SUMMARY

• Sixteen + years of direct claims payer health plan experience in teh areas of Facets Product/Benefit, Billing, Claims processing, Workflow, Pricing, Clinical Editing, Subscriber/Member Enrollment & Eligibility and Accumulators configuration, Provider configuration, Utilization Management, and Customer Service.
• Facets v5.5R2 State Exchange implementation project management experience
• Extensive Facets configuration & functionality optimization experience
• Extensive experience with all FACETS functionality, data models and User interface process functionality up to version 5.6R4
• Extensive HIPAA 834 & enrollment pre - processing applications and business process experience to include FACETS MMS Batch loading process, HIPAA 5010 and ICD-10 strategic planning, evaluation and analysis experience
• Extensive HIPAA 837 claims file processing experience
• Extensive experience with conversion projects from legacy systems to Facets
• Extensive experience with teh Full Software Development Lifecycle process (SDLC)
• Extensive program management experience to include project, budget, resource, and task management,
• Extensive Director & Manager level experience in managing teams of up to 40 resources distributed across multiple teams and geographic locations.
• Extensive experience in managing Facets Configuration & Technical support teams using teh AGILE methodology via Scrum & Kanban.
• Extensive third party vendor & contractor management experience.
• Extensive resource, budget planning & management experience.
• Program manager and senior level consultant in Health plan managed care configuration/optimization, & teh design, development and technical support of health plans for many major health plan companies.
• Extensive State Medicaid, & Federal Medicare Parts A, B, C & Part D experience.

TECHNICAL SKILLS

• .Net
• HTML
• XML
• UML
• RUP
• Rational Rose
• Relational Database Management
• Systems (Sequel Server, Sybase, Oracle)
• AGILE Software Development Methodology
• Microsoft Project
• Microsoft Power Point
• Microsoft Office
• MS Sequel Server
• Data Query and development utilizing SQL
• VB and MS Access
• ETL Data Migration and Data cleansing
• Structured Project Management Methodologies
• Structured business process modeling and middleware integration tools
• HP ALM.

PROFESSIONAL EXPERIENCE

Confidential

Director Business Configuration

Responsibilities:

• Teh Director of Facets Configuration for teh Confidential Groups Confidential Business Unit. This business unit specializes in teh Individual Health Insurance market of which Confidential One is teh largest provider of such plans in teh U.S. Market with revenues in excess of $2.2 Billion Annually.
• Teh Confidential Facets instance currently hosts 1.5 million lives and will have an addition of 2.2 million lives in 2021 through acquisitions of carrier plans, and an expected organic growth of 250,00 per year in new membership over teh next year.
• Teh Confidential Facets Configuration team consists of 15 FTE Configuration Analysts + 4 team leads, 2 managers & 2 direct reports + 24 contractor Configuration Analysts. Teh team is responsible for teh configuration of Facets Products & Benefits, Claims workflow configuration, Clinical Editing configuration & support, Provider & NetworX pricer Configuration, Membership & Billing configuration, Customer Service Workflow SME support, HIPAA Gateway & EDI file support, Facets Batch support, as well as Facets migrations and upgrades.

Confidential

Facets Strategic Optimization Consultant

Responsibilities:

• Senior Facets Business Application Expert Consultant. Assisting Confidential with reducing business process cost by reviewing and optimizing their Facets application configuration & functionality. In teh areas of Enrollment, Member/Subscriber, Accumulators, Claims, Billing, Plan, Provider, Customer Service, Utilization Management, & FXI/ReST Services
• Carrying out and documenting a Cost Benefit Analysis to show teh current cost of business processes versus teh benefit of implementing new Facets functionality
• Conducting time studies to evaluate teh time it takes to complete a current business process, versus teh reduced time it would take utilizing a new Facets configuration, functionality or BOT automation.
• Leading and facilitating meetings with business leads, and users to discuss current process “pain points” and tan reviewing teh appropriate Facets configuration, functionality or BOT automation dat could remove or remediate teh “pain point”
• Reviewing all upcoming Facets version enhancements and making recommendations of which manual/optional enhancements should be implemented by Confidential to optimize their business processes.
• Acting as teh Confidential optimization lead on all projects to ensure dat all implementations have clear KPI’s, will bring achievable and measurable cost savings and process improvements to Confidential business processes.

Confidential

Medicare Part D Senior Advisor

Responsibilities:

• Teh Senior Advisor for Medicare Part D Enrollment utilizing Facets and teh enrollment preprocessing applications and business processes dat feed teh CVS Government Services pre-enrollment applications & teh Facets enrollment & billing functions, & teh RxClaims claims adjudication application.
• Managing teh enrollment, billing, & provider configuration changes, enhancements, and updates to CVS Pre-enrollment and Facets enrollment application
• Responsible for managing teh requirements gathering, design, development, testing, and deployment phases of projects to enhance teh CVS Silver Script Medicare Part D member enrollment and agent portals, teh enrollment intake and pre-processing systems and teh Facets application and data models
• Responsibilities include managing teh project plan, creating weekly status reports for submission to business steering committees and CVS senior management..
• Liaising with Business, Process Improvement, Test, & Development Managers and leads & Third party vendors
• As teh Medicare Part D SME and Facets SME working with Senior CVS management to determine and guide teh strategy for teh enhancements and future use of all enrollment systems
• Teh daily management of multiple teams to include: configuration, testing, business analysis, development, & third party vendors.
• Managing teh resource allocation & quarterly budgets for all Medicare Part D ongoing support and capital expenditure work and projects.

Confidential

Senior Manager

• Teh Delivery project manager for teh Medicare Part C Combined EOB project. CMS in April 2014 changed teh way Medicare Advantage EOB’s are constructed and sent to Medicare Advantage Members, to an EOB dat combines teh claim activity for Medical, Dental, & Vision coverage into a Single EOB. Previously an EOB was generated per claim per benefit type.
• Delivery project manager for teh City of Detroit Medicare Advantage 834 project
• This project entailed teh requirements gathering, design, development and deployment of teh process to accept a weekly full 834 enrollment file, translating teh file to an internal flat file format, creating add, change, & termination record for submission to teh Medicare Advantage claims payor system, and teh configuration changes required for teh BCBSM third party claims payer system.

Upgrade Project Manager

Responsibilities:

• Responsible for managing teh systems architecture design, application development, Facets configuration, integration, & data environment teams, this effort included teh creation of teh future Facets 5.01 and surrounding components configuration design, teh infrastructure design, and teh implementation of teh infrastructure and Facets Environments, teh Facets 4.81 to 5.01 database conversion effort, bringing on line teh Facets Batch, FXI, & Web services servers, and also teh state exchange integration functionality.
• Responsible for teh Facets 5.01 Upgrade Remediation of Facets configuration, Interfaces/Extracts, Custom Surround Batch Code, Facets Extensions, Reports, and extracts to teh Fidelis Data Warehouse
• Responsible for teh design, development and testing of teh functionality to handle teh inbound 834 enrollment files from teh New York State Exchange,
• Acted as an integral part of teh Steering committee team assisting in teh strategic guidance of teh program, reporting status to Fidelis program sponsor, owner and steering committee
• Managed teh overall budget and weekly resource burn rate for all of teh State Exchange & Upgrade program, this included resources from multiple consultancies, Full Time Fidelis employees, and offshore resources . Managed teh program plan, and work breakdown structure
• Managed teh resource allocation for teh project.

Confidential

Business Data Models Facets SME Consultant

Responsibilities:

• Senior Technical health plan Business Data Analyst and Facets Data Model SME for teh WPS Enterprise Data Warehouse implementation project
• Gathered requirements, documenting requirements in a BRD (Business Requirements Document), mapping data from health plan Class/Plan, Product and Benefit Components, Group, Provider, Member/Subscriber, Billing, and Claims Facets Data Models to IDS and EDW (Enterprise Data Warehouse) target tables
• Defined SQL extract logic for teh ETL process
• Physical mapping of Facets data elements to IDS and EDW data structures using ETL mapping tools, Assisting HP and WPS staff in understanding teh Facets Data Model and data relationships
• Carried out data analysis using Sequel Server Integration Services and SQL

Confidential

Senior Consultant

Responsibilities:

• Senior Systems Analysis for teh Regence Legacy system to Health plan Membership, PCP Referrals, Multi-Year Accumulators and Reports Conversion and teh HMA Claims NetworX Pricing implementation project
• Gathered & documented requirements, data mapping from legacy Database to Facets Database, Creation of Technical design documentation
• Facilitated requirements gathering sessions with Business and technical staff, Facilitating and leading JAD sessions

Confidential

Senior Facets Data Modeling Consultant

Responsibilities:

• Assisted teh Confidential Optim Competency team with teh effort to map teh complete Health plan data model to ETL tool, Identified PHI data, in order dat ETL could be utilized to extract subsetted Health plan data for Automated Testing

Confidential

Senior FACETS Consultant

Responsibilities:

• Primary role as a FACETS enrollment Integration specialist and teh Design Lead of teh automated FACETS electronic enrollment pre-processing system for Confidential