- Healthcare insurance professional and consultant with extensive experience in medical and dental health insurance and insurance processes and systems.
- Knowledgeable and successful in business process improvement, business consulting, solution assessment, report development, functional specification development, systems implementations and management.
- Skilled leader in providing guidance and hands on delivery of requirements collection, end user experiences, and bridging the technical and business worlds to bring business solutions to customers.
- Extensive experience with health insurance administration including configuration of payment pricing arrangements (PPS, DRG, capitation, FFS) for inpatient, outpatient facility claims, medical providers, vision care products, dental benefits, and consumer directed healthcare (HSA, HRA, FSA) and the administration and system configurations for large group, individual, Federal, Medicare, Medicaid lines of business.
- Direct experience with Electronic Data Interchange (EDI) including as 837(inbound and outbound), 835, 270/271.
- Experience with reporting health insurance metrics and data.
- Experienced with waterfall and SCRUM/Agile project methodologies and directly with Lean Six Sigma. Participated with administration platforms including UHG’s Cirrus platform for Benefit Configuration, TriZetto’ s Facets, Pegasystems 6.3, 7.2, 7.3, Pega Claims Workstation (CWS) 7.1, and BCBS Interplan Telecommunication System (ITS).
- Tools utilized include CA Agile / Rally for building and tracking Features, User Stories and Tasks.
- Worked with project sponsors, stakeholders, technical development and architectural staff, business subject matter experts, product owners, business systems analysts / architects and program managers.
- Managed teams ranging in size from 5 to 20 analysts, and across multiple states in a remote environment.
- Business analysis and requirements capture, business process reengineering.
- Health insurance focus on claims (professional, institutional, pharmacy, vision, dental), EDI, provider reimbursement methodologies, product and line of business benefit design and configuration, auto - adjudication, enrollment, reporting, and customer service modules to include correspondence and telephonic.
- Business Intelligence (BI) and reporting requirements, design, and specifications development.
- Manager of staff includes telecommuters across multiple States for benefit configuration, claims administration and claims systems implementations including work on Facets implementation for Cambia, a multi-million-dollar project.
- Project management using waterfall and Agile / SCRUM methodologies to include Lean Six Sigma approaches. Tools used include Visio, MS Project, CA Agile (Rally).
- Reporting to the department Vice President, interacted with other Vice Presidents to obtain requirements, provide status reports and support the marketing and underwriting divisions with respect to ROI.
Associate Director, Configuration Strategy & Implementation
- Led a team of 13 staff and provided subject matter expertise and leadership to assigned Cirrus program activities.
- Estimated work effort, prioritized and assigned tasks to Cirrus Configuration team and monitored results and QA employees' work. Remote plus travels to client sites.
- Led meetings, assigned tasks, documented decisions and next steps, and managed to completion.
- Oversaw the work and provided direction to less experienced team members.
- Identified issues and oversaw completion of next steps.
- Maintained and/or created metrics and performance data to provide insight into overall performance, including process improvement, issue resolution and all aspects of Benefit Configuration build activities.
- Facilitate daily stand-up meetings, developed and monitored Kanban Board for the team and worked with product owners to assure features and stories are accurate and groomed.
- Remote plus travels to client sites.
Lead Business Architect
- Collaborated with product owner to shape business solution requirements and solutions including coaching and mentoring in Agile techniques and deliverables, feature and user story identification and composition, backlog grooming and prioritization.
Lead Business Architect
- Served as Lead Analyst in driving out user stories and use case requirements in preparation for detailed specification development.
- Worked directly with project Product Owners and SMEs as well as with on and offshore technical resources staff in high level technical design information regarding User Interfaces/Experiences, detailed system designs, interfaces, and reporting requirements.
- Assist with QA and UAT testing, as needed.
Lead Business Architect
- Provide senior / lead business analysis and subject matter expertise and experience to internal Optum True Agent (OTA) project.
- Served as lead analyst in driving out user stories and use case requirements in preparation for detailed specification development.
- Worked directly with project Product Owners and SMEs and on and offshore technical resources staff in high level technical design information regarding user interfaces and experiences, detailed system designs, interfaces, and reporting requirements
- Assisted in QA testing, as needed.
- Provided senior / lead business analysis and subject matter experience to vendor led Pega project high level requirements gathering.
- Served as lead analyst in driving out User Stories and Use Case requirements in preparation for detailed specification development.
- Worked directly with Confidential Business and Virtusa technical staff in high level technical design information regarding user interfaces / experiences, detailed system designs, interfaces, and reporting requirements
- Assisted in QA testing, as needed.
- Assisted Pega staff in driving out high level functional requirements in preparation for detailed specification development.
- Worked directly with Pega and Virtusa technical staff in high level technical design information regarding Pega system, interfaces, and reporting requirements.
- Prepared project estimation for resource and durations of each phase for Virtusa senior management.
Lead Business System Architect / Analyst
- Conducted As-is and To-be process sessions, developed and elaborated Use Cases and specifications and assisted with Unit and QA testing.
Lead Business System Architect/Analyst
- Led a team of Business Systems Analysts to conduct as-is and to-be design sessions with business teams, facilitate DCO sessions, create use cases, assist with testing and interact with business and development teams to resolve questions / issues.
- Managed a team of two employees located in Colorado, two contractors based in Washington, and one consultant based in India.
- Worked with clients to review, triage, and design operational and analytical reports for subject areas including enrollment, billing, claims administration, capitation and risk assessment, provider networks and reimbursement for Medicare Advantage, Medicaid, ACO, Federal Employee program (FEP/FEPHB), ASO, and commercial underwritten lines of business.
- Worked with the client subject matter experts to determine business requirements for development of functional and technical specifications, data gap analysis for data modeling/architects, extract transformation and load (ETL) designers to assure requirements for data capture and reporting is achieved.
- Provided client assessment, planning, testing, and implementation of the Confidential hpXr data warehouse tool, work extensively with clients to implement the Confidential Consumer Directed Healthcare (CDH) suite of applications.
- Facilitated client site business process modeling sessions for as-is and future state impacts and opportunities for administration efficiencies.
Confidential, Tukwila, WA
- Provided project oversight, coordination, planning, resource leveling, documentation, and reporting of business operations for specialty redesign efforts at four medical facilities including working with medical personnel, facility management, and business operational staff to increase productivity resulting in increased patient access and satisfaction.
- Oversaw and/or provided documentation of process flows and workloads for patient care representatives within certain specialty clinics to assess redesign efforts and impacts.
- Oversaw and assisted with developing metrics for business operations clinics to measure pre and post redesign impacts against success criteria.
- Participated in and achieved onsite Lean methodology for project managers.