SUMMARY:

• Managing QNXT Configuration of Healthcare Member Enrollment/Eligibility, Benefits and Provider Data for new business and acquisition initiatives through Closure, Stabilization, Integration and Expansion phase
• Ensuring Centers for Medicare & Medicaid Services (CMS) ICD - 10 compliance, by performing impact analysis, remediation enhancements and testing of a 66-vendor ecosystem, consisting of functionality that receives (via EDI), adjudicates and prices health insurance claims submitted by healthcare providers, and processes payment remittances; vendor systems also maintain member eligibility and utilization functions
• Providing verification of vendor technical design documents to validate requirements are meeting defined specifications
• Managed development of Provider Portal systems to integrate with legacy Internet portals, and dedicated to enabling Providers to register for participation in ICD-10 compliance testing
• Performing validation of claims processing system to ensure uninterrupted production operations once providers begin submitting claims on enhanced platforms
• Operationalized Administrative Services Organization (ASO) for new Mental Health lines of business; facilitated management review and approval of signage, administration manuals and communication letterheads
• Managing validation of Clinical Editing Services’ dual-processing of new diagnosis and procedures codes capabilities
• Working with vendors to assess CMS' ruling on grace period for continuing to process legacy medical codes, subsequent to compliance date; thus, enabling management to make informed business decisions on whether to extend the duration for provider claim submissions and assess the potential risks of that decision
• Coordinating efforts with vendors to conduct validation of DRG (Diagnosis-related group) Grouper/Pricer dual processing capability of new and legacy diagnosis and procedures codes, which ensures uninterrupted Medicare payments to hospitals
• Operationalize products by facilitating Code Translation application work sessions to ensure knowledge transferred
• Providing oversight for claims systems front-end, backend & reporting business & technical requirements review sessions
• Create, track and maintain program/project timelines containing all key deliverables, major milestones and dependencies
• Manage scoping, requirements, design, code/unit, integration testing, system testing and implementations phases, including building of testing approaches and plans for development of business applications and process methodologies
• Promotion of code from development, test to production environments, issue/defect to apply fixes to ensure “go decisions”
• Verbal communication style is assertive - not aggressive or passive; superior technical and non-technical writing abilities, with ability to present strategies to management and peers
• Management style is partnering, consultative, collaborative and consensus oriented.

TECHNICAL SKILLS:

Software: MS Word Suites (Word, PowerPoint, Excel, Outlook, Project Server, SharePoint), JIRA, Primavera P6, OPPM, HP PPM, Planview, Clarity, SAP, QNXT, FACETS, NASCO, Serena Business Mashups, LiveLink, eRoom

Database: Oracle, MYSQL, MS SQL, MS ACCESS

Programming Languages: .NET, ASP.NET, Java, JavaScript, JQuery, HTML/5, XHTML, SQL Server, MYSQL, C++, C#Framework ITIL, NIST, DISA / STIG (Security Tech Implementation Guidelines)

Operating Systems: UNIX, Windows 8/10, iOS, Linux, IIS

Methodologies: Agile, Waterfall, SDLC, PMLC

PROFESSIONAL EXPERIENCE:

Confidential, Southern, California

Program/Sr. Project Manager

• The company is a multi-state Manage Care Organization (MCO) healthcare insurance Fortune 300 company, offering multi-state Medicaid Solutions, Medical Clinics and Healthcare Insurance services
• Responsible for managing configuration work-streams for the company’s acquisition of Total Care Inc., which will provide access to a market of 2.68M lives. The project activities are focused on Day-1 after the acquisition/close activities, such as
• Change of control, re-contracting, continuing operations and employee transition
• Stabilizing joint operations and human resource activities, and enabling support of future growth and expansion through the integration of I/T systems and vendor services.
• Enabling the organization to progress to market expansion opportunities
• Managing project budget, scope and schedule activities for QNXT Configuration of Member Benefits, Provider Contracts and Provider Record Data for functions that include Eligibility & Enrollment and Claims & Encounters.
• Providing management of a Master Certified Provider File project impacting 9 States (NM, IL, WI, WA, SC, Fl, OH, TX & UT) and $130,000,000 in reportable/reimbursable dollars. The company is facing state reimbursement and provider paid claim recovery challenges from claims and encounters where provider information on the submitted claims do not match the provider file for respective states. The goal of the project is to reduce claims rejections for Medicaid services rendered by unregistered healthcare providers for all states impacted.
• Managed healthcare provider contracting, credentialing and configuration workstreams for Fully Integrated Managed Care (FIMC) Implementation for company’s health plan located in the state of Washington, with the goal of integrating medical and behavioral health services. This initiative improved access to care, and linked crisis response with community and clinical services affecting 96,000 enrollees

Environment: Facets 4.8/5.3; Primavera P6, OPPM; MS Project 2013; Visio 2013; MS PowerPoint 2010

Confidential, New York

Program/Sr. Project Manager

• Company offers Medicare Advantage and/or Medicaid Managed Long Term Care and Medicaid Advantage. This mix of government programs, products and services creates diverse and complex requirements, which must be navigated while meeting CMS’ ICD-10 compliance regulations. Reporting to the VP/CIO, David’s role is to manage a program encompassing 8 workstreams comprised of Claims, Testing, Provider, Training, Vendor & Operational Readiness, Government Reporting and System/Application Sun-setting. Using SharePoint for document collaboration and creation of real-time visibility into all project workstreams for stakeholders; and sharing links to project related artifacts, including charter, schedules, risks and issue logs, and Bi-Weekly, Weekly, Leadership and Steering Committee Status Reporting. The scope of the program covers 26 impacted functional business areas and 28 vendors; the work effort encompasses:
• Produced an Operational Readiness Strategy
• Drafted an ICD-10 Claims HealthRules Front-End, and Backend & Reporting Business Requirements Documents
• Drafted a Claims Backend & Reporting Technical Requirements Document
• Conducted Claims Frontend Development & Testing
• Creation and execution of Authorizations & Clinical Editing test cases
• Performed TransSend EDI 837, HealthRules Claims Processing, and EOP, EOB, 835, Checks and 277 Testing
• Conducted System Integration Testing with MS DRG Grouper/Pricer Testing for Provider End-to-End Testing
• Managed implementation of ICD Medical Codes Translation Mapping Tool for Utilization Management Auths
• Conducted 5010 paper-based claims (Lason) Testing on McKesson MCO and HealthRules claims systems
• Performed Vendor Readiness Compliance Validation activities
• Executed Claims & Reporting Development & Testing of 100 inbound/outbound data feeds into data warehouse
• Developed medical diagnosis & procedure code crosswalk to enable reporting to validate legacy claims system
• Performed Functional Impact Analyses, and establishing Operational Readiness Command Center
• Created Transition Support Plans and ensuring updates to Operational Tracker Tool
• Implementation of enhancements to Government Reporting, mandated by CMS and New York State
• Executed both Key (Early Adopter) and Open Provider Testing activities to validate compliance
• Facilitated HealthRules & McKesson MCO Contingency Plan Go/No-Go Decision
• Drafted and execution of Training Plan to educate internal and external stakeholders on new medical codes.

Environment: Optum EasyGroup DRG v32 & 33 Grouper/Pricer & Claims Editing System (CES), McKesson MCO Claims Platform, HealthRules, Salesforce Service Console, JIRA, SharePoint; Test/QA Management, Genesis & Exodus Data Warehouse & MS Project

Confidential, New Jersey

Sr. Project Manager

• Managed a federal mandate project to replace ICD-9 Diagnosis Codes with the ICD-10 Diagnosis Code set, and remediate Surgical Procedure Codes (PCS) that are required to report inpatient treatments; responsible for the enhancement and remediation of all business processes, systems and applications within the Claims Processing and Customer Services divisions, while maintaining current ICD-9 processing. The scope of the project encompassed:
• Remediation of impacted Inquiry Documents database, and analysis/remediation of new inventory during execution
• Reduction of manual processing of ICD-10 claims by automating Desk Procedures that could be automated
• Remediation of Edits, Desk Procedures and workflows to accommodate ICD-10 diagnosis and procedure codes
• Built new claim edits to reject claims with no primary diagnosis, and/or allow ICD-9 and ICD-10 claim submissions based on date-of service, and reject combinations of ICD-10/ICD-9 codes listed on the same claim
• Performed remediation activities for vendors, impacted Customer Service and Member/Provider portal applications
• Loading of ICD-10 codes to NASCO mainframe tables in test environment impacting institutional and professional claims, authorizations, and benefits and pricing functions
• Produced monthly budget / earned value reports (planned versus actual with cost and schedule variances)

Environment: Planview, Serena Business Mashups, Provider, Member & MTM Portals, EDI Gateway, ClaimXten, iCore, NASCO, Model Office, FEP, FACETS, DRG Grouper, Per Diem, APC Pricer, Research Station, CDH, eFDE, Burgess, UCSW, Purge Pend, Online Inquiry Database, Claim Edit, Care Core, Interact/BPM, ITS, MPL, Flex link, Open Connect, MS Project & MS Office

Confidential, New York

Sr. Project Manager

• Led a team of Business Development Subject Matter Experts to establish a new line of ancillary products, which included an Employee Assistance Program (EAP), Dental, Vision, Hearing, Accidental Death & Dismemberment (AD&D), and Life and Pet insurance products. The goal of this initiative was to brand and co-brand new products to further differentiate Emblem from its competitors. The activities required to establish the new line of business included but was not limited to:
• Creating a detailed ancillary products business plan that encompassed competitive analysis and financials
• Updated Sales and Account Management customer engagement worksheets with new product data
• Engaged Vendor Management to operationalize the EAP product line with Third Party Administrator (TPA)
• Established a new Profit & Lost (P/L) receptacle for income landing and payables with Finance and Billing groups
• Set up banking ABA Routing wires for Electronic Fund Transfers (EFT) with vendors
• Created a process for the Group Administration team to reconcile member enrollment data with vendors
• Managed a Patient Protection Affordable Care Act (PPACA) Women’s Preventive Services (WPS) health care mandate, focused on the delivery of services such as mammograms, screenings for cervical cancer and prenatal care. The goal of the project was to ensure these health benefits are covered with no cost sharing. The activities included in this project were to:
• Establish a short term solution by pending claims and manually waiving cost sharing (1100 claims per week)
• Manage a long term solution to write business requirements, code, QA, test and deploy an automated solution
• Work with Religious Organizations that are eligible to apply for permanent or temporary exemptions
• Facilitate build of exemption artifacts and eligibility process with Marketing, Legal & Account Management
• Code changes to benefits on all systems/platforms based on which organizations applied for an exemption

Environment: HP PPM, QCare, CoreProd (Medical System), ProdHosp (Hospital System), MS Project and MS Office Suite

Confidential

Sr. Project Manager

• Managed implementation of healthcare products quality improvement initiative, encompassing 1000 health benefit products, including Chemotherapy, Chiropractor, Colonoscopy and EEG/EKG Services, to increase Measures That Matter (MTM) scoring for internal and external audits. Applied SLDC and PMLC methodologies by:
• Drafted charter, requirements to determine impacted functions and determined level of work effort (LOE)
• Designing a 3-tiered business process improvement solution to analyze and synchronize EOBs with products to meet contractual obligations with member-groups, and operationalized process
• Created procedures to maintain release notes and configuration control of benefit summaries across all system environments, and the maintenance of a benefits control document lockdown list using SharePoint 2007
• Led effort to design Group Benefit products’ standard templates between NASCO and Facets to gain efficiencies by streamlining and synchronizing benefit types to establish core medical codes across product types, and differentiate them by dollar differences, co-pays, co-insurance and jurisdictions
• Managed discovery/assessment phase of CMS mandated ICD-10 diagnostic and procedure codes implementation. Identified requirements necessary for the Data & Informatics functions and EDI Consolidated Gateway, to include EDI X12 Claims transactions (270, 271, 278, 835, 837P and 837I) in support of the ICD-10 integration

Environment: TIBCO, Serena Business Manager, Clarity, SharePoint, MS Project 2010, Object Data Store, Business Intelligence Cubes, Electronic Data Warehouse, and MS Office Suite

Confidential, South Carolina

Sr. Project Leader

• Used MS Project Server 2002 to build project plans to manage all project activities.
• Managed work effort to upgrade MS Project Server 2002 to release 2007, and upgrade the client application from MS Office Project 2003 to release 2007. The activities required to address this business need included:
• Identifying backup, recovery, and disaster recovery procedures
• Installing ASP.NET 2.0.50727 in IIS, and Microsoft .NET Framework version 3.0
• Ensuring an SMTP server and mail client was available
• Creating necessary service accounts and adding appropriate local groups on servers
• Installing and configuring SQL Server 2005
• Creating communication and training plans and artifacts
• Creating a web application to host Project Web Access site
• Creating administrative accounts and requisition of hardware and software licenses
• Facilitated work effort to upgrade 1400 servers with migration of respective applications to Windows Server 2003, while reducing the hardware footprint to 700 virtual and physical machines. Upgrade and migration activities included:
• Migrating the end user community from Windows 2000 & XP to the Windows 7 desktop platform
• Execution of requirements, design & engineering, build and deployment phases for all servers
• Performed scoping, analysis, design, SIT & UAT testing and implementation for impacted applications
• Led ITIL (IT Infrastructure Library) effort to develop and deploy an Audit Request Methodology to refine the I/S governance standards and processes for interactions between Information Systems and Corporate Audit to ensure processes allowed proper planning, prioritization, and execution of internal and external audits, including:
• Conducting work sessions to design Audit Methodology
• Defining new work activities to be incorporated within Work Request Management System & Planning System
• Defining Internal and external roles and responsibilities for I/S Audit Support organization
• Managing team to develop process workflow diagrams integrating new methodology into WRMS and MPS systems
• Led CMS Baseline Compliance Automation Project to establish configuration defing standardized levels of security and support within SOC (Security Operations Center) across all network devices and platforms: Web-based, UNIX and Windows server Operating Systems, routers, switches and firewalls. Based on NIST, DISA (DIACAP - Department of Defense - DoD) / STIG (Security Technical Implementation Guidelines) for Medicare and TRICARE. This initiative involved:
• Determined gaps in operational effectiveness and efficiency to apply and maintain solution sets for policy
• Managed deployment of ArcSight Network Configuration Manager (NCM) module across all enclaves
• Managed enhancements of security, using methods to scan, detect, report on and fix security vulnerabilities and configuration problems for 154 SQL, Oracle and Sybase application databases, and 130 UNIX servers requiring remediation by UNIX and Database Administrators executing Systems Readiness Review (SRR) scripts

Environment: Mainframe Express® Enterprise Edition (COBOL), HP PPM, ASP.NET 2.0.50727, In ternet Information Services, .NET Framework version 3.0, SMTP, SQL Server 2005, UNIX, Windows 2000, XP, MS Project Server, and MS Office Suite

Confidential

Project Manager

• Managed a portfolio of projects under the Core System Replacement Project, a program established to migrate all application functionality and convert data from a mainframe-based system (Long Range System Project), to an open (non-host) systems environment called QNXT
• Managed the analysis, design, application development, testing and implementation of an EDI 276/277 & 270/271 Transaction solution to enable medical providers to request and receive insurance benefit eligibility and claim status, which included HIPAA-compliant NPI (National Provider Identification) functionality, for QNXT 3.4 Claims using a Mercator interface. The requirements in scope for this work effort included:
• Enhancements to Mercator QNXT 3.4 Private Business’ 276/277& 270/271 request and response processes
• Meeting Private Business lines’ NPI Requirements for EDI 276/277 & 270/271 Transactions, and modification of EDI 276/277 & 270/271 processing for FEP, Blue Card, 65C Plus, Quest and After Home After Care
• Facilitated implementation of QNXT Pay Cycle Pay Daily System, which enhanced the claims payment system to enable Finance & Accounting to run payments daily versus once-per-week. The workstream’s scope required modifications to existing SQL jobs to appropriately select medical providers for payment on a designated day, and included:
• One time automated data load to update QNXT’s provider attributes to indicate the day of the week to pay providers
• Building and execution of test plan and scenarios/cases, which consisted of dropping claims, running payment and mass adjudication with On-Demand Payment options that included Argus pharmacy claims
• Development of weekly medical Reports-To-Members, meeting Department of Labor requirements, and generation of Reports-To-Providers and checks, including EFT’s (Electronic Fund Transfers) to providers as designated
• Coordination of communications to providers on changes to claims submissions and payment dates, and interfacing with the Argus Team to determine impacts to pharmacy cash flows and interest payment penalties
• Led design, development, testing and implementation of Pay-To-Provider UI to enable manual entry and payment of claims. Enhancement enabled capability prompt for selection of Pay-To and service location for providers
• Used QCSI New Extensible Technology, a QNXT Microsoft .NET framework claims processing software package, to process 65C Plus & Quest plans, enabling return of information for examiners to make correct selections. Facilitated code promotion walkthroughs for project deliverables with Developers, Database Administrators and SQL Server Administrators to review object inventories and implementation checklists for production deployment

Environment: Mercator, QNXT, Facets, Argus, Microsoft .NET, EDI 276/277 & 270/271, UNIX, Planview, MS Project Server

Confidential, New York

Project Manager

• Performed needs and business analysis to develop learning solution to address business competency gaps for implementation of a Human Capital Management System (HCMS) and Learning Management System (LMS) called Learning Edge
• Led the Marketing team to analyze, develop and implement Change Management campaigns and programs to increase awareness and appropriate usage of the HCMS/LMS and content
• Recommended solutions and strategies to ensure awareness and appropriate use of the learning system’s and tools
• Development, publishing and tracking of communication plan, schedule and resource allocations according to program goals
• Developed live and virtual marketing events to identify, publicize and leverage internal and industry best practices
• Performed analysis of training materials and program’s message design to ensure requirements were achieved.

Environment: SABA LMS, UNIX, MS Project Server and MS Office Suite

Confidential, New York

Business Technology Program / Project Manager

• Managed multi-million dollar cost savings initiative to identify, rationalize, evaluate, test, remediate, package and install 3000 business applications, for integration with Pfizer's Common Desktop Environment. The project standardize the PC software environment, combined with the implementation of an ITIL (IT Infrastructure Library) Service Level Management (SLM) framework wrapped as Desktop Managed Services, and CMM for continuous process improvement
• The scope of the program included leading 85 IT and Business resources and 35 business units with a consistent, secure experience of internal and external tools and application services, while achieving major costs savings through the centralization of image engineering and support services, and standardization of core applications. Also built an implementation methodology encompassing application rationalization, testing, early adopter programs, deployment and governance processes
• Managed multiple global network security initiatives in concert with the Worldwide Security & Privacy Services Group, to develop and execute a program to integrate appropriate levels of security for multiple share drive access across 8000 Windows 2000 and Windows 2003 file servers on the network; and monitor and remediate, via McAfee ePO, 118,000 network workstations, Laboratory Notebook Benchtops devices and servers that were vulnerable, resulting from Microsoft’s discontinued support of Windows 2000 SP3 and an internal IT audit finding indicating resultant security vulnerabilities
• Facilitated removal of server file shares and elimination or significant reduction of the number of shares with open access, which was limited to group and application shares. Used McAfee ® ePolicy Orchestrator ® (EPO), IBM Tivoli, and Systems Management Server (SMS) to identify non-compliant systems running SP3 or lower; engaged system/business application owners to remediate Benchtop Laboratory Devices, servers & workstations by proposing SP4 or XP system upgrade options
• Managed a comprehensive GxP Computerized Software Validation project for the Dictaphone Freedom Recording System (DFRS), to ensure the system met its intended business requirements, and was in full compliance with 21 CFR Part 11 FDA regulatory validation guidelines, and prepared for internal audits. The system is used to support collection of information on clinical trial adverse events reporting. Some tasks executed to validate the DFRS system were:
• Determined Installation Qualification (IQ), Operational Qualification (OQ) & Performance Qualification (PQ) protocols were employed for DFRS implementation. Established security processes and procedures for application and physical access including firewall protection. Conducted Gap Analysis on all SOPs, system documentation and deficiencies for testing and remediation.
• Implemented Windows NT, and Novell Network Infrastructure technologies, and performed design of Local Area Networks (LAN); managed security initiatives on Corporate-Wide Area Networks (WAN)
• Developed Request For Proposals (RFP) and Requests For Information (RFI) for vendor Submissions; built multi-matrixed project teams to successfully integrate solution into client environment
• Planned and managed functional configuration and implementation of Adobe Acrobat Standard & Professional v6 Plug-in, to enhance the application’s API’s Save and Save As functionality, enabling backward compatibility of integrated document-based applications (PfLITE & SMART) to submit PDF documents to the FDA in compatible formats for medicine submissions. The project’s scope impacted stakeholders in the World Wide Regulatory Affairs & Quality Assurance, Safety & Risk Management and R&D Informatics group

Environment: Windows Server, IIS, UNIX, SharePoint, LiveLink ECM, Macromedia Flash 8, Namo WebEditor, Hyena v5.0, MS Project 2000, Visio 2000, MS Access 2000, Inquisite v6.0, eProvision, Documentum eRoom, Exchange v5, MS Outlook, Windows XP, NT Server/ Workstation v4, NOVELL NetWare v5.0, cc: Mail, ADE 2.0 & DB6/DB8, Lotus Notes v4, and Domino