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Project Manager Customer Service

Location:
Elgin, South Carolina, 29045, United States
Posted:
November 28, 2017

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Senior operations leader

Focused leader, recognized for delivering superior results in the health, property & casualty and life insurance industries

Articulate communicator, capable of building and maintaining meaningful and lasting relationships

Visionary, with track record for finding innovative ways to grow membership and revenue

History of success, leading initiatives for start-up health plans, building brand awareness and product management

Known for managing complex large scale multi-million dollar projects with 100% success rate

Championed the development and implementation of strategic plans

Executive Leadership Competencies

Key Influencer Relationship Building

Complex Operations Management

Supplier/Vendor Relations

Contract Management

Budgeting/Cost Controls

Workflow Optimization

Strategic Planning and Growth

New Business Development and Implementation

Product/Brand Development

Purchasing Management

Government Relations

Staff Hiring, Development, Management and Training

Team leadership and development

Professional Experience

AETNA 6/2014 - PRESENT

Chief Operating Officer

Responsible for the operations of the health plan, including setting and implementing strategic plans that support success rates for service, regulatory metrics, and contractual requirements through the leadership and management of:

Claims and encounter management (adjudication, pends, outliers, reporting)

Provider network (contracting, relationship management, credentialing, geo adequacy management)

Member outreach, service and growth through brand awareness, community involvement and social media messaging

Member and provider service call center service levels and metrics

Member enrollment and eligibility functions

Grievance and appeals processes and reports

Technology, infrastructure and reporting

State legislation relationship management

Technology operations and implementations

Expansion and growth implementations

Vendor management and oversight (vision, dental, incentives, NEMT, technology)

Key Results:

12/15 – 10/17 - Led and managed the successful and early implementation and operational standup of the Maryland health plan effective 10/23/17 with State certification of network approved to serve members in 13 service areas effective 10/23/17

State certification of network and services to expand into 3 additional counties effective 1/1/18

Membership growth targets being met with demonstrated results of 30% of membership coming through self-selection for yearend 2017

Development of programs and campaigns for children centered on improving child health outcomes.

Establishment of direct connections for members experiencing a behavioral health crisis for help

Senior Program Business Manager, 6/14 to 6/17

6/14 – 12/15 - Right hand to the COO in the build, implementation and standup of new health plans in New Jersey, Louisiana and California with focus on all lines of business including, TANF, CHIP, LTSS, MEDICARE DUALS, and Behavioral Health.

12/15 – 6/17 - Interim COO in Maryland to implement TANF, CHIP and ABD lines of business to lead the build of all operations for the new health plan. Development and maintenance of key relationships with state leaders influencing the decisions for this plan’s rollout and operational reporting once implemented.

Key Results:

Successful implementation of Aetna Better Health of New Jersey 1/1/15; 12,000 new members as of 1/15/15. Project had previously been delayed multiple times due to outstanding issues. Executed a new timeline and successfully deployed the MCO 12/1/15 with membership effective 1/1/15 (TANF, CHIP, MEDICAR DUALS and LTSS)

Successful implementation of Aetna Better Health of Louisiana 2/1/15; 95 day total timeline from start to go-live; 20,000 members as of 2/1/15; $2 Billion in estimated new revenue (TANF, CHIP)

Successful implementation of the Aetna Better Health of Louisiana behavioral health line of business 12/1/15; adding another 40,000 members to the Louisiana enrollment (Behavioral Health)

Led the implementation of new value add benefits in Louisiana including the pilot rollout of TeleMedicine, CMS Text4Baby Program, incentive gift card programs for members

Led the implementation for the Aetna Better Health of California with a start of 1/1/17 in the Geographic Managed Care Region (Sacramento and San Diego) (TANF, CHIP, Behavioral Health, LTSS); 50,000 members estimated

Led the implementation for the building of the new Aetna Better Health of Maryland plan as the implementation COO with an early start of 10/2317 (TANF, CHIP, ADB); 10,000 members estimated by yearend 2017

COMPUGROUP MEDICAL

Interface Manager, 2/14 to 6/14

Established a new operational strategy to decrease customer loss and streamline processes within the Electronic Data Interchange (EDI) team supporting all lines of business including Commercial, Medicare and Medicaid. Established policies, workflows, governance committees and project management principles. Led and managed a SWAT team of five direct reports in the revamping of daily operational processes while resolving customer issues and improving claims submission and processing for providers.

Key Results:

Cleaned up 5 years backlog of customer unresolved issues and implemented new processes for streamlining issues for tracking, reporting and escalating issues

Established new protocols for EDI processing to address slow turnaround times

Opened communication between management and employee to support improvements in employee morale

SOUTHERN FARM BUREAU INSURANCE

Director of Strategic Operations, 5/11 to 2/14

Facilitated and supported strategic plan development and implementation combined with managing project methodologies and processes within the organization addressing the need for both short-term and long-term business and operational goals. Affected changed throughout the organization to transition the company culture to project and goal based focus with attention to specific long-term business direction engaging and motivating employees through team structures and employee forums.

Key Results:

Led and implemented MobileAgent – the first insurance multi-state mobile app with first in the industry that is 100% mobile based with real time claims reporting and roadside assistance support capabilities

Developed the leads and relationships to sell the app resulting in recoupment of development and long-term maintenance costs. The MobileAgent app build costs were $0 as a result of this work. Profit is anticipated to be realized by end of first year (approximately $300k projected)

Implemented a common digital technology solution across multiple states, including legacy migrations, server consolidation and decommission, and integration of new technologies, workflows and process definitions for IT and business departments

Developed and designed a succession planning program and leadership training criteria for Executive Management

Developed a new project management office to institute project processes, governance committee structures, reporting metrics and change management

AXIOM SYSTEMS, INC

Project Manager (4 month contract), 1/11-4/11

Directed the HIPAA 5010 and ICD-10 assessments for Metropolitan Jewish Health Systems (MJHS). Conducted assessment to determine payer/provider exposures and gaps associated with compliance mandates of HIPAA 5010 and ICD-10. Facilitated activities with business and provider organizations compiling data and information associated with current processes and operations of claims, billing, eligibility, enrollment, authorizations, referrals, customer service, staff training and financial services for all lines of business including Commercial, Medicare and Medicaid.

Key Results:

Generated a HIPAA 5010 report and ICD-10 assessment report for payer and providers discussing findings, level of risk exposures, remediation suggestions and recommendations along with providing a roadmap for vendor facilitation in meeting the mandates

Filed for compliance and regulatory audit of ICD-10 readiness

SC DEPARTMENT OF HEALTH AND HUMAN SERVICES

Integration Manager (6 month contract), 1/10-9/10

Managed strategic plan development to support the Medicaid System Replacement (MMIS and MEDS) by establishing new processes, operations and standards of the project and training departments. Instituted critical path planning strategies and risk management for initiatives aligning to CMS MITA standardization. Defined and proved a reusable state Medicaid system model to initiate cross-state consistency in the administration of Medicaid, while also leading the planning for the development and implementation of an Enterprise Architecture model leveraging MITA standards and TOGAF.

Key Results:

Defined and implemented metrics and reporting standards for performance, new training operational models to facilitate cultural change and new PMO processes to establish a working PMO within the State Agency

Facilitated the planning, design, development, deployment and operations of supporting structures to align with a new Medicaid system for the state of South Carolina in accordance with CMS MITA standards

Led the definition of the SC Enterprise Architecture Capability Model to create a reusable State Medicaid package aligning to CMS standardization requirements

Lead and facilitated State readiness reviews on operational processes and systems

Produced opportunities to increase operational relationships to develop a multi-vendor operational structure for processing transactions and hosting applications in a multi-vendor operational environment

NOVANT HEALTH

Senior Project Manager (60 day contract), 11/09-12/09

Outlined the strategic initiatives and projects required for defining, consolidating, migrating and upgrading all Electronic Health Record (EHR) software in preparation for 5010 and ICD-10 transition for the hospitals, operation facilities and provider offices of Novant Health Group located in North Carolina, South Carolina, Virginia and Georgia supporting all lines of business including Commercial, Medicare and Medicaid.

Key Results:

Established vendor management protocols for the agreements of practice management system upgrades and 5010 compliance with HRE transactions, Allscripts-Mysis and Siemens products in use.

Outlined the upgrade of systems, infrastructure and processes accommodating 5010 and ICD-10 standards

Prepped the customer for systems readiness review audit

PREMIER ALLIANCE GROUP

Project Manager II (6 month contract), 6/08-3/09

Supported the $7M multi-system GIS technology data migration and upgrade project and relating subprojects consisting of 350 requirements, multiple vendor implementation for Duke Energy in Charlotte, NC.

Key Results:

Succeeded with data migration and conversion for data cleanup and issue resolution and worked with technologies including: Informatica, ETL designs, SQL Server, .NET, Magik, GIS systems, DB2, Data Warehousing systems, Web and Portal Pages. Worked extensively with GE, IBM and GIS Engineers to assure data integrity and accuracy in the transition of the data from legacy to new common platform.

Managed and tracked program and project statuses in the utility technology projects with customer and business divisions in the Midwest region and Carolinas, along with virtual and remote resources including overseas resources located in India, Pakistan and New Zealand

BLUECROSS BLUESHIELD OF SOUTH SC

Senior Project Manager, 4/04-6/08

Provided leadership and mentoring for staff including performance reviews, conflict resolution and employee development while focusing on reduction of employee turnover issues. Led and implemented highly visible projects across the Blue Cross organization.

Key Results:

Developed and delivered training and operational programs, including documentation, for education on methodologies, processes, implementation of software and best of breed practices and processes

Led, managed and oversaw projects related to :

Government mandated compliance efforts including HIPAA, NPI, ICD9, Medicaid processing for South Carolina, Medicare programs including Medicare Part D, Dental HIPAA transactions

Vendor project implementations

Web and e-commerce projects involving vendor products such as BenefitFocus and other BlueCross proprietary systems

BCA ITS releases

Managed projects for partner BlueCross Plans, BCA compliance efforts and contracted health insurance services for HealthNet and WellPoint

Lead data center build and claims data migration efforts for $65M Medicare contract

HUMANA INC.

Senior ecommerce Regional Project Manager, 1/99-4/04

Managed merger activities, provider network coordination efforts and implementation efforts for the Midwest and Mid-south regions of the country. Managed contract delivery and execution projects for physicians and hospitals networks working with Medicare, Medicaid, Dental, Pharmacy and Commercial lines of business to improve claims transaction processes between providers and clearinghouses. Converted hospital networks, providers and service providers to electronic transaction services through clearinghouses and handled sales/marketing related presentations to promote ecommerce and HIPAA compliance.

Key Results:

Increased self-service usage by providing technical consulting to internal and external customers resulting in a 25% increase in overall web registrations and a 35% increase in EDI activity within the first five months and significantly reduced the number of service and problem related telephone calls using eCommerce, EDI, .NET, and Web Services with DB2

Led efforts for the first round government HIPAA security transactions and code set implementations with clearinghouses, web transaction providers, eCommerce transactions, EDI and ASC transactions, end user networks and Web content management projects and DB2 migrations

Improved services for second level ecommerce and EDI support for customer service, providers and market offices through training and education to providers and staff increasing office operational efficiencies for providers and hospital operations

Migrated hospital and provider data to new systems and EDI solutions implementing new practices using clearinghouse tools and worked with ACS to transition remaining manual paper claims users in MidWest/MidSouth regions to overseas (India) operations

Education

Indiana University

Business Sciences Bachelor Degree with High Honors; Religion Minor

University of Kentucky

Associates Degree, High Honors

Furman University

Project Management Certification Program



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