SUMMARY:

• 18 Years of Information Technology Health Care Industry experience include working with Confidential Family of Companies, Confidential, Confidential and Confidential
• Prepared Monthly Encounters Data Validation Report to track MCO’s Encounters submissions Data Quality and measured it against MMIS data for Timeliness, Accuracy, Completeness and Utilization for the State of Iowa Medicaid.
• Executed Health Insurance Exchange implementations, HIX readiness, and system integrations project budgets exceeding $12 million while having as much as 48 resources per project
• As an I.T Application Dev Manager, managed 9 direct reports software developers that help automate aspects of Inbound/Outbound file management through application development process.
• Analyzed encounters claims data to determine Provider Participations , Enrollment/disenrollment Trends, Payment Performance and evaluate MCO’s performance overall quality care that ultimately played key role in rate setting and risk adjustment payments
• As an I.T. Operations Manager for the CMS Healthcare.gov marketplace enrollment discrepancy resolution, a remediation business process outsourcing program, direct and overseen daily operations of complex federal program with over 30 staff and multiple work streams
• Developed requirements to integrate multiple, disparate CMS data sources into a database warehouse, allowing for the automated creation of a consolidated case workbook for the analysts which saved over $3M
• Partnered with CVS CareMark and Catamaran for PBM data solutions
• Managed mixed team of on - site and off-shore EDI developers. N egotiated agreement on EDI file data specifications with Trading Partners and vendors in accordance with HIPAA guidelines
• Hands on experience transacting in EDI standards - ANSI X12 Claims (837), Remittance & Payment (835/837), Member Eligibility (270/271), Claim Status (276/277) and Enrollment (834)
• Lead projects on Commercial and Government managed Medicare and Medicaid business models (MMIS). Worked with both Payer and the Provider side of the business. Vendor Management, Provider Management, Medicare & Medicaid Dual Coverage and targeted population
• Success stories include driving multiple teams to meet strict SLA requirements for the State of New York, Illinois, Georgia and State of Florida
• Incident Management and Problem Management - ITIL - using HP Quality Center and Test Director

TECHNICAL SKILLS:

Business Intelligence: Oracle 9/10, SAS, Microsoft SQL, SQL Loader, MS Excel incl. VBA and SQL

Analytical Skills: Defect Triage, Problem Solving, Gap Analysis, Visual Modeling, BRD/FSD documentation, Facilitating JAD sessions/meetings

Line of Business: Affordable Care Act (ACA), Health Insurance exchanges, Capitation and Managed Care (MCO), Pharmacy, Medicaid, Medicare and Commercial Plans

Methods: CMMI, SDLC, Agile Scrum

PROFESSIONAL EXPERIENCE:

Confidential

Program Manager, Data Analytics (Program Integrity)

• Conducted JAD sessions with stakeholders to identify requirements based off Iowa Medicaid Contract (SLAs) with respective MCO’s (AmeriHealth, Amerigroup and United Health Care)
• Created development plan for the Encounter Data Quality Dashboard project defining timelines, milestones and established regular cadence
• Identified gaps in current internal encounter data processing. Accounted for the risk factor. Proposed and implemented mitigation efforts
• Lead Data analyst team in integrating MMIS Data Mart and converting it into useable Data Warehouse.
• Facilitated ETL and data conversion requirements in order to extract and load critical data elements into Encounter Data Warehouse
• Managed program data integrity and analyzed encounter data to investigate Fraud, Waste and Abuse and reporting compliancy issues
• Successfully managed customer expectations, budget, scope of services, and quality of deliverables

Project Manager

Confidential

• Policy based payments- Effectuations with CMS
• Outbound File management - X12 834 Compliance Check, Business Rules Edits, Invalid Files, Remediation and Resubmissions
• Enrollment Reconciliations - ER&R, Pre-Audit Files, RCNO and RCNI files
• Manage multiple large projects involving numerous software development efforts to deliver new products and features to existing clients
• Utilized SDLC within PMP framework for standardized project structure and reporting.
• Responsible for change management of new implementations including communication and training plans, testing, and feedback cycles with user adoption top-of-mind.
• Managed a staff of two project managers and nine technical engineers in addition to facilitating cross functional communications between stakeholder departments both within the company and in client project teams.
• Provided daily, weekly, and milestone progress reports directly to executive leadership
• Responsible for coaching junior staff in project management practices and tools, as well as implementing standardized software delivery project plans and reporting mechanisms

Confidential

Team Manager, Business System Analysis

• Team Manager for the HealthCare.gov marketplace enrollment discrepancy resolution and Form 1095-A remediation program, a business process outsourcing program valued at over $84M for calendar year 2015. Reconciled discrepancies in APTC premium tax credits
• Participated in establishing program structure, organization, operation model, and vision
• Participated in mobilizing staff in less than 30 days to support the program, including data clerks, case analysts, and outreach agents, utilizing staffing agencies, subcontractors, and direct-hire staff.
• Developed requirements to integrate multiple, disparate CMS data sources into a single database, allowing for the automated creation of a consolidated case workbook for the analysts which saved over $12M
• After the initial surge and operations were stabilized, utilized ITSM methodologies to test and implement a tiered analyst model to provide a more cost effective workforce based on case complexity and escalation capability
• Achieved all program milestones on plan, including resolving over 320,000 cases for the 2014 tax year

Confidential

Consultant/Subject Matter Expert - Encounters

• The State of NY implemented their own exchange functionality. Confidential was required to report Health Exchange claims in PACDR format. Worked in gathering business requirements, writing and reviewing the BRD’s. Participated in Gap and Risk assessment meetings. Based on HIX companion guide, performed GAP Analysis - teamed up with State Business Unit. Prepared Implementation plan and recommend possible system changes to accommodate State requirement. The system change included both Medical and Pharmacy(NCPDP) encounters

Confidential

• The State of New York required submitting encounters with member having both Medicare and Medicaid dual coverage’. Worked with Claim Adjudication team to identify Medicare Paid Amount and architect a system change within Confidential that allowed reporting members with dual coverage to New State populating both Medicare and Medicaid Paid Amount on the Meds III submission file. Wrote Business Requirements, worked with IT and NY State Market teams and managed entire process until completion

Tools: - Edifecs, Xengine, HTR, Paradigm, SQL, Oracle 10

Confidential, Philadelphia, PA

EDI eBusines Consultant

• Prepared implementation plan and negotiated agreement on EDI file specifications with Trading Partners and vendors in accordance with HIPAA guidelines. Interfaced with technical staff, trading partners, Clearinghouses and internal staff including programmers on all HIPAA related information and changes
• Teamed up with Senior Management, Legal to formulate EDI Trading Partner Agreements in accordance with HIPAA compliancy rules. Wrote companion guides for several EDI formats evaluating system requirements and business rules
• Teamed up with Senior Managers in managing System (EDI and data processing) requirements, System design and Architecture, develop and test EDI Portal Redesign applications and transactions. Worked on EDI Portal from its inception to completion and then support it
• Interacted with BlueExchange(BX) team in their efforts to implement real-time eligibility transactions(ANSI X12 270-271) and connectivity with trading partners in line with their business rules
• Used SQL queries to analyze incoming customer information against IBC system data to validate expected test results. Worked with trading partners to implement and troubleshoot connectivity to EDI systems that included Secure FTP, FTP with PGP encryption for batch transactions and Webservices for real time transactions

Confidential

Sr. EDI Developer

• Played a leading role in the testing of various HIPPA Transactions/mapping and Code Sets including ASC X12 837, 270/271, 276/277, and 835 with Claredi and in getting it certified
• Served as a liaison between IT staff and Client. Provided resolutions relative to EDI implementation, transmission protocols and Value-Added-Networks (VAN) communication problems
• Designed and created medical reports for physicians and practices for in depth analysis based on patients and insurances data, to support above application. Used Parameterized PL/SQL /Crystal reports
• Performed Data Conversions from different databases and mapped it into our Oracle database structure so that the relational Data integrity is maintained and at the same time all the data information is preserved