SUMMARY

• Highly accomplished Senior Healthcare Business/Operations Analyst and Project Manager with a proven track record managing complex operations and IT systems implementation/migration projects within the private and public sectors of the healthcare industry. Practiced in clarifying business requirements, performing gap analyses between goals and existing IT capabilities and operational processes/procedures, and designing process and system improvements to increase productivity and reduce costs. Extensive experience in requirements analyses, configuration, implementation and optimization of AMISYS and FACETS for healthcare plans. Strong communication and interpersonal skills, adept at facilitating discussions and negotiations between executives, IT staff and end users. Recognized project management skills, consistently delivering complex, large-scale projects on time and within budget with the highest quality outcomes. Areas of expertise include:
• Business and Process Analysis, Redesign and Implementation Utilizing SDLC
• Complex IT Implementation, Conversions, Migrations and Upgrades
• Project Management, including Tracking, Budgeting, Risk Assessment and Contingency Planning
• Management of Cross-Functional Teams and Effective Communications Protocols
• In-depth Knowledge of: HMOs and other Managed Care Programs Government Plans Including Medicaid, Medicare, SCHIP and Government Employee Health Plans Preferred and Exclusive Provider Organizations PPOs/EPOs Independent Practice Associations IPAs Third Party Administrators/ Management Service s Organizations TPAs/MSOs Business Process Outsourcing Evaluation and Implementation Union Trusts and Self-Insured Employers

PROFESSIONAL EXPERIENCE

INDEPENDENT CONSULTANT

Confidential

• Project management, risk assessment and contingency planning
• Information Systems IS requirements analysis, RPF/RFI development, proposal review, system vendor selection, procurement and installation
• Configuration, data mapping, acceptance testing and management of new /converted information systems
• Evaluation and implementation of electronic data exchanges
• Intra- and interdepartmental workflow redesigns and implementations
• Development and implementation of systems testing criteria for both IT and operations processes
• Development of Project Management Offices PMOs , implementation of wiki software solutions, policies and procedures, and staff training
• Audits of internal systems, policies, processes and data integrity on behalf of employer groups, union trusts
• Medicaid program development, network development, operations and expansion planning
• Prenatal Risk Assessment product IS and operations design, development and product launch
• Utilization review and case management product developme nt, including financial analysis and marketing plan

VICE PRESIDENT

Confidential

Directed IT and Operations departments for IPA management business grown to 29 IPAs with over 450k members in Southern California. Converted 16 unique IPAs to AMISYS in nine months while managing and improving operations for existing IPAs. Responsibilities included development and management of multiple conversion project plans and system enhancements selection and implementation of wrap-around software products implementation of electronic claims processing, converting existing claims entry to imaging, OCR and electronic entry, eliminating a 100k claims backlog and regaining health plan compliance. Developed numerous automated solutions for configuration updates, membership entry, health plan reporting, capitation, pricing and benefits table updates, and generation of physician directories. Managed a staff of over 60 employees in nine geographic locations.

DIRECTOR OF OPERATIONS

Confidential

Directed all aspects of national PPO development and operations for The Affordable Medical Networks. Management of all operations departments, with a staff of 180 and an annual budget exceeding 9 million, encompassing: PPO Data Management for hospital and outpatient care networks, including directing the development of corporate-wide relational data base and software applications for provider demographic and contracted rate schedules National Claims Pricing, including monthly billing and savings reconciliation Provider Relations for network of over 80k health care providers, with comprehensive credentialing, provider training programs and materials including electronic updates PPO Reporting, analyzing client data, producing annual saving and penetration reports. Directed data conversion and operational integration following COMPARE's acquisition of OUCH Systems and merge with Alta Care Networks. Developed process for assessing client technical requirements and defining needs prior to network implementation.

DIRECTOR OF OPERATIONAL SERVICES

Confidential

Launched JBI's TPA product, including analysis and redesign of JBI's managed care system now AMISYS to allow for triple option processing. Managed TPA operations staff, including development of benefit plans, reporting, financial and funds management, and operations policies and procedures. Developed of regional PPO/EPOs and integration of external PPO networks. Managed Options for Healthcare utilization review/case management product. Performed IS requirements analysis and designed operations for triple options health plan in Madrid, Spain, including network development, provider reimbursement methodologies, capitation/risk pools, member enrollment and electronic funds transfer premium payment system. Performed comprehensive operational review and audit for PhilamCare, a 350k member HMO in the Philippines.

PROJECT DIRECTOR

Directed operation development, systems installation and testing, and star-up operations for Health Plan of San Mateo, a 40k member Medi-Cal HMO. Installed AMISYS, developed operational policies and procedures, training material, and system management protocols for five HMOs nationwide, including configuration, data mapping and system acceptance criteria. Acted a primary liaison between clients and JBI technical staff for development of functional enhancements to the core system.

OPERATIONS DIRECTOR

Directed start-up and operations for the Santa Barbara Health Initiative, the nation's first Medicaid managed care plan. Managed IS staff, financial and reporting analysts, claims processors/adjudicators, provider and beneficiary services support personnel. Responsible and accountable for all operational areas, including government compliance, reporting and audits. Directed software development and enhancements of existing managed care system to comply with Medicaid requirements, including test criteria, and technical and user documentation. Developed electronic eligibility interface and reconciliation process with State of California.