SUMMARY:

• Delivers through leadership and expertise within the Health Insurance Exchange (HIX) relations, application implementations, and business process engineering designed for information technology (IT) projects in health plan environments.
• Project, program, and portfolio management experience spans large and complex Healthcare IT integration, infrastructure management, and organizational business transformation.
• Managed teams of various sizes ranging from small 3 member team projects to PMO matrix teams of 32 client, consultant and external vendor Project team members.
• PMO experience included driving service excellence and mitigating risks to gain increased value from the business’ vendors throughout the project which enabled controlling costs.
• Healthcare project experience includes working with CMS and clearinghouses to ensure that member’s claims and payment transactions are processed successfully and member eligibility is consistent in all systems.
• Possesses expertise in working with Healthcare Exchanges, the Affordable Care Act (ACA) Mandate, HIPAA 5010 transactions, ICD - 9 and ICD-10 code sets, strategy development and implementation utilizing the industry tools and technology that improves operational performance.
• Roles/Responsibilities
• Program Manager; Project Manager (CPM); Business Process Consultant; Product Manager
• Resources - proper staffing mix both on- and off-shore; Cost - revenue and expenses; Schedule - On-time delivery, scope management, change control; Planning; Financial Management; Risk identification and mitigation; Issue tracking and resolution; Oversight status and PMO reporting
• Solutions
• Facets Claims and Enrollment Application Implementation
• Health Rules Claims and Enrollment Application Implementation
• Business Process Engineering
• FACETS Enhancements
• Business Process Improvement/ Business Transformation

TECHNICAL SKILLS:

• ICD-10 / 5010
• 270, 271, 276, 277, 278, 834, 835, EDI transactions
• 837I and 837P Claims EDI transactions
• FACETS Claims System
• QNXT Claims System
• Health Rules Claims System
• Web portal, IVR
• MS office suit
• PMI Methodology - Certified Project Manager
• MS Project/MS Project Server
• Plan view
• 834 and 820 HIX Reconciliation
• DMAIC/Lean Six Sigma
• Microsoft Dynamics CRM
• Agile, Waterfall, SDLC
• Direct Enrollment Portal

PROFESSIONAL EXPERIENCE:

Confidential, Long Beach, CA

Program Manager

Responsibilities:

• Marketplace Product Strategy and Planning for State Expansions
• Manage 834 & 820 Reconciliation processes between Molina and SBM/FFM markets
• Gap Analysis of the Managed Care Member Workflow system to support the Marketplace LOB
• Drive process and policy consistencies for all 9 Molina State Based Health Plan organizations
• Optimize operational automation of the CMS reconciliation files and file error resolution process
• Drive the change from CMS manual workbook payments to the CMS policy-based payments process to meet the CMS 2016 CSR Reconciliation deadline
• Develop and implement the strategy for the Special Enrollment Period and drive the necessary system changes for the restructured enrollment verification process

Confidential, Owings Mills, MD

Program Manager

Responsibilities:

• Liaising with the DC Health Benefit Exchange (DCHBX) to ensure system data equivalency
• Liaising with the Maryland Health Benefit Exchange (MHBE) to ensure system data equivalency
• Define and execute the guidelines for 834 file data error resolution between CareFirst and DCHBX/MHBE
• Manage 834 enrollment error tracking system enhancements and create standard operating procedures
• Responsible for developing the Transformation Model and develop workflow efficiencies within the CareFirst error tracking system to minimize Time-To-Resolution

Confidential, Durham, NC

Sr. Project Manager

Responsibilities:

• HCR 2015 Small and Large Group Product Implementation
• Facilitate requirements discussion between the core project group and the business
• Create and deliver the Communication Plan
• Create and deliver the Training Plan
• Create and deliver the Process Plan
• Create and deliver the Staffing Plan
• Create and deliver the Risk Plan
• Create and deliver the Transition Plan
• Create and deliver the Go-Live Plan

Confidential, Boston, MA

Sr. Project Manager

Responsibilities:

• Develop, manage and deliver the ACA Dental Product Implementation/Children’s Medicaid low-income plan for plan year 2014
• Develop, manage and deliver the ACA out of Pocket Accumulator Implementation for plan year 2014
• Develop, manage and deliver the ACA Qualified Student Health Plan Implementation for plan year 2014
• Drive the development for the Mass Health Connector 2.0 - 834 5010 EDI HIPAA Enhancements for plan year 2014
• Drive the development for the Mass Health Connector 2.0 - 820 5010 EDI HIPAA Enhancements for plan year 2014
• Develop, manage and deliver the BCBSMA Private Exchange Dental Product Implementation for plan year 2014

Confidential Madison, WI

Sr. Project Manager

Responsibilities:

• Manage the health Rules Claims Interface exchange team to deliver system enhancements required by WEA business
• Drive the health Rules Enhancements and upgrades to ensure an on time implementation delivery
• Manage and deliver the 837(I) and (P) EDI 5010 HIPAA claims transactions
• Manage and deliver the 835 EDI 5010 HIPAA transactions
• Manage and deliver the 834 EDI 5010 HIPAA transactions

Confidential, Dayton, OH

Sr. Project Manager

Responsibilities:

• Manage and deliver the 837(I) and 837(P) EDI 5010 HIPAA claims transactions conversion from the HIPAA 4010 format
• Manage and deliver the 835 EDI 5010 HIPAA transactions conversion from the HIPAA 4010 format
• Manage and deliver the 834 EDI 5010 HIPAA transactions conversion from the HIPAA 4010 format
• Monitor and drive the ICD-10 and Facets Enhancements/upgrades
• Manage and deliver the Enrollment Data extracts and crosswalks

Confidential, MN

Program Manager

Responsibilities:

• Develop and define the Test Strategy
• Manage and monitor the Business Acceptance Test Plan results
• Develop and drive the NASCO Migration Testing
• Develop a strategy for the NASCO ICD-10/ICD-9 conversion from the legacy system
• Drive the Data Mapping process
• Manage the Dual Processing testing results and provide solutions during gap analysis

Confidential, Chattanooga, TN

Sr. Project Manager

Responsibilities:

• Define and develop the ICD-10 Code Mapping process
• Create the ICD-10 Governance model with roles and responsibilities
• Create the Request for Proposal and schedule demonstrations for various ICD-10 Vendor mapping tools