PROFESSIONAL SUMMARY:

Healthcare professional with 20 years of industry experience, who specializes in Medicaid and Medicare Managed Care operations and information technology. Leverages previous experience from the provider and payor end of managed care to quickly envision client data solutions with the goal of empowering users to make assessments, discover patterns, extrapolate trends, look for anomalies/paradigm shifts, and derive fact-based conclusions for visual presentation to different audiences. Skilled architect/mentor with full DWH/BI life cycle experience including: requirements gathering, documentation, database/data warehouse architecture, performance tuning, database/ETL development, Quality Assurance/Testing, n-dimensional design, and business intelligence reporting. Highly proficient with connecting dots from idea to data-model to front-end, undirected data mining, and quickly diagnosing system configuration issues based upon data analysis and previous business experience in provider contracting, claims payment operations, provider/member grievances/appeals, medical necessity review, and utilization management operations. Well-versed in medical terminology with the ability to communicate the complex using simpler analogies with most levels of business, technical, and senior staff. Involved with eleven 11 Enterprise System Implementations FACETS, 6 legacy system conversions to FACETS, 12 BI solution implementations, and 2 external vendor implementations

Specialties:

• Technical: RDBMS, Multidimensional Database, Master Data Management, AND BI application architecture, T-SQL performance tuning, SSIS package performance tuning, SSAS data processing and MDX performance tuning.
• Business: Data Governance Facilitator, Managed Care Medical Data Expert, Utilization Management, Credentialing, Claims Auditing, HEDIs, Eligibility, Directed Data Mining, Actuarial and Financial Reporting, MEDPAR, CMS/DRG reporting, Medical Necessity 1st and 2nd Level .
• Other: SQL-99/2003 ANSI SQL Standards, T-SQL, PL/SQL, MDX, DMX, Team Foundation Server, MS Office Suite, HIPAA Transaction Sets 270, 271, 278, 820, 834, 835, 837

EXPERIENCE:

Executive Health Resources

Confidential

• Technical Team Leader for integration of internal data and 835/837 data of over 3,200 client hospitals
• Hospital Analytics solution architect including ETL architecture, DBMS data/security architecture, OLAP architecture, Mining Model Architecture, Info Delivery Portals including integrated Metadata Repository
• Release manager for deployments of SSRS Reports, Database Objects, and SSAS Cubes.
• Database migration planner and executor from SQL Server 2008 R2 Standard to SQL Server 2012 Enterprise on new Windows 2012 Enterprise Server.
• Ensure proper configuration of SAN storage solution for a BI workload
• Create maintenance strategies with database administrators
• Work with BIDS HELPER team on codeplex.com to enhance RDBMS to OLAP metadata interchange--making it a better productivity tool for our team.
• Lead consultant on enterprise wide data strategy and business intelligence charter
• Educate team on the use of PowerPivot to gain quicker business insights

Confidential

• Create enterprise business intelligence roadmap strategy for the client and PMO staff.
• Mentor development staff on the creative uses of SQL to achieve quicker and more agile solutions with data
• Mentor ETL architects and implement SQL Server Integration Services SSIS best practices, policies and procedures for data integration.
• Mentor business analyst staff on the proper alignment of technical solutions with business requirements.
• Oversee power user development of data mining models to facilitate predictive patient care models.
• Work with DBAs on the appropriate data architecture and system configurations of SQL Server 2005/2008 BI.
• Establish data quality management strategy with claims, provider relations, eligibility, and utilization mgmt dept reps.

Confidential

• Perform enterprise data quality assessment of a 28 Terabyte Healthcare EDW
• Mentor staff on the appropriate use of Ingenix Episode Groupers including correct inputs, outputs, and ways to integrate with existing data.
• Perform detailed QA and gap analysis of front end interface functionality
• Improve analysis of medical conditions, utilization costs, and medication adherence outcomes models.
• Update QA process as needed to identify data integrity issues which impact the accuracy of RationalIQ utilization and cost metrics.
• Interface with clients and drive data/integration requirements gathering efforts regarding medical claims data.

Confidential

• Convert 40 RUBI claims reports to Crystal Reports 10 via T-SQL stored procedures.
• Create reusable Facets model user-defined function libraries based on subject domain.
• Convert legacy and access sourced reports to standard Facets-sourced environments.

Confidential

Lead Business Intelligence Analyst/Product Lead

• Business Analyst Specialist III Data Warehouse
• Business Analyst Specialist II Data Warehouse
• Lead requirements definition, data modeling sessions and development efforts for seven implementations FACETS system to meet various requirements of different ASA/MSA contracts.
• Develop company-wide data reporting strategy with internal and external business partners 7 .
• Information Solutions Reporting Team Lead in eight different business areas of the company
• Facets Data Model Educator/Business Rule Repository Developer
• Establish and influence more business intelligence centric QA and Test Plans.
• Together with business sponsors, establish company data governance program, execute informatics agendas, and gain cross departmental consensus.
• Subject matter expert for data integration of UM/CM/DM, Providers, Network Contracting, HIPAA 837, NPI, etc , HEDIS, Eligibility, PCP Assignments, Capitation, Claims, State Medicaid Rate Data, MedStat Advantage Suite, ViPS MedMeasures
• Performs detailed data analysis and statistical analysis. Develops complex ah-hoc reports as required.

Environment: Oracle 9i, 10g RAC, Sybase Version 12.5, SQL Server 2005

Senior Statutory Reporting Analyst

Statutory Reporting Analyst

• Analyze internal regulatory/financial report processes, programs, and systems and makes recommendations for improvements in quality and efficiency for systems, software, and procedures.
• Review PA Department of Public Welfare state reporting requirements/specifications, modifies/develops reports as necessary, and communicates with IT personnel, other internal business units, and senior staff to ensure data integrity of the company's data warehouse.
• Suggest business improvement processes along with monitoring of data integrity and error reporting.
• Enterprise Data warehouse team lead
• Facets system team lead in construction of COB, EPSDT, Member/Provider Appeals system extensions
• Completes state-mandated reports as assigned through the development /maintenance of spreadsheets, databases, queries, system modules, and the policies/procedures relating to each report.
• Act as a department HIPAA liaison. Tracks and forecasts implementation issues affecting reporting.
• Confidential Liaison to MSO and physician offices with regards to contractual and managed care issues.
• Facilitate new and existing managed care/PPO contracts and their renewal/re-negotiations. Assist in creating a new MSO group contracting strategy/repository as relates and evaluates its pre- and post-financial feasibility.
• Create Access database system and triage process improving provider enrollment turnaround time by 50 and decreasing loss of revenue/credentialing write-offs for the MSO.
• Perform PCP Profiling and develop disease management outcome reports
• Confidential Supervisor of six 6 employees and responsible for preparations of NCQA site visits.
• Lead system implementations to meet requirements of multiple client payors Aetna/US HealthCare, Cigna, Physician Health Organizations, and IPAs .
• Assist in developing company business process for maintaining NCQA certification status.
• Confidential Credentialing Associate for an IPA
• Investigate and pay claims for MSO