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Manager Project

DeSoto, Texas, 75115, United States
August 22, 2018

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P O BOX **** DeSoto, Texas **123

972-***-**** (H) 973-***-**** (C)


A versatile business professional with demonstrated proficiencies in business analysis, business requirements gathering and documenting, business process alignment, system implementations, conversions, and testing. Significant experience working for health plans specializing in all aspects of health information technology with extensive knowledge of the interrelationships among business processes, applications, and data. Expert skills include:

Self-starter, experienced at working in fast-paced environment

Hands-on experience with core system implementations

Extensive training development and execution

Analysis of business requirement definition documents and functional design documents

Configuring health benefits and provider contracts in core systems

Thorough testing of configuration and business processes, includes creating test scenarios, executing test scripts, documenting results and reporting issues

Experienced team leader and adept at driving team tasks to completion

Effective personal interaction skills with the ability to work closely with both technical and non-technical clients to define business needs and develop workable solutions

Extremely organized and detail-oriented with effective time management skills

Work well in team-oriented, collaborative environment; accomplish assignments with minimal supervision

Effectively prioritize and manage multiple, simultaneous tasks

Results driven with strong analytical and problem solving skills


Independent Consultant

Cigna-HealthSpring 07/2016 – 09/2016

As a QNXT Configuration Analyst for this Client, I provided them with configuration support to help clean-up their backlogged configuration CCRs (configuration change requests) as a result of contract changes, changes to fee schedules, new contracts and changes to benefits. Completed QNXT configuration tasks to assigned CCRs and I provided documentation of configuration solutions for CCRs worked via configuration and or deployment. I assisted with their 2017 Service Group review for their 2017 benefits.

San Francisco Health Plan 09/2015 – 06/2016

As a Provider Contract Configuration Analyst for this Client, I assisted them with their reconfiguration project for Contracts. Analyzed contracts, recommended updates from best practices and configured the new set up for the contracts. Took 99 contracts and was able to create 9 for a particular portion of their contracts. This reduced their maintenance on these contracts and helped them to resolve issues quicker not having to update 99 contracts and only 9 for this subsection of contracts. Reviewed other sections of their contracts and provided recommendations for updates to improve effectiveness of these contracts. I also assisted their SMEs with best practices of QNXT with focus on Contracts.

America Postal Workers Union Health Plan 03/2014 – 06/2015

I provided testing support to this client as a Test Analyst for their QNXT implementation. Responsibilities included: creating and executing test cases to test system configuration and business processes, documenting issues related to test results, retesting after fixes were made, analyzed business requirement definition documents and functional design document, recommended changes based on client needs, created test cases for system enhancements.

Senior Whole Health 02/2013 – 03/2014

Provided support as a Claims/Benefits/Provider Contract Subject Matter Advisor for client’s QNXT implementation. Responsibilities included: Review and feedback on configuration set up for all their lines of business, which consisted of Medicare and Medicaid plans, Created and executed test scripts and test cases, Analyzed and reported defects as well as troubleshooting configuration issues based on testing results, Documented the vendor’s anomalies and submitted them for review. Also was responsible for maintaining configuration documentation related to health benefit set up.

Boston Medical Center HealthNet Plan, Inc, Boston, MA 03/2012 – 12/2012

As a Documentation Specialist with this client, my responsibilities were to assist with their Claims Adjudication Manual (CAM) project. Specifically, to help create written policies and a procedure manual to be used by their Facets claims processing staff. After completing the development of these policies, I was asked to train their staff on these newly developed policies. Once the CAM project was completed, I was asked to stay on to assist with the development of their training manual for their new hires. I worked with the newly hired Quality Training Manager to develop and create training documentation.

Martin’s Point Health Care, Portland, ME 10/2011 – 02/2012

As a QNXT configuration Specialist with this client, my responsibilities were to work issues received from the claims department, create the Medicare 2012 benefits, for 3 plans and to create documentation to track these changes and new benefit builds. For the issues received, they were analyzed and updates made to the current benefits to correct the problem so the claims would be processed correctly.

Security Health Plan, Marshfield, WI 11/2010 – 05/2011

As a QNXT Subject Matter Advisor with this client, my responsibilities included processes and translation of them into detailed configuration requirements. Identified changed requests and presented change control documentation. Executed system tests (unit, and regression), analyzed and reported defects as well as troubleshoot configuration issues based on testing results. Documented the vendor’s anomalies and submitted them for review. Also was responsible for maintaining configuration documentation and participated in the business process alignment sessions.

MMM Healthcare, San Juan, PR 01/2010 – 09/2010

As a QNXT Training Coordinator, I have worked with a Medicare Advantage Company to assist them with implementing a new claims system for their organization. With the Train the Trainer approach, I prepared the Subject Matter Experts (SMEs) to train the end Users. I conducted Train the Trainer sessions to supply the SMEs with information and techniques on how to effectively train. I also assisted the SMEs with developing their training material and business scenarios for training. Set up schedules of when classes would be held and the time in which each business area would be trained and secured location and resources for training. In addition I partnered with the Testing Project Manager and trained Testers on the new claims’ system so they would be able to successfully perform end to end testing. I also partnered with the Workflow Coordinator to develop future state workflows which the SMEs used to develop their desktop procedures.

Health Alliance, Urbana, IL 09/2009 – 12/2009

EHealthPartners, Atlanta, GA,

Manager 01/2007 – 09/2009

Sr. Consultant 11/2005 – 01/2007

Sub-Contractor 06/2005 – 11/2005

Recruited by a midsize Health Insurance carrier in the Midwest to develop and deliver the training curriculum for TriZetto’s QNXT 3.4 claims payment application specific to the client’s business requirements. I developed and implemented a successful train the trainer approach which required business owners from all functional areas as well as their identified trainers to be involved in the process from end to end ensuring that all participants had the same understanding of how the new system would be used. Additionally, I was able to leverage the experience gained from training and expand my role to help the client with Business Process redesign which had been neglected and was severely behind. Working with each functional area through their current workflows and policies and procedure I was able to guide them through redesign using the new system utilizing the already defined training curriculum. As a result I enabled this component of the project to quickly catch up and align with the other project deliverables.

Worked with a leading Medicaid/Medicare Health Insurance carrier in Boston to develop and deliver the training curriculum for TriZetto’s QNXT 3.2 claims payment application. Along with their trainers developed and implemented a successful training approach for their end-users. In addition gave the trainers one-on-one sessions to ensure they had a full understanding of QNXT’s functionality.

Brought in by the project manager to provide oversight and guidance for all system configuration, testing, and training for the implementation of TriZetto’s QNXT product (version 3.2) at the leading mid-size Medicaid/Medicare plan in Oregon. In addition I assisted with the transition of all claims payment activities from an external third party administrator back to the health plan. This required developing a fully functional claims department of about 36 associates from 2. Hired again by the client to provided post-implementation support including issue analysis, resolution and any retraining required by new or current client associates.

Specific responsibilities I performed to help ensure the project came in on time and budget include:

Acting as the Test Lead for the implementation of QNXT 3.2

Responsibility for the test plan development, test execution, reviewing and reporting results to project leadership as well as the direct day to day management of 7 – 10 team members.

Subject matter expert providing advice and consultation to help client adopt best practices for configuration of the application.

Provided support with issue analysis and recommend resolutions for reported system issues from end users post go live.

Assisting with development of training materials and execution of training for TriZetto’s QNXT 3.2 product specific to the clients business requirements

Independent Consultant 01/2004 – 12/2004

Horizon Blue Cross Blue Shield of New Jersey, Newark, NJ

Rehired as an independent consultant by my previous employer based on my experience to provide guidance and conduct a gap analysis of the configuration of TriZetto’s QNXT system specifically benefit plans and benefits to ensure there would be minimal manual work-arounds and reduce the number of high priority issues post go live. I accomplished this by:

Conducting gap analysis between benefit documentation and actual benefit configuration in the QNXT system

Documented and made changes to the configuration when discrepancies were discovered

Creating benefit models to be used going forward when building any new benefit plans to ensure consistency and accuracy

Developed test scenarios and scripts for QNXT testing of all lines of business as well as reviewing completed test cases and providing feedback to test analyst.

Horizon Blue Cross Blue Shield of New Jersey, Newark, NJ 06/1990 - 04/2003

Project Manager – Recovery 12/2001 - 04/2003

As a project manager for recovery and claims payment accuracy I was instrumental in recovering for the health plan over 25 million dollars in overpaid claims through useful analysis and management of internal audits. To accomplish this goal I:

Oversaw, immediate impact projects, and phases of larger projects designed to improve Claims Payment Accuracy through effective utilization of specialized tools as well as standard project management methodology, tools and practices.

Provided oversight and coordinated project tasks within the team. To ensure the team was able to produce quality results on time and within budget I In addition to managing the team to ensure they were clear regarding their roles and responsibilities, scope of work, resources, and time frames to ensure project management methodology was consistently applied to produce quality results on time and within budget.

Developed process improvement recommendations through root cause analysis, developed workflows to increase team efficiencies and conducted on the floor refresher training.

Coordinated the implementation of online workflows with intranet workgroup including the coordination of audit report testing

Produced monthly overpayment trend results to executive management and developed and presented process improvement opportunities to the Enterprise.

Ensured compliance and awareness of relevant state and federal laws, regulations and other mandates

Sr. Quality/Staff Support Analyst 08/1999 - 12/2001

Key responsibilities included supervision, guidance and coaching of Quality Analysts as well as serving as the liaison between the quality team and operations’ area to resolve any issues or conflicts that developed.

Assisted with the creation of the Quality Analyst workload management tool.

Identified quality improvement opportunities as well as recommending solutions in the operations areas. Traveled internationally on several occasions to perform on-site training and quality assurance audits to off-shore vendors, which included system training, product and benefit design as well as claims and referral processing. Acted as lead for all quality related issues.

Provided daily support to the operations’ area by guiding them through the analytical process using available tools to find solutions to issues.

Performed refresher training when needed.

Prepared and maintained procedural, process and quality protocols.

Reporting of all quality results and trending

Implemented corrective action plans when required

Special Project – Core System Replacement Project

Configuration Team Member/Test Analyst 11/2000-12/2001

Selected to join the core system replacement project as part of the configuration/testing team. This was the largest project initiative the enterprise had undertaken and critical to the growth of the organization. My expertise and contributions included:

Executed unit testing/validation of the QMACS benefits module

Developed scenarios & scripts for testing of the QMACS product

Designed and maintained all configuration documents used by the project team

Built benefit plans and terms on QMACS and completed configuration pilot claims testing

Assisted with updating the testing database and validated training materials for QMACS

Provided process improvement recommendations for system/operations differences

Performed post processing analysis of claims tested in QMACS.

Assisted with creating QMACS discrepancy database and assisted with maintaining QMACS testing and discrepancy databases.

Planning and facilitation of the QMACS project meetings

Quality/Staff Support Analyst, 08/1997 – 08/1999

Key responsibilities included performing quality review on medical claims, correspondence and telephone calls of Member Service Coordinators in the Medicare and Non Medicare Operations areas as well as medical claims for our off-shore vendors.

Provided daily feedback to the operations teams on quality assessments, which included advising, coaching and developing team members to meet and exceed operational goals.

Identified deficiencies with individuals and/or areas and provided recommendations for improvement.

Education and Training

Rutgers University, Newark, New Jersey, 6/86 to 5/88 & 1/96 to 5/98

Social Work

TriZetto’s QUniversity, 3/2007

QNXT 3.2 and 3.4 Bachelor Certifications

QNXT 4.6

QNXT 4.7

QNXT 5.1

QNXT 5.20

QNXT 5.20.003

Facets 4.71, 5.0 & 5.2

Microsoft office suite of products including: Word, Excel, Power Point, Access, Visio and Project

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