- Posses14+ years’ experience in portfolio management, product management, business analysis, and implementation of state - of-the-art technologies in Health Care and Health Information Management.
- Entrepreneurially-driven, analytical, and skilled at strategic planning, product management, and client relations.
- Passion for solving global health problems and well-versed in emerging market-focused product development.
- Adept at leading teams in implementing solutions which advance business growth and competitive positioning.
- Able to guide product concept, scope, commercial timing, and financial analysis to optimize revenue results
- A committed and highly focused leader with a comprehensive knowledge of Health and Human Services ( Confidential ).
- Project management experience includes the ability to identify requirements and facilitate delivery within timeline, scope, quality, budget, and fiscal constraints. Expert in SDLC using Agile/Scrum, Waterfall, and RUP.
- Directed the development and management of benefit plan designs and administration for the Medicaid Managed Care, CHIP products, Managed Long-Term Care, Medicare Advantage and Special Needs Plans (SNP).
- Provided Medicare Part D Prescription Benefit Design Consultation, Formulary Development, & Pricing solutions.
- Defined Quality improvement strategies for CMS STARS, HEIDIS programs, defined performance goals, managed budget and effectiveness and implemented change at strategic and operational levels.
- Oversaw compliance with regulatory and accrediting agencies, which include National Committee for Quality Assurance (NCQA), and Centers for Medicare & Medicaid Services (CMS).
- Results focused leader of financial and operational reporting with expertise in improving an organization’s performance and achieving strategic goals by implementing targeted analysis, and metric creation.
- Certified Confidential HIT program specialist focused on achieving the triple aim of providing quality, affordability, and accessibility of healthcare, and the adoption of certified EHR’s and Confidential ’s.
- Experience with Enterprise Business Intelligence solutions and Data Science using SAS, R, Python, Machine learning technologies and data visualization with R and Tableau.
- Excellent Communicator with good presentation skills, leveraged business, technical and financial acumen to communicate effectively at all levels of organizations.
- Certified Confidential HIT program specialist focused on achieving the triple aim of providing quality, affordability, and accessibility of healthcare to populations and adoption of Electronic Health Records and Confidential ’s.
- Portfolio Management & Product Management
- Product Strategic Planning & Execution
- Market Research & Consumer Research
- New Product Development & Launch
- Marketing Strategy & Sales Support
- Product Performance & Budget Development
- Program Strategy Alignment, Stakeholder Engagement
- Enterprise Initiatives & Business Initiatives
- Operational Excellence & Financial Performance
- Business Case Development & ROI
- Competitive Intelligence & Market Positioning
- Financial Planning, Sales, & Forecasting
- Business Process Design, Re-engineering
- Descriptive, Predictive, & Exploratory Analytics
- Managed Medicare & Medicaid Benefit Design
- Medicare Part D Prescription Drug Benefits
- Medicare & Medicaid FFS and Capitated Plans
- Continuous Quality Improvement- CMS STARS, HEIDIS
- Population Health & Disease/Case Management
- Medicare Advantage Plans (HMO, PPO, SNP)
- Medicare, Medicaid D-SNP, C-SNP, I-SNP Categories
- Value Based Insurance Design, Value Based Benefits
- Medicare & Medicaid Risk Adjustments
- SNP Specialized Provider Networks, Model of Care
- Consumer Engagement & Co-ordinated care
- PBM, Medical, Rx, Lab, & Wellness Integration
- PBM Cost Effectiveness & Utilization MGMT
- Long Term Care & Medial Therapeutic MGMT
- Medicare & Medicaid EHR Incentive Program
- Pharmacy PDL, & Innovative Formulary Strategies
- Pharmacy Medication Therapy MGMT & Adherence
- Pharmacy Trend, Spend & Performance MGMT
- Pharmacy Step Therapy & Prior Authorization
- Pay for Performance P4P, Bundled Payments
Portfolio Management, Product Management: Strategic Vision, Strategic Road mapping, Business Case Development, Product Prioritization and Launch, Organizational Goals, Business Strategy, Marketing Communications, Revenue and Market Share Goals, Market Assessments, Go-to- Market Strategies, Product Value Proposition, Feature Prioritization, Investment Planning, Segment Trend Analysis, SWOT Analysis, Quantitative Analysis, Product Performance-KPI’s.
Healthcare Business Domains: Managed Medicaid, Medicare Advantage Plans (HMO, PPO, SNP), C-SNP, D-SNP, I-SNP, MMP and LTSS Populations. Eligibility and Enrollment, Medicare Part D Prescription Benefits, Medical Informatics, Value Based Medicine, ACO P4P, Reference Administration, Benefits Management, Member Management, Program Integrity Management, Business Relationship Management, Prior Authorization, Case Management, Claims/ Encounters, TPL, Contractor Management, Provider, Pricing, Financial Management, Electronic Data Interchange. Provider Network Management.
Medicaid, Medicare Analytics Models: Probability Statistics, Inferential Statistics, Hypothesis Testing, Adjusted Clinical Groups (ACGs), Chronic Illness and Disability Payment System (CDPS), Clinical Risk Grouping (CRG), Diagnostic Cost Groups (DCGs), Episode Risk Groups (ERGs). Episode Treatment Groups (ETGs), Impact Pro, Medicaid Rx, Pharmacy Risk Groups (PRGs). Group Co-Morbid Clinically Linked Conditions, Hierarchical Condition Categories
Healthcare Business Domains: Health Insurance Exchange- HIX, Plan Management, SHOP and SHOPPING, Financial Management, Customer Service, Communications. Integrated Eligibility and Enrollment, CHIP, SNAP, and TANF. EHR Meaningful Use, CAQH-CORE, NCQA HEDIS Quality Measures, HL7 Standards, PPACA, NwHIN, Health Information Exchange ( Confidential ). Medicare Hospice and Long-Term Care.
Portfolio Management, Business Analysis: Caliber RM 2008 SP1, HP Quality Center 10.0, Enterprise Architect 9.3, Rational Requisite Pro 7.1, Share Point 2010. MS Visio 2010, Rational Rose 7.1, Visual Paradigm, Clear Case 7.1 and Clear Quest 7.1, Jira, Rally, Agile Scrum, Rational Unified Process (RUP), JAD, RAD, Waterfall. PMBOK, MS Project, MS-Office (Word, Excel, Power Point). Teleologic Doors 9.3.
Medical Terminologies, HER, HIPPA Compliance: ICD9-ICD 10 Remediation. Revenue Codes CPT, HCPCS, NDC, ETC, HIC3, DRG, APG, APC, FDB. Preferred Drug Lists (PDL), NCPDP D.0 Compliance, CCD, HIPPA 270, HIPPA 271- Provider Inquiry and Response. HIPPA 834 Member Enrollment, HIPPA 820 Payment Remittance, MCO’s Capitation Management. EDI HIPPA Transactions 835, 837, 276, 277, 278.
Healthcare COTS, ETL, DW/BI Technologies: IBM CURAM 6.0.5- Healthcare Reform, Integrated Case Management, Verification, Social Assistance, CHILD Welfare, CHIP, Outcomes Management, Social Enterprise Collaboration. Managed Care, Network Management, ACO, Value Based Solutions. Data Visualization with R and Tableau. SAS Enterprise Guide, SAS Meta Data Repository, Master Data MGMT. DW Architecture, Data Stewardship, Data Governance, Multi-Dimensional Modeling, MOLAP, ROLAP, HOLAP, SAS 9 series, Informatica 9.0, Oracle Corticon 11g, Oracle 11g RDBMS, IBM iLog JRules7.1, SOA, ESB, Business Rules Engine, Business Process Monitoring. R, Python, Tableau, and Big Data Analytics.
Sr. HIT Strategy & Product Manager
- Partnered with leadership to define quality initiatives, strategy and success criteria for the future.
- Worked with multiple lines of business - Managed Medicaid, Medicare Part D, Exchanges & Commercial.
- Responsible for product planning and execution including gathering and prioritizing product and customer requirements, defining the product vision and working with the IT, Sales, Marketing and Finance teams.
- Defined clinical quality and utilization performance measures and scoring strategies for payment innovation.
- Provided Therapy class review for the top 15 therapy classes and insights for top 10 traditional and top 10 specialty drugs. Developed formulary strategies including indication based formulary, pricing and rebates, outcomes based contracting, biosimilar preference, hyperinflation management.
- Provided Data Science Analytics solutions to clients with SAS, R, and Python technologies giving strategic insights on drug costs and utilization trend through data visualization using Tableau.
Sr. HIT Strategy & Product Manager
- Spearheaded product strategy, planning, design, and implementation for the Confidential Integrated Healthcare Delivery System for MN-DHS. Lead business, technical, and financial disciplines toward program’s strategic objectives.
- Translated strategy into defined programs, priorities, timelines to ensure alignment of enterprises strategic plans.
- Provided Operations and Maintenance (OAM) support and change management strategy for the Integrated Eligibility, Medicare, Medicaid Managed Care, CHIP, SNAP, & TANF, IBM Curam Social Welfare Products.
- Interpreted data and presented results in a concise manner with objective evaluations and recommendations.
- Mentored cross-functional teams in quality improvement promoting HIT industry’s best practices.
- Release Lead - Managed cross-functional release teams responsible for On-Time, On-Resource, On-Budget & High-Quality Release of products.
Sr. HIT Strategy & Product Manager
- Provided product vision and direction for the Confidential Integrated Eligibility, Health Exchange, Medicaid Management Information Systems (MMIS), portfolio of products for Common Wealth-KY and DHS-MI.
- Performed market research and reported on competitors, worked closely with current and prospective customers aligning product direction with their needs.
- Adopted SEI Capability Maturity Model MITA 3.0, optimized business processes toward Level 3, 4 maturity.
- Adopted Medicaid Information Technology Architecture (MITA 3.0), and MITA Business Architecture, MITA Information Architecture, MITA Technical Architecture, and the CMS 7standards.
- Supported B2B testing for EDI HIPPA 834- Enrollment Transactions and HIPAA 820-payment transactions and provider HIPPA 270, HIPPA271 eligibility inquiry and responses.
- Followed Agile SDLC methodology, lead the IT teams into self-organization and cross functionality, facilitated sprint planning, retrospectives, and scrum events.
Sr. Business Analysis Lead
- Championed delivery of a next-generation product- NexGen, for Medicare and Medicaid payers with accountability for scope, requirements, use cases, business rules, interfaces, reports, and BPM.
- Developed business case and strategy for software as a service (SaaS) initiative and secured funding.
- Responsible for sub systems- Benefits Administration, Claims, Financial, Pricing, EDI, BRM, Reference, Pharmacy, Prior Authorizations, Prospective Drug Utilization Review - Pro-DUR, Retro-DUR, and ePrescribing.
- Directed the strategy for disease management solutions & outcomes tracking for specified therapeutic categories.
- Represent business operations in the development and maintenance of various operational requirements such as prior authorization criteria, claims pricing, client set-ups and clinical edits.
Sr. Product Manager
- Provided product vision in support of Web Continuous Quality Improvement (CQI) program standardizing the compilation of data from various enterprise systems, providing quality data over time for performance initiatives.
- Successfully implemented patient centered and outcomes driven member centric automated business models.
- Provided business readiness, and organizational work design activities aligning people, processes, and technology with the healthcare policy.
- Enforced quality control & Confidential compliance for Clinical Trails and Electronic Data Management Systems (EDMS).
- Implemented medication adherence solutions including methodologies for assessing medication adherence, outcomes/costs, interventions to improve medication adherence, and research and clinical Implications
- Provided statistical analysis using SAS/Base, SAS/stat, SAS/graph, SAS/Macro, and SAS/Access. Managed the implementation of complex analytical and logistical software packages for large datasets.
- Optimized patient care by achieving fully transparent 360-degree view of clinical data from electronic health records, personal health records, claims/encounters, and regional health information exchanges.
- Masterminded product integration management plan and adopted Agile/Scrum approach to achieve a highly efficient SDLC and stringent adherence to quality parameters.
- Administered recipient portfolio management systems consisting of member diagnosis, matched instructions, prescriptions, enterprise instructions, primary care provider messages, plan management, and medication lists.
Global Business Development Manager
- Managed large global relationships by leveraging technology to streamline client operations, deliver new business values, and enhance competitive position.
- Held important and varied portfolios in servicing fortune 500 customers across US, Europe and Asia in the Pharmaceutical and Biotechnology industries.