Peter Kapasakis, MHA

Senior Level Business Analyst

**** **** *** **, *******, VA 23120 804-***-****

acqx81@r.postjobfree.com www.linkedin.com/in/peterkapasakis

BUSINESS QUALIFICATIONS

Gather, evaluate, and document requirements for complex new systems or system enhancements based on business user input, technical requirements and constraints;

Evaluate, analyze, streamline and document solution processes;

Develop innovative strategies for meeting business requirements, including leveraging the capabilities of existing technology tools or acquiring/developing new technology tools;

Conduct high-level analysis based on user requests. Recommend and document potential solutions;

Plan, organize, coordinate, and assign tasks required for more complex implementations

Subject Matter Expertise in healthcare processes, reporting and analytics;

TECHNICAL SKILLS

Design complex automated and manual solutions to solve business problems and achieve business objectives;

Data retrieval from data warehouse;

Analytics using SQL, IBM Modeler/SPSS Clementine;

Ability to extract and analyze raw data;

Deep understanding of the healthcare landscape;

Technical problem solving skills.

PROFESSIONAL EXPERIENCE

VERISK HEALTH, RICHMOND, VA

Director of Suspect Analytics, Business Owner

October 2014 – May 2015

Oversaw a team of healthcare professionals such as: data analysts, actuaries, clinical analysts, business intelligence analysts and mathematicians;

Directed a team that developed methods which discovered hidden and undocumented diagnoses in the Medicare and commercial population which exposed increased risks to health plans;

Interfaced with IT staff to ensure quality and validity of client data sets such as provider, claims, lab and pharmacy data;

Worked with clients to gather requirements, implement timely deliverables and review reports;

Managed resources to ensure that projects were completed on time and client deliverables were met.

Reported to senior leadership team on the status and progress of projects departmental goals;

Coached team to ensure that the principles of the organization were followed and internal goals of the research and analytics team were met.

MAGELLAN HEALTH SERVICES, GLEN ALLEN, VA

Senior Manager, Pharmacy Program Integrity, Fraud, Waste and Abuse, Business Owner

June 2005 – October 2014

Oversee Program Integrity for Tennessee, Kentucky, South Florida and several commercial plans covering millions of lives;

Manage desktop and onsite audits of thousands of pharmacies across several states;

Responsible for the identification and recovery of inappropriate claim submissions and payments;

Present findings, case status, issues and recommendations to state and commercial clients;

Attend national and regional fraud related conferences such as NAMPI and NHCAA;

Develop data mining techniques and algorithms that detect fraudulent activity within healthcare data and expose aberrant behavior of pharmacies and recipients such as anomaly detection and social network analytics;

Provide subject matter expertise for fraud related issues;

Develop processes and procedures that ensure proper payments and claim adjudication;

Assist in the development of fraud related reports used as part of client and departmental reporting;

Attend Fraud and Abuse related seminars, workshops and training sessions;

Assist in investigations by offering information and evidence pertaining to fraudulent activity;

Ensure compliance with state, federal and commercial requirements.

Senior Manager, Behavioral Health Special Investigations

Led a team of investigators and fraud analysts

Developed data mining techniques and algorithms that detect fraudulent activity within healthcare data and aberrant behavior of providers and patients;

Managed a team of investigators and analysts that audit and review allegations of fraud waste and abuse;

Assisted in the development of fraud related reports used as part of client and departmental reporting;

Manager, Healthcare Econometrics, Business Owner

Managed projects for the development of advanced Medicaid and medical management reporting tools and led a team of data analysts that performed ad hoc reports, complex statistical analysis, and data intensive queries for over 20 states.

Solved intricate business needs by creating teams of analysts that tackled complex client and business problems such as syndromic surveillance, time series analysis, cost effectiveness, fraudulent behavior and other health data metrics.

Manager, Quality Assurance and Change Control Management

Managed group which audits pharmacy claims for payment, coding accuracy, and ensures that claims conform to client plan design;

Collected and analyzed operational metrics and indicators from business units which monitored performance and ensured each business unit maintained a level of production within company and client standards;

Managed all SAS 70 and external audits;

Participated in the contract life cycle by providing cost models for the development and requirements for reporting.

Interfaced with product development, system architecture, and software design teams to develop enterprise wide solutions for Magellan and its clients.

Designed new reporting deployment models to better serve client reporting needs and keep the organization on the forefront technology.

RELATED PRIOR EXPERIENCE

Access Managed Health Care, Floral Park, New York

Chief Information Officer (January 1999 – June 2005)

Managed company-wide team of data analysts and programmers;

Supervised the development and administration of medical claims processing protocols and strategies;

Oversaw statistical analysis of 1,000+ healthcare providers’ accounts;

Identified, analyzed, and created Fraud and Abuse Detection Models;

Instrumental in obtaining first ever URAC accreditation for claims processing;

Developed statistical reports based on claims, treatment and utilization data (encounters);

Designed patient treatment guidelines by creating On Line Analytical Processing (OLAP) cubes;

Oversaw isolation of influential data elements using Analysis of Variance (ANOVA);

Supervised encounter data extraction methods for HEDIS reporting.

EDUCATION and ACCREDIDATIANS

Masters of Science, Healthcare Policy and Management (2003)

SUNY at Stony Brook, NY

Healthcare Policy and Administration

Medical Informatics

Healthcare data structures and analytics

Accredited Healthcare Fraud Investigator (2008),

National Health Care Antifraud Association, Washington, DC

Advanced Graduate Certificate, Healthcare Management (2003)

SUNY at Stony Brook, NY

Organizations and Group Dynamics

Organizational Planning

Bachelors of Arts (1985)

SUNY at Stony Brook, NY

Social Data Analysis and Applied Social Research

Experimental Psychology and Research Methodology

PROFESSIONAL AFFILIATIONS

National Health Care Anti-Fraud Association (NHCAA)

National Association of Drug Diversion Investigators (NADDI)

National Association of Program Integrity (NAMPI)

International Network for Social Network Analysis (INSNA)

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