality assurance duties in order to ensure the accuracy and integrity of the converted data loaded into destination Javelina system. The quality assurance procedures included both SQL queries to pull and compare before and after data files as well as analyzing data through the Javelina user interface

· Assisted in the testing and subsequent documentation of all Javelina system enhancements and version updates

· Assisted the data conversion team in the identification, documentation and reporting of all errors, and defects identified through the quality assurance procedures. Also provided input, documentation and examples to the development team to help facilitate the correction of the stated defects

· Worked directly with large government and self-insured Javelina client users to gather requirements in a benefit analyst capacity as part of three separate system implementations

· After gathering business requirements, wrote business and system use cases in order to establish system enhancement needs and subsequent requests

· Work as lesion between the El Dorado development group and the user group to facilitate the creation of proposed system enhancements

· Work as a subject matter expert related to Javelina system functionality

· Designed and created error reports to be delivered to the client that included the details pertaining to each error returned when the EDI import or export processing for the following Javelina system entities has been completed in Javelina.

· Analyzed the root cause, and provided detailed Javelina system, technical or policy & procedure development solutions in order to address, as well as assist, in the correction of the EDI import/export process errors returned following the data import of each of the following entities into Javelina.

· Provider

· Member

· Accumulators

· Claims

· MRDT Data

· El Dorado Inc. Javelina claims system experience implementation experience on all modules and data conversion tools

· Three total implementations, including one domestic self-insured plan and two foreign health plans

· Worked at Unisys on the QNXT claims payor/operating system designing screens for the HealthPAS variation of the system and configuring the system to allow appropriate claims payment for the states of WV and KY

· Created and assisted in testing of Member/Enrollment configuration, as well as supporting mapping documentation between the client’s mainframe system to QNXT 3.4 data tables/elements

· Completed Member/Enrollment Maintenance Contingency Plan

· Created documentation and performed presentations to demonstrate Member/Enrollment functionality changes for QNXT 3.4

· Responsible for configuring Coordination of benefits including COB carriers, COB templates, COB edits, and COB rules based upon various types of business

· Acted in a mentoring role to answer functionality questions regarding all QNXT Modules.

· Created and ran weekly SQL report to track contract and benefit terms that were set to pend, for review and manual intervention

· Worked directly with developers offering full support related to conversion of data from legacy to database systems including data mining, EDI, schema, and data mapping analysis

· Assisted Provider Contract and Benefit configuration as well as Medical Policy, and other areas of configuration in order to properly implement plan specific requirements

· Defined business requirements for clients migrating to QNXT system

· Performed conversions to QMACS/QNXT; coordinated system loads and updates to minimize user impact and optimize system performance

· Coordinated training and documentation of QNXT system; demonstrated QNXT system to prospective clients

· Received in-depth training from Cognizant (QCSI / TriZetto) regarding how to handle Medicaid and Medicare issues using available QNXT functionality.

• Liaison between MC and east coast Department of Health utilizing QMACS system
• Performed QMACS/QNXT training on State Medicaid regulations as well as plan-defined regulations
• Provided support to both internal customers and Provider Network for provider contracts, credentialing status, claims payment, authorization requirements, call tracking and member enrollment on versions of QNXT up to version 5.9
• Worked closely with Member Services and State-appointed Ombudsman to resolve membership complaints and requests on QNXT version 3.6
• Designed and implemented products tailored to client needs as well as custom reports on versions of QNXT up to version 3.6

• Managed a team of thirty claim analysts
• Oversaw the processing and payment of healthcare claims for Medicaid and Commercial insurance lines of business
• Established all quality and production standards for the claims department
• Assisted in the department of processing and procedures regarding the processing and payment of claims

· Spent years working at TPAs - have had the unique opportunity to work both as an end user and as a configuration/business analyst on many claims payor/operating systems

• · Developed claims policies and procedures based upon health plan provisions and medical claims policy

· Responsible for the development and implementation of plan contract and benefit provisions and exclusions as outlined in self-funded plan’s master benefits summary

· Evaluated medical and dental claims submissions processed on the Q-CARE and RIMS operating systems

· Trained associates on provider and eligibility module functions of the PruTrac II operating system

· Processed medical claims based upon health plan provisions and exclusions

· Special Projects Coordinator, sensitive case handling, high-dollar claim adjudication, NY DRG calculations, COB adjustments, claim appeals, and claim fraud identification

· Responsible for the implementation of new business, including interpretation of RFP’s, provider contracts, and benefit plan summaries

· Managed a staff of 19 claims analysts, claims support associates and appeals coordinators

· Established production and quality claims standards

· Oversaw all operations related to commercially based and self-funded medical and dental claims administration accounts