SUMMARY

• An accomplished Operations Management and Systems Analyst with over 15 years of business management experience in the healthcare industry including revenue cycle management, development and fundraising and health information technology HIT .
• In-depth understanding of provider networks, managed care contracts, accountable care organizations ACO , patient benefit plans, and administrative procedures that support new and existing contractual agreements within hospitals and Centers of Excellence.
• Extensive knowledge of health care accreditation programs and process-The Joint Commission.
• Demonstrated understanding of HIPAA, ICD-10, and health insurance operations eligibility, enrollment, billing, claims, group contracts, etc. and claims/billing transactions including 276/277, 834, 835/837i p, etc.
• Recognized leader in the implementation of electronic medical records/health records EMR/EHR , mHealth, health information exchange HIE , and business, procedures and work/patient flow analyses for health care institutions.
• Demonstrated success in fundraising, developing endowments, leadership gifts and capital campaigns, grant writing, Board development, etc. for hospitals.
• Technical understanding of complex project management and process improvement methodologies e.g. PMP, Sigma, Change and Configuration Management, etc.
• Certification in Healthcare Business Analyst and Drug Safety Associate and Pharmacovigilance Planning.
• In-depth knowledge of FDA, International Conference on Harmonization ICH and Good Clinical Practice GCP guidelines for drug development process and adverse event management programs using Oracle Argus Drug Safety Database and Medical Dictionary for Regulatory Activities MeDRA .
• Proficient with Microsoft Office Suite Word, Excel, PowerPoint, Access , MS Visio, MS Project, Raiser's Edge, Gift for Windows, etc.
• Mathematical acumen and working expertise in statistical tools such as Spotfire and Optum.

PROFESSIONAL HIGHLIGHTS

Confidential

Vice President, Business Development Operations

• Oversees overall operations including strategic planning and provide leadership to directors, managers and officers. Provide leadership and oversight of all client engagements and make data and related decisions by maintaining, validating, analyzing and reporting data that impact operations in relation to productivity, operations, costs, quality and timely completion of assignments. Lead teams in the development and implementation of new projects. Works with executives and administrators of institutions to develop, implement, and manage service line expansion plans and new business development activities including setting strategic goals for growth initiatives. Oversees the preparation and maintenance of corporate financial and operational reports using data and analytical tools.
• Conducted end-user trainings including HIPAA , revenue cycle management, ICD-10 implementation, service line expansion, network assessments and audits for health care providers.
• Increased corporate revenue by 40 in six months resulting from strategic planning and reorganization of operations.
• Exceeded revenue projects and operational metrics annually since 2011.
• Led corporate expansion into global markets in Europe and Africa.
• Raised six-figure funds and build endowments for a leading medical center.

Confidential

Business Analyst

• Participated in transaction analysis and mapping needs, system/interface analysis, and worked with programmers to implement changes as needed.
• Developed and maintained functional specifications for new/existing applications needed to maintain/enhance EDI processing and address the requirements of new trading partners.
• Coordinated the setup of new Trading Partners, including planning, project management, testing, documentation, and implementation.
• Read and interpreted 997/999 acknowledgments and 835 responses
• Mapped 4010 and 5010 differences
• Project: The Cigna HIPAA Health Insurance Portability and Accountability Act EDI Project was about the conversion from ANSI Version 4010 to X12N Version 5010. Conducted in-depth pharmacy claims and data analysis to monitor Medicare Part D Pharmacy for payers involving Cigna Insurance, Cigna Care Network, Medicare Advantage, Medicare Parts A, B and D, Medicaid, and Commercial AETNA, HAP etc. .
• Monitored Medicare Part D contract including, but not limited to, rebate amounts, claim pricing and benefits, formulary coverage/tiering application and contractual performance measures, but also included validation of claim adjudication accuracy from both a pricing and benefit perspective.
• Established and conducted monitoring activities centered on key CMS audit findings and best practices including, but not limited to, formulary administration, point of sale edits, coverage, and claim rejected reports.
• Gathered accurate and relevant incident information and documented problems for escalation.

Program Related Investment Officer/Grants Administrator

Developed and managed social investment initiatives and annual program budget of over 20 million in grants loans, and endowments worldwide. Performed due diligence on grants and investment projects to ensure their compliance with the foundation and the U.S. Internal Revenue Service IRS guidelines. Monitored grant projects in education, environment, workforce development, tourism, economic development and financial services in the U.S. and field offices.

Confidential

Department of Health Care Coordination

Director, Medicaid Public Benefit Services

• Streamlined revenue projections and aggressively increased the reimbursement rate for public benefit programs by 40 within a seven month period. Supervised the preparation of programmatic and clinical research proposals to public and private funding sources.
• Analyzed Medicaid, Medicare, SSI/SSD, Social Security programs for impact on operations.
• Researched and wrote policy reports and position papers on benefit programs.
• Represented VIP in a variety of contexts, such as public speaking at major events, testified on HMOs before the New York State Assembly and Senate on public policy and benefit issues. Spoke to the media about the transition from Medicaid into managed care and its potential impact on patients and families.
• Led VIP into partnerships with other State and national organizations and networks such as the New York Medicaid Task Force.
• Participated in The Joint Commission JC and the National Quality Assurance NCQA accreditation survey processes.

Confidential

Weekend Nursing Home Administrator Part-Time

Supervised the operations of the 240-bed nursing home facility on weekends. Implemented quality assurance and improvement programs in compliance with new Federal and State laws and regulations. Prepared official reports for presentation to the Board of Directors, state and federal agencies. Attended meetings with the Administrator, Board of Directors, insurance companies, and Medicare and Medicaid program administrators.

Research Associate

Researched and wrote reports for policymakers on health care reform legislations and their impacts on New York State health care systems.

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