Professional Summary

. Over ** years of Health Care & Managed Care Organization business

analysis, project management, and management experience, delivering

information services to meet critical business needs.

. Expert knowledge of Healthcare EDI practices, trading partner

relationships (national, state and private agencies) and all HIPPA

compliant x12 ANSI transaction sets.

. Detailed troubleshooting and business analysis skills with the ability

to write requirements for and read all healthcare EDI transactions

sets such as 837 claims (both institutional and professional), 834

eligibility and 835 remittance advices. Also experienced with 4010

and 5010 transactions sets.

. Working knowledge of all Healthcare Codes Sets such as ICD9 and HCPCS.

Also Expert knowledge of NPI standards and all other provider

identifiers. (ex. Taxonomy & UPIN)

. Advanced SQL query skills and EDI mapping software for both inbound

and outbound EDI.

. Expert knowledge of Diamond 725 Claims Processing System

. Strong communication and conflict management skills with peers and

subordinates. Maintain professional relationships with state

regulators such as TennCare, CMS and the Tennessee Department of

Commerce and Insurance. Expert ability to cross communicates between

Executive Management, Business Analysts, Systems Analysts as well as

operational and functional teams.

. Professional relationships with EDI management and support staff at

TennCare, CMS, TDCI, all major clearinghouses such as EmDeon (WebMD),

and McKesson.

. Managed projects to include EDI, Decision Support, and Special

Projects for executive leaders.

. Knowledge and expertise in the following disciplines: EDI/Trading

Partner relationships, Claims management systems, Business

Analyst/Systems Analyst, HIPAA Compliance (Health Care transactions

sets 837/835/834), Six Sigma (Green Belt Certified), Enterprise

Project Management (leveraging PMI standards)

Professional Experience

AmeriGroup Corporation

Memphis Managed Care Corporation (1995-2009)

Manager Information Systems/EDI Claims Management

. Management and support for 30 associates, vendor management, and

direct liaison for State Regulators (TennCare).

. Liaison between IT department & other Managed Care departments

regarding Business practices for EDI, System Administration, Web

Development, and Change Management. This also includes all basic

managerial duties associated with standard business practices. Heavy

interaction with Vice Presidents, Senior Management and Board Members

regarding IT issues and strategy.

. Technical lead for all IT issues surrounding EDI.

. Created EDI Summits which provided forum for MMCC providers to provide

input on IT systems and functionality needed.

Asst. Manager Information Systems System Administration/eCommerce

. Responsible for management of and creating standard operating

processes for EDI, E-Commerce, Business Analysts and Systems

Analysts teams.

. Developed processes and standards for reach team

. Developed standard methodology used by Business Analysts for

requirements preparation.

E-Commerce Supervisor

. Assumed responsibility for E-Commerce team in addition to EDI.

. Architect and Business Analyst Lead for Web Portal development which

allowed providers and customers to submit claims, check status of

claims, submit claim appeals and check eligibility.

EDI Team Lead

. Mentor and supervision of 5 employees including EDI Developers,

Business Analysts, Systems Analysts and Operators.

. Developed EDI standards and improved EDI submission rate from 5% to

87% with 75% of the process automated.

. Developed rules and business analysis process for reporting.

. Developed EDI manual for and providers.

. Developed Standard Operating Procedure manual for Business Analysts

and Developers.

. Worked with files from providers prior to HIPPA standards in various

formats.

. Implemented standards using 837 transactions set to adhere to HIPPA

standards.

Other positions held at MMCC. Additional details provided upon request.

. EDI Systems Analyst

. Systems Analyst

. IS Operator

. Asst. Network Administrator

. Help Desk coordinator

. Customer Service Rep.

Mid South Clinic (1994-1995)

Encounter Clerk

Responsible for greeting patients, Tenn Care verification, & encounter

generation

Federal Express (1992-1994)

SDT Team Lead

Responsible for document sort team nightly operations. Performed accuracy

audits to ensure documents were sorted to the correct state location.

Assisted with the hiring process with department leadership.

Pinkney's Furniture & Interiors (1989- 1992)

Manager of Operations

Managed up to 10 associates that included Sales, office staff, and delivery

personnel. Responsible for accounts payable/receivable, & payroll. Direct

liaison for all wholesale furniture relationships.

Education and Certification

Six Sigma Green Belt certified

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