Overview

• Led the completion of project deliverables, utilizing multi-year strategic Architecture Roadmaps, Opportunity assessments, and Business cases
• A proven track record within the industry that demonstrates abilities to work closely with C level executives and line personnel
• Analyzed large Health Insurers' key business functions for improving efficiency, quality and achieving cost savings
• Impacted business areas included Marketing, Product Management, Membership, Claims, Medical Management, Finance, Provider Operations, CRM Customer Relationship Management and Regulatory Reporting
• Risk profiled health plan membership Commercial, Medicare, Medicaid
• Identified target populations for enrollment in Products utilizing risk scores, which would significantly improve Medical and Administrative Cost Ratios, resulting in significant cost savings and additional premium revenues
• Led Data Governance efforts for Member, Product and Provider domains, for a large MCOs Managed Care Organizations and PBMs Pharmacy Benefit Managers , supported by a multi-domain MDM Master Data Management implementation and an enterprise wide Data Analytics platform
• Followed an analytic consulting approach where the project team closely collaborates with the business partners to bring about operational changes through improvements in workflow and implementing new technologies
• Developed outcome metrics, value stream and score card documents
• Mentored direct reports via a hands-on approach in Business Process Modeling, Data Analysis, Business Analysis including the orchestration of Functional Requirements through Use Cases and Wireframes
• Demonstrated proficiency in interpreting and presenting information, from disparate sources, towards writing Business and Technical Requirements Documents
• Developed expertise in using Requirement and Project Management Tools, Visual Aids such as Process Flows, Sequence Diagrams, Workflow Diagrams, Data Flow Diagrams and Activity Diagrams using UML Unified Markup Language
• Demonstrated ability to drive and champion multi-year delivery roadmaps
• Demonstrated a willingness to work a flexible schedule, to accommodate project deadlines and travel requirements

Technical Proficiencies

Tools Technologies:

Productivity Software: MS Office Professional Suite Word, Excel, PowerPoint

Visual Modeling Tools:

MS Visio, Rational Rose

Databases:

MS SQL Server, MS Access, UDB DB2, Oracle

Requirements Management Tools:

Rational Requisite Pro, Caliber, DOORS

Project Management Tools:

MS Project, PlanView, HP PPM

Professional Experience

Confidential

Sr. Business Solutions Architect

• Provided leadership in analyzing and solving complex development and business relationship issues and demonstrated sound judgment to determine when to escalate issues
• Worked on multiple strategic and tactical project initiatives as well as tier integration activities, for ESI's Medicare, Medicaid and Health Care Reform business
• Served as the primary liaison for the business stakeholder, development and testing teams, to ensure a complete and comprehensive understanding of the overall objectives for each project under the Government Programs' Integration and Market Portfolios
• Led the creation and maintenance of Project Charters, ROMs Rough Order of Magnitude , WBS Work Breakdown Structures , Heat Maps and Business Architecture Road Maps across Government Program Portfolios
• Participated in the creation, development and governance of a Business Capability Model underpinning ESI's GP Business
• Built and managed a concurrent process for performing intake, prioritization, analysis, resolution and metrics reporting for critical operational issues impacting ESI's GP Business. Some of the Transactional and Operational capabilities which benefited from the timely resolution of issues were:
• Med D aka Medicare Part D Claims Adjudication Retail, Direct, Mail Order
• Med D Claims Adjustments
• PDE Prescription Drug Event Reporting
• Financial and Operational Analytics
• Pharmacy and Client Audits
• Led Training Sessions for ESI's Express One Project Delivery Methodology
• Mentored fellow BSAs in developing proficiency in Healthcare concepts, to rapidly absorb technical information, and apply concepts where necessary to drive progress
• Presented and defended key deliverables for each Project like Business Requirements, Business Impact Assessments and Project Metrics to ESI's OAR Organizational Alignment and Readiness team comprising of VP level leaders from Business and IT
• The OAR team has been formed to ensure a successful integration of ESI's core business capabilities with Medco
• Leveraged relationships with Sr. IT and Business Leaders as well as ESI's vendors to lead successful Product Demonstrations
• This ensured ESI was knowledgeable of the latest technology trends through and post integration

Confidential

Project Lead

• Led the implementation of, short and long term, data solutions compliant with EDG standards
• Provided targeted direction to the Central Product Library CPL Implementation program which is being looked at as a single source of truth for the product domain, would provide an environment that supported product development and management capabilities
• Led data profiling activities, mapping of data sources, data movement, interfaces, and analytics, with the goal of ensuring data quality
• Conducted data quality audits to identify gaps/inconsistencies between business processes, data, and database design and creating data quality score cards
• Utilized data disguising technology e.g. data obfuscation, data redaction, data masking in pilots for mastering data for sub domains
• Established methods and procedures for tracking data quality, completeness, redundancy, and improvement
• Formulating the information and security data model for accessing and updating master data that would support Product Definition and Configuration, business and information disclosure needs. Key areas of work, spanned across:
• Indemnity PPO ,Managed Care HMO, POS, Direct Access , Prescription and Dental Plan options such as Deductibles, Accumulators, Co-Payment options, co-insurance values, lifetime maximums
• Optional coverage riders that can be added to a plan
• Procedures, revenue and diagnosis codes that are covered or excluded
• Eligibility rules for certain medical services
• Customer plan ratings
• Bundling of product services within and around sales packages. For e.g. Integration of CDH Consumer Driven Health products such as HSA and HRA
• Wrote and obtained Business and IT approvals on Business Requirements for a phased MDM Master Data Management roll out that leveraged EDG deliverables
• Led IT decisions regarding methods, techniques, and procedures for project design and completion. Managed resources, budgets, and deliverables
• Proactively identified and managed issues and risks leveraging Agile techniques like daily sprint meetings with analysts, developers, architects and stakeholders

Lead Business Analyst

Confidential

• Participation in Vendor evaluation and selection, business case development, root cause assessment discussions
• Created Current and Future process work flows, identified candidate processes for automation and/or improvements and identified gaps for capturing business requirements
• Analyzed the UI and Data Model of a real time Medicaid eligibility decision capture COTS software application
• Wrote business requirements for:
• Provider contracting activities, definition of new provider types and specialties, new types of service for additional benefits, and table changes for realizing key Claims,
• Provider Operations, Medical Management and Claims functions
• Configuring the MLTC Benefit, by documenting and obtaining approvals, for each covered service, on the right BSC Benefit Service Category ,TOS Types of Service , POS Places of Service , CPT Codes, HCPC Codes, Diagnosis Codes, Revenue Codes and Bill Types
• Reverse engineering a risk and eligibility determination tool towards identifying membership for selling the MLTC product
• Customizing the UI and table definition updates in the Medical Management system
• Internal and external Encounter, Enrollment, Operations and Premium Reconciliation Reporting functions in the PeopleSoft Financials system
• Achieving a carve out of the MLTC members from a fully capitated to a FFS fee for service arrangement
• Inter department and inter organization system interfaces, for maintaining the integrity of the Enrollment process from initiation to eligibility confirmation
• Wrote training documents for end user reference
• Wrote test scenarios in parallel to Business Requirements development leveraging the acceptance criteria for each requirement
• Maintained traceability between test scenarios and business requirements
• Managed and coordinated the entire Testing effort for the MLTC project
• Led issue and status updates in core and work group meetings
• Mentored fellow business analysts, evaluating their work product and suggesting improvements.
• Presented project accomplishments and progress updates for C-level attendees in steering committee meetings

Senior Business Analyst

Confidential

• Special Needs Plan SNP Implementation
• Implemented the SNP product, which was designed to bring down medical costs and improve care for Medicare beneficiaries, who were eligible for Medicaid , were institutionalized and/or had one or more of severe and disabling chronic conditions
• The aim of the product, similar to MLTC, was to bring hospitalization costs down offering a richer benefit for the Medicare Advantage population with an emphasis on preventive care
• VDSA and MMSEA Section 111 Reporting
• This program enabled Horizon to electronically report, on a timely basis, to the federal government on group health plan information, liability insurance including self-insurance , no-fault insurance, and workers' compensation arrangements
• The program also queried CMS Center for Medicare and Medicaid Services on Medicare beneficiaries' eligibility
• CMS in turn responded with eligibility decisions and provided guidance on whether Medicare was the primary payer for health and prescription benefits
• PBM Pharmacy Benefit Manager Enrollment Reconciliation
• The project sought to preserve the integrity and achieve accuracy of Horizon's members' Enrollment and Eligibility information that was shared with the PBM, significantly reducing data cleanup and administrative costs

Senior Business Analyst

Confidential

• BlueCard Implementation
• Implementing the exchange of electronic data between individual BCBS health plans, by providing a common format which links the claims processing, customer service, and managed care functions for each plan

Senior Business Analyst

Confidential

• Member Book Of Record
• Implementing a unified customer view from disparate and siloed systems by migrating it to a common hub, using WCC Websphere Customer Center , a MDM Master Data Management off the shelf package, which would be customized to conform to corporate Data Governance Policies
• The project would ensure membership data in the hub is reliably consolidated, its exceptions stewarded and policies implemented
• The data would have a set of highly visible business dependencies benefiting among others the sales, marketing, customer service and enrollment organizations within the company

Business Analyst

Confidential

• MedCard Product Line
• Launching a new product line featuring automatic benefit/eligibility verification, paperless claim processing, linkages to Payers , Providers, Managed Care Groups, and Patients

Business Analyst

Confidential

• Stock Borrow Loan Application
• Project implemented the Stock Borrow Loan application for the Securities division
• The application interacted with the real-time trading system through an MQ series interface
• Reports could be run at any time by providing date and stock criteria

Business Analyst

Confidential

• AGI Africa Governance Inventory Portal
• The AGI portal was meant to be a flexible management tool to assist African governments and their development partners to improve programming, coordination, monitoring and mobilization of resources in governance
• It is also useful for sharing governance experiences and promoting regional partnerships
• A scalable application evolving according to the needs of its users, the AGI Web Portal provides a reliable and cost-effective tool for governance focal points in beneficiary countries to manage their country homepages, to maintain their governance databases and to provide password-protected access to development partners
• The goal of the Portal is to encourage governments, the donor community, the private sector, and civil society organizations to enter and update information online on governance projects and activities