Objective: To obtain a challenging Senior level Executive Director position as a Healthcare Economist working in collaboration with the Centers for Medicare and Medicaid Services CMS Programs, Health MITA, MMIS for Health Systems Management HSM Operating Unit OU overseeing Department Managers encompassing staff across high profile programs for CMS profile management monitoring and compliance protocols.

Qualifications include: - B.Sc. degree in Management Science, fifteen plus 15 years of experience in project management for information systems - Knowledge of Medicaid Eligibility and Enrollment and managing Customer Call Centers - Experience with IT Project Development Lifecycle - Knowledge of Project Planning tools such as Microsoft Project - Ability to communicate effectively with project staff and customers to solve complex issues - Strong interpersonal and written communication skills - Knowledge of human services programs - Understanding of systems design and development processes.

Professional Summary:

• Possesses executive-level management and leadership experience, with proven expertise in business development in the Federal Health arena and have the ability to think and plan strategically.
• Possess strong technical aptitude with solid experience in IT Project Development Lifecycle, including systems integration and AGILE Development for large complex systems.
• Medicare/Medicaid experience background working in geriatric special needs. Documents clinical care efficiently and completely in the Electronic Medical Record.
• Ensures every patient is provided with excellent quality clinical care in accordance with evidence based medicine and quality assurance programs.
• Serves as a resource to clinical staff in dealing with complex psychosocial issues and accessing community resources.
• Provides Direct Care Coordination services to patients with complex social/emotional needs.
• Assists clinical staff in identifying resources outside the patient's benefit plan.
• Contacts patients/families/care providers as appropriate to facilitate and coordinate access to community services.

Policy Research, Medicaid Research - Medicaid Subject Matter Expert SME :

• Worked for the protocols for The Centers for Medicare and Medicaid Services CMS , in partnership with the entire health care community to improve quality and efficiency in an evolving health care system and provides leadership in the broader health care marketplace.
• Developed and maintained system-wide training program and developed and implemented Centers for Medicare Medicaid Services CMS system-wide regulatory strategies.
• Implemented standardized policies and procedures that ensured all information was accurately abstracted and in full compliance with applicable rules for implementation relating to Plan s of Care POC or Individual Support Plan ISP for: Pre-Vocational Day Services Supported Employment Intake Assessment Job Placement, Job Training Support Residential Habilitation Supported Living Nursing Home Host Home In Home, Respite Services and Assisted Living Facilities ALF .

Healthcare Economist/Analyst able to:

• Developed analysis of healthcare utilization, costs and outcomes data in support of identifying efficiencies in healthcare operations and services.
• Worked within Medicaid multi- or interdisciplinary teams.
• Identified potential areas for medical cost improvements and operational efficiencies.
• Conducted analysis of program effectiveness data through qualitative and quantitative analysis of utilization, healthcare costs, and program outcomes.
• Develop and analyze reports to measure utilization of clinical outcomes, and network performance.
• Operated with very large data sets and performed data extraction, merged, manipulated, cleaned, qualified checking, recoded and analyzed.
• Created data charts, table, etc., interpreted findings and prepared other materials such as briefs, information papers, and fact sheets , clearly communicated results to leadership and stakeholders as needed.

Employment:

Confidential

Direct Care Counselor, Therapeutic Behavior/ Rehabilitation Specialist Contractual

Assignment: Sheppard Pratt Hospital/Health Systems, Towson, MD Waldorf, MD

Project Manager PM , Educational Director ED F/T Contractual

Special Education Officer, Program Analyst F/T Contractual

Confidential

Senior Analyst, Medicare data for fraud, waste and abuse FWA :

• Under direction from management, assist with updating and providing Anti-Fraud training to Company associates relating to Medicare Part D standards, conducted and/or assisted in investigations related to Medicare Part D Pharmacy claims.
• Assisted department management with reports regarding Medicare Part D as needed.
• Identified problems and made recommendations to management, as they related to risk mitigation and effective external/internal controls for Medicare Part D Pharmacy Business Operations.
• Used a variety of data analysis methods, supporting the functional requirements of a fraud prevention system, and testing the outcome of the system.
• Identified, analyzed and categorized fraudulent health care claims submissions and enrollment activity.
• Facilitated operational activities with CMS entities, law enforcement, compliance and external vendors, in support of the fraud, waste and abuse department.
• Coordinated deliverables between multiple vendors, data entry, research activities and documentation of operational processes and policies.
• Developed and maintained fraud investigation strategies in all areas pertaining to fraud, waste and abuse.
• Used well-developed understanding of the health insurance/health care industry, and an in-depth understanding of health care data and the methods of data analysis.
• Innovative, analytical, thinker and developed conceptual informatics solutions to scientific problems and integration into other information systems, internally and externally.

Roles and Responsibilities included:

• Conducted data mining, analysis, and reporting used available tools and data sources.
• Identified aberrant billing patterns through utilization reviews.
• Served as an auditor for fraud investigations and provided subject matter expertise.
• Identified and recommend policy, procedure, and system changes, enhanced investigative outcomes and performance.
• Collaborated with customers and the IT organization, developed business and functional requirements and performed analysis activities.
• Supported system testing analyst, examined claims for compliance with relevant billing and processed guidelines.
• Proactively identified opportunities for fraud or emergent schemes.

Other Related Consultancy:

• A subject matter expert SME who provides professional or advice in a particular area such as management, accountancy, education, special education law, human resources, marketing and public relations and consultancy work, which falls under two general categories:
• Internal Consultant - Operates within an organization but is available to be consulted on areas of specialize services by other departments or individuals acting as clients or
• External Consultant - Employed externally either by a firm or some other agency and expertise is provided on a temporary basis, usually for a fee and generally engages with multiple and changing clients.

Confidential

Technological Proficiencies / Applications Web Languages

• Databases: Knowledge of principles, concepts, and methods of SQL, Oracle databases, Microsoft Windows NT Server, Power Point, Adobe Acrobat, Excel, Access, and Outlook.
• Experienced in the designing, testing, and maintaining technology solutions.
• Operating Systems: Microsoft Office Applications and Microsoft Office Suite Windows server 2000 .

SharePoint Developer

• Led the design, development, implementation and customization of an Enterprise Level SharePoint portal solution for the Program and supported sites built in SharePoint 2010.
• Information Systems Security Professional ISSP / Information Technology Infrastructure Library ITIL .
• Performed administrative functions by modifying web and portal pages based on customer request in SharePoint 2007 developer.
• Uploaded finished intelligence information used due diligence followed Standard Operating Procedures SOP , mentored 45 75 team members based on size of project and documented.
• Demonstrate ability in .NET technologies such as ASP.NET, VB.NET and Visual Studio.NET as well as ASP, HTML, XML, XSLT, JavaScript and VBScript.

.Net Programmer / Engineer / Developer

Skills:

• 8 years of experience working in a .Net environment ASP.Net, VB.Net or C .Net .
• 8 years of Project management experience.
• Software development background with VB, C , SQL, QTP automated test development.

IT Quality Assurance Analyst QA Analyst

• 8 years of solid experience in Quality Assurance and Software Testing, using manual and automated testing technologies.
• Works closely with business, architecture, development, and operations teams using agile scrum approach aiming to ensure test coverage and quality of the delivered product.
• Analysis, Planning, Hands-on testing, reporting and support.
• Business Requirement Analysis, writing test plans, test cases, and user scenarios, test execution and defect tracking.
• Collaborates and supports Business, Development, Operations, Customer Care and Support teams to improve Quality and product delivery.
• Knowledgeable which supports Web System, Software Integration, and End to End testing tasks to assure application accuracy, quality, and adherence to regulatory, industry standards for ultimate customer satisfaction.