Healthcare Management Summary of Experience:

• Over 15 years of experience in the Healthcare Management Industry
• Electronic Health Records
• Medicare/MedicaidFraud Waste Abuse.
• Proficiency in Business Analytics Methodologies
• Project Management XLC Oversight of Commercial and Government Contracts/Agencies
• Budget Review Staffing Requirements
• Contract Performance Review/ IV V
• Change Management
• Health Insurance Portability and Accountability Act HIPAA as it relates to the implementation of Transactions/Code Sets
• Analyzed procedures surrounding the Provider Fee Scheduled, Appeals Processes, and denial data.
• IT Help Desk Tier 1-3 Analysis and Resolution
• Test case development , UAT Testing, User Manuals
• Broad understanding of the CMS business operations in both central and regional offices
• Familiar with X12 and NCPDP standards for electronic processing
• Fluent with ICD-9 and ICD-10 code sets and their uses for coding diagnoses
• EDI Electronic Data Interchange knowledge
• Agile Methodology
• Extensive experience with billing/rebilling, appeals, third party billing and coding
• Commercial, Home Health, DME, TPL/COB, Laboratory and Medicaid/ Medicare account management
• Business Analytics for Medicare and Medicaid Services
• Provider and Member Support Call Center Management and Training
• SharePoint Website documentationmanagement
• Data Mining Reporting Analytics

Professional Experience:

Confidential

• Monitor government HHS contracts and daily interactions on the Medicaid Affordable Care Act ACA Projects
• Reported Directly to District's CIO Project Management Office PMO
• Manage various releases throughout the projects
• Manage project Lifecycles and adhere to timeline constraints
• Provide cost effective contact resolutions and contract performance review
• Assist with preparation of technical documentation and presentations
• Provide independent verification and validation IV V of contract work
• Determine appropriate staff to attend meeting and sign off on contractor completion gates
• Act as a government liaison between DC Government and other contracting 3 party agencies
• Address concerns issues and actions items in timely manner through JIRA
• Tracking of contractual hours and 90/10 Federal grant money
• Provide weekly status reports on various HHS projects
• Work on Federal Advance Planning Documents for Federal Funding
• Broad understanding of Business Processes, Business Rules in the As- Is To Be functional design
• Assisted District Policy Legal team in program research and federal justification

Confidential

• Provide leadership and guidance to a team of 9 Business Analyst, 3 Technical Writers and 2 Subject Matter Experts
• Interview, hire and maintain reasonable staffing levels across the agencies MMIS area
• Designate appropriate team members for the SCRUM Teams for sprints
• Develop project plans in an XLC Life Cycle and technical documentation templates
• Assign and track analytic workloads throughout teams
• Maintain project risk and issues within the project charter
• Develop strategic implementation process for aligning the agency with the project schedule
• Design look and feel of the Requirements and Business Rules Repository system
• Identify staffing needs, evaluations and interviewing
• Oversee various system implementation under the MMIS project in terms of complexity, cost, software and hardware
• Coordinate and participated in all stages of project development including research, design, programming, testing and implementation.
• Key Liaison across all functional areas, including business units, information technology and outside vendors
• Create, refine, and enforce a structured process for the design, development, testing and deployment of all systems
• Oversee the development of the state's business intelligence efforts
• Prepare technical solutions for RFI , Acquisitions Strategies and RFP for vendor
• Provide creative solutions to unique business area functions

Confidential

Oversight

• Provide lead oversight and analysis on the T-MSIS project for the Center of Medicaid and Medicare Services.
• Evaluateproject, communication plans and technical documentation for quality assurance and technical relevance.
• Develop training documentation and guidelines for the states to adhere to during design and implementation phases.
• Traveled to various state sites to monitor the progress of the system implementations and upgrades.
• Reported and tracked the states progress and maintained project dates, conversion plans and implementations for CMS.
• Participate in the onboarding process of 40 states to assist with the integration efforts.
• Develop project plans to assist with technical interface requirements, migration and test plans.
• Identify, refine and augment acceleration strategies for the State Medicaid CHIP agencies.
• Collaborate and identify best practices, lessons learned from the states and disseminate the information to the states.
• Maintained the project SharePoint site and the contractor to state website information which included the Frequently Asked Questions FAQ list.
• Created and maintained the Project Toolkit which provided project guidance, inventory of resources, case studies and reports

Confidential

• Lead the Business Analytics for the development ofthe business rules and functional requirements for Maryland Medicaid System.
• Validate and provide system software solutions to various areas of Maryland Medicaid such as claims, TPL, Pharmacy, Provider, POS and Recipient areas.
• Visualize the overall concept for the recipient and provider as it related to the MMIS and eCAMS system
• Facilitate MITA requirement and Business Process Sessions
• Construct and document business rules and Use Cases for the design, UAT and implementation phase
• Provide leadership to mid and junior analyst by delegation of assignments and overseeing work teams
• Track and maintain implementation dates and mid checkpoint sprints
• Report and track team stats and project completions and accomplishment

Confidential

• Utilized Project Management skills to run EDI/HIPAA implementation project and Call Center
• Produced Business Requirements and Requirements Traceability Matrix
• Serve as a liaison between the business and I/T organizations in the development of new I/T solutions and enhancements to existing applications.
• Establish Use Cases and User Manuals
• Suggest areas for improvement in internal processes along with possible solutions.
• Interface with appropriate technical personnel for hands on problem solving and support
• Trading Partner Management
• Assisted with claim production from 4010 to 5010
• Medicaid and Commercial Enrollment based on 5010 modification and companion guides
• Produced Business Process Models and Scope Statement
• Wrote statements of work for new projects
• Facilitated the discussion and planning of Project Life Cycles
• Maintained 49 states Companion Guides
• Tracked and maintained EDI issues/ Supervised Tier 1- 3 Helpdesk Assistance
• Conversion of ICD 9 to ICD 10 Implementation

Confidential

Business Analyst II Center for Medicare Medicaid Services

• Produced Business Requirements and Requirements Traceability Matrix
• Understanding of The Physician Quality Reporting Systems
• Established Requirements surrounding theEHR incentive payments and measures utilizing the NHIN structure
• Processing of RCR Requirements Change Request through the Change Management Process.
• Utilized the Change Management for Data Enterprise Architecture to update the system environment.
• Integrate evolving requirements into the production support environment, working with development staff to understand implications and impact of proposed and upcoming system changes
• Interface with appropriate technical personnel for hands on problem solving and support
• Utilized Quality Center for reporting incidents in the database, maintain an accountability andassign ownership
• Serve as a liaison between the business and I/T organizations in the development of new I/T solutions and enhancements to existing applications.
• Facilitate meetings and discussion as needed during the project lifecycle.
• Created/update documents required as part of the system development lifecycle SOW, business functional requirements, detail functional design, technical design input.
• Utilized Excel to document requirements and the traceability matrix
• Establish Use Cases and User Manuals
• Research and Analyze system development and provide Gap Analysis
• Medicare Fraud Waste and Abuse for the HEAT project with Department of Justice
• Data MiningUsing Business Intelligence tools such as Cognos and SAS, Lexus Nexus
• Prepared Power Point presentations reports based on the data collected and presented it to DOJ and CMS

Confidential

Project Manager II CMS Center for Medicare Medicaid Services Baltimore MD

• Implementation of Healthcare Federal Mandates including ICD9 to 10 and 4010 to 5010 conversions.
• Conducted Town Hall Meetings for Providers
• Assisted with verbiage for CMS Final Rule regarding EHR Incentive Program
• Provided direction to providers for advancing HHS efforts of Electronic Health Records EHR
• Worked with CMS Medicaid in the advance planning and development of upcoming structural changes
• Project Management Dashboards
• Setting guidelines for the new HIM regulations
• Processing of RCR Requirements Change Request through the Change Management Process.
• Designed Dashboards, Flight Tracking, Project Plans and Implementation schedules
• Work on the 5010 HIPAA implementation of Version 5010, D.0, and 3.0
• Maintain project budget spreadsheets, and correspond with various contractors across the regions
• Development of White Papers and testing criteria
• Submit written requirements including budget needs for various contract proposals within CMS
• Business Requirements, Budget Reports, and Budget Tracking
• Assist and actively strategizing with workgroups on overall product/project development
• Worked on the implementation of new J Codes for the new billing system
• Record and maintain the Issues Log for the 5010 Project

Confidential

Research Analyst DC Medicaid

• Provider Outreach for current changes in the Medicaid Business requirements and software
• Guided providers through the NPI implementation and new DC Medicaid processes
• Analyze and provide best business practices for claims adjudication and processes
• Facilitate provider training in EDI through provider enrollment and software packages
• Worked closely with providers and staff through enrollment and EDI issues
• Prepare weekly status report for management.
• Process Change Management CM requirement processes.
• Responsible for overseeing escalating issues from Provider Relations Department
• Provided pharmacy management for the set up of the Medicaid Pharmacy Call Center
• Report all finding to the District Government through various reports.
• Troubleshoot provider payment, retractions, adjustments and voids
• Oversee Call Center Inquires Help Desk Tickets
• Supervised and lead two separate departments Data Entry and Document Control in daily operations.
• Mandated the Business Requirements for the Batch Control Specialist
• Worked all claim rejection reports based on the Incorrect ICD code classification and billing structure.
• Delegated priority claims to appropriate staff
• Performed daily Quality Assurance on each staff member
• Ensured that the department upheld time constraints set by MMA for the Medicaid project
• Facilitated training workshops based on team strengths and weakness
• Developed various forms and protocols that are designed for maintaining daily operations
• Created and submitted various proposals to upper management for revamping of Claims Department
• Received training and worked on the MMIS system in conjunction with the claims adjudication for optimal payment reimbursement