SUMMARY

A Healthcare Management Professional with extensive experience and demonstrated proficiencies in managed care Project Management for product development, business operations and systems infrastructure development and integration initiatives. Progressive healthcare experience includes the management and delivery of solutions to support various medical and behavioral health care models, information technology initiatives and business continuity plansfor payer and Provider organizations.

Key proficiencies include:

Leadership and Management

• Strategy Development:Strategic and analytical contributor. Identification of issues and facilitation of business problem solving within established framework and present recommendations to Senior Management and Executive Leadership
• Industry Knowledge:In-depth knowledge of managed care organization critical operations and current trends affecting marketplace. Understanding of implications, development and recommendation of strategies to ensure continued organizational success
• Communication: Preparation and distribution of materials to Senior Management and Executive Leadership to include: strategy proposals, issue and risk assessment reports, cost to implement/ROI assessment, budgets forecast and actual , project dashboard and regular status reports
• Team Leadership:Cross-functional team facilitation of resources from various levels line, Manager, Director and above within the organization

Claim Processing System Enhancements Payer and Provider

• Implementation oversight and planning for ICD10 and HIX/HIE regulatory mandates
• System integration and development of solutions to accept and process files from various claims processing environments to include Qcare, Facets, NASCO, FEP, Blue Card ITS
• Implementation oversight of core new business processes and claims processing system logic enhancements reflective of industry and government mandated requirements ICD, HCPCS, CPT and DSM code enhancements
• Management of system development activities, configuration and testing of system logic to support professional and facility claims acceptance and adjudication
• Management and testing of the development of EDI gateway and compliance software updates development and coordination of critical health information exchanges with third parties and trading partners

Mergers and Acquisitions

• Project management implementation responsibility and oversight of system integration activities associated with merging multiple HMO business operations into one consolidated entity provider of on-going support to leadership and functional business area owners pre, during and post-merger and acquisition initiative to ensure business and technical goals and objectives are attained in a quality, timely and least-costly manner
• Actively involved in strategy discussions with functional business area owners to develop new or consolidate existing processes and critical claims processing system data elements from multiple environments
• Facilitator of impact discovery sessions with functional business area owners to define the scope of systems integration and process re-mapping activities to ensure continuity and best-in-class operations

Provider Relations, Contracting and Product Development

• Active involvement in Provider rate setting and fee schedule development, implementation and external communication
• Management of revenue optimization efforts to increase plan reimbursement dollars received by HMO for Medicare product beneficiaries
• Implementation oversight for the development of various PPO, HMO and Medicare product launches to include: Mass. Dual Eligible Demonstration, New York State APG and Bridge Program, Healthy Living PPO and BCN Advantage
• Review and interpretation of CMS regulations to support development and implementation of programs and reimbursement methodologies purposed to provide services for Medicare and Medicaid beneficiaries
• Management of HMO service area expansion and HMO product licensing for additional geographies

EXPERIENCE

Confidential

SeniorImplementationDirector

• Provider of oversight, account management, implementation, and maintenance of new product offerings for Public Sector Medicaid/Medicare , Federal Government, Health Plan and Commercial clients. Active participant in the pre-RFP and RFP process to identify opportunities that leverage the use of existing business and systems infrastructure to create and offer solutions purposed to service the needs and expected outcomes of the managed behavioral health program. Additional responsibilities include the following:
• Management of product development implementation activity to ensure its compliance and alignment with mandate or client contract requirements. Oversee and provide input on the preparation of RFP responses, contract amendments, project implementation plans, risk analysis, issues tracking and client implementation budget documentation
• Leader of discussions with operations functional area SMEs to assess local and government mandate requirements and carry out subsequent implementation tasks to include solution discovery, requirements gathering, design/development, testing thru production release
• Facilitate discussions with cross-functional workgroups to identify, strategize and resolve critical business issues having potential of significant impact to expected project scope and timeliness outcomes
• Preparation of communications to SeniorManagement and Executive Leadership teams to include: weekly status reports, issues/risk assessment briefings, opportunity assessments, etc.

Selected Achievements:

• Implementation Project Manager and Value Options point of contact for ICD-10 enhancement mandate. Responsible for coordinating code remediation efforts of all functional area teams to include identification of systems and process impact, systems remediation planning, trading partner readiness, quantifying risks and impact, solution development and vendor testing
• Matrix team lead of cross-functional SMEs responsible for evaluating, establishing a reimbursement model, determining operational impact and modifying claims processing and ancillary systems to reflect code changes as part of the APA 2012 CPT Code Enhancement mandate
• Implementation Project Manager for 7 10 functional area teams to plan, design and develop solutions to support Behavioral Health components of the Massachusetts Duals Eligible Enrollment initiative a partnership with ValueOptions
• Account management, implementation and budget oversight for the following product/service launces:
• ICD-10 / DSM V Code Conversion regulatory initiative
• CPT Code Enhancements regulatory initiative
• Military OneSource Implementation budget: 2.8M
• Massachusetts Dual Eligible Enrollment Implementation budget: 1.8 - 2M
• Blue Cross Blue Shield of Rhode Island Implementation budget: 800 - 900K
• Employee Assistance Programs various commercial clients Implementation budgets: 250 - 300K/per client

Confidential

Program Manager/Consultant

Oversight of various core program teams responsible for providing direction on defining in accordance with corporate goals , developing and testing the production of deliverables required to support an array of large enterprise-wide initiatives with budgets > 500k and product launches to include the following:

Product Launches:

• Professional and Facility Provider APG Claims Reimbursement Payment Methodology
• Confidential product

Enterprise-wide initiatives:

• Mergers and Acquisitions - GHI HMO into HIP HMO
• Conversion of Amisys to Qcare Claims processing system cut-over approach
• All critical claims processing system files Provider, Membership, Benefits, etc. and 18 months of historical data claims data, member accounting, COB, etc.
• Expansion of HMO product offering service area into 18 additional counties and Provider re-contracting effort
• Actuarial and Underwriting Operating Model Initiatives
• Development and enhancement of actuarial and underwriting operational processes
• Development of sales process improvement and automated group load solution proposal - group load - initial invoice
• Provider Data Demographics Systems Accuracy Initiatives
• Benefit Plan/Member Servicing Enhancements
• Customer Service and Claims Processing System Installations and Enhancements

Selected Achievements:

• Appointed to serve as corporate liaison between business/technical groups and executive sponsors in support of their attainment of project goals by overseeing centralized services definition, planning, scheduling, costing, risk assessment and tracking to effectively monitor the committed scope, budget and timing of initiatives
• Actively identified, provided direction, and/or remediated, when possible, any major implementation risks that would adversely affect expected performance of any given initiative
• Facilitated and provided counsel to business stakeholder teams from lifecycle inception through implementation, to ensure critical compliance with organization goals and objectives and best-in-class industry standards
• Performed research and analysis of key corporate initiatives as a means to assist operational teams with defining priorities and securing funding to implement and operationalize business or systems enhancements
• Expert knowledge of program and project management principles, practices, techniques and tools and, IT operations and infrastructure, systems engineering principles, mainframes and distributed systems environments

Confidential

Senior Project Manager

Demonstrated broad knowledge and corporate facilitation of business processes improvement changes with an emphasis on supporting initiatives through acquisitions, marketing strategies, and operations. Effectively integrate Confidential Networks business functions and work processes used to support business partners and the customer/client needs. Strategically prioritized, planned, coordinated, and drove projects to ensure on-time requirements-compliant completion while maintaining high quality standards. Held project management responsibilities for all enterprise-wide Claim Operations division projects and provided implementation oversight for the following initiatives:

Enterprise-wide initiatives:

• Mergers and Acquisitions Confidential
• Conversion of Amisys to Facets claims processing system group renewal approach over 12 month period
• All critical claims processing system files Provider, Membership, Benefits, etc. and 24 months of historical data claims data, member accounting, COB, etc.
• Medicare Revenue Optimization recoupment of member reimbursement from CMS
• FormWorks implementation replacement of MacessEntrandex
• EDI Scrubbing enhancement to EDI logic program
• Provider Data Operations process improvement initiative

Selected Achievements:

• Actively contributed to the design and development of department wide standard ePMO project management tool kit items to include work plans, charters, budgets, risk and issue matrices, etc.
• Performed research and analysis of key initiatives in order to define and secure resources necessary to accomplish project tasks within established budget and timeline parameters

Confidential

Project Manager/Analyst

Successfully built and steered teams to maximize performance in consistently delivering projects on time and within budget in a fast-paced, time-sensitive environment requiring superior strategic planning, organization, and leadership skills. Evaluated project needs and worked with leadership teams to create the appropriate level of governance structure to ensure outcomes were monitored. Dwight was responsible for overseeing the development, execution, updating, and reporting of project plans and schedules. Improved operational efficiency by enhancing the Global Vehicle Development Process Operations standards and business processes

Selected Achievements:

• Actively served as the liaison between business user and technical systems groups
• Improved customer service by leading discussions with end users to capture and develop business requirements, procedures and functional specifications
• Designed, developed, and implemented a broad range of detailed process maps and diagrams to evaluate current and proposed processes for future implementation
• Implemented the successful change management plan throughout the Global Vehicle Development Process Operations group