Work closely with the IT and Underwriting department to defines and implements procedures for releasing products throughout the whole product life cycle. reporting and validating all projects assumptions utilized in the forecast and providing variance explanations between the current and previous forecasts.

1. Darlene Jones
dajones574@aol.com
Brooklyn, New York
Cell: (347) 860-7210
Innovative tech savvy professional with strong quantitative, Health care background, project management, communication
and data analysis skills. Adept at working in fast paced environments, anticipating problems, analyzing situations, meeting
critical deadlines and proactively coming up with solutions that continuously meet business needs as well as ensure
companies are in compliance with applicable accounting standards and policies.
AREAS OF EXPERTISE
 Audits and Compliance
 Business Analysis
 Benefits Management
 Systems Configuration
 Database Management
 Vendor Reporting
 Medicare benefits
 Medicaid benefits
 Pharmacy Management
 ICD 9/10
 Claims adjustment
PROFESSIONAL EXPERIENCE
CONFIGURATION ANALYST April 2011-May 2016
EMBLEM HEALTH
New York, NY
Work closely with the IT and Underwriting department to defines and implements procedures for releasing products
throughout the whole product life cycle. reporting and validating all projects assumptions utilized in the forecast and
providing variance explanations between the current and previous forecasts.
 Construct and build products for use in testing and in production; identifies and implements processes to
strengthen, streamline and automate build processes.
 Ensure consistency between the performance of a system and the purpose for which it was installed
 Work hand and hand with programmers, technicians, developers and testers to ensure the efficient performance
of configuration functions.
 Keep the system current of CPT, HCPCS, DRG, and ICD-9/ 10 codes as well as pricing, billing rates; analysis,
data entry, testing and documentation of configuration set up for all Lines of business, including Medicare and
Medicaid.
 Responsible for defining requirements detailed, analyzing business needs, and validating solutions with the
business for Production.
 Support SOX process by running audits on users and analyzing access processes and groups for metering
applications.
MEDICAL INSURANCE CLAIMS PROCESSOR May 2007 – April 2011
EMBLEM HEALTH
New York, NY
Achieve accurate and timely submission of claims through audit and processing of client data as well as continuously
improving revenue cycle processes.
 Manage incoming medical claims for multiple groups Spearheaded a broad scope of internal business processes
that encompassed the daily management of billings, collections, reconciliation, general ledger and month-end-
closings.
 Ensure timely and accurate claims adjudication
 Follow company guidelines and policies for adjudicating claims and responding to members
 Process claims with a high level of accuracy and speed to meet departmental goals
 Assist in training and development of claims analysts.
 Understand and follow mandated (i.e., HIPAA, ERISA, Etc.) regulations promulgated by state or federal
governmental agencies
EDUCATION AND PROFESSIONAL CERTIFICATIONS
Two years, Physiology, NYACK COLLEGE, NEW YORK, NY
TWO YEARS, NURSING, BOROGH OF MANHATTAN COLLEGE, NEW YORK, NY
HIPPA CERTIFICATION, NEW YORK, NY
MEDICARE/MEDICAID CERTIFICATION. NEW YORK. NY