Lansdale, PA *9446
Individual Summary: strong and successful employee in Payment Integrity & Healthcare Cost Containment. I have dedicated over 15 years developing myself in healthcare finance (actuary, provider reimbursement, Informatics) to understand the underlying drivers in medical cost. Built data driven models that allow workforce to prioritize work efforts and focus on critical issues. I migrated IBCs entire professional provider fee schedules to Highmark’s platform. All claims paid correctly after go-live date. Created audits that have recovered $10s of millions of dollars. Supported contract negotiations with carrier and provider groups. Modeled impact scenarios that facilitated new payment models. Analytically, creative thinker: Use a combination of formal tools and "out of the box" curiosity to design optimal solutions. I have been asked several times over to join different departments within IBC because of my track record of success. IBC made an enterprise version of a network provider-profiling program I created and is now in use across the organization via cubes.
Technical Skills: Oracle PL/SQL, Teradata SQL, Visual Basic for Applications, MS Access, SQL Navigator, Visual Basic, MS Excel, Tableau, basic R, basic SSAS/SSRS
Independent Contractor August 2018 to Present
Creating data models from healthcare claims data that show provider outliers who are over-utilizing services. Quantifying over-utilization and creating reports/visuals that bring insights to the business users.
Independence Blue Cross Philadelphia, PA January 2015 to July 2018
Lead Health Researcher
Create financial models that show the impact of medical policy changes. Create provider profile models that show providers who bill differently than their peers. Reprice claims to create new bundled rates. Participate in strategy meetings to design ways to lower health care cost. Create payment accuracy audits to make sure claims are adjudicated correctly. If claim paid wrong, price the correct paid amount and send the overpayments to the mainframe for adjustment. I have identified well over $20 million in recoveries over 5 years of work. I have used the data models to identify providers who are outliers. Monies were recovered. The company recreated a provider-profiling program I made. Worked with the data-warehouse group to build program. The data was distributed to the company using cubes. The company is using these data driven insights to guide workforce decisions on provider network.
Independence Blue Cross Philadelphia, PA Jan 2015 to June 2015
Lead Systems Analyst in Data Warehouse
I was asked to join the data warehouse team to bring business acumen to the group. I transferred business knowledge into design specs, helped source EMR data, migrated data between platforms and did some ETL programming. The company then transferred me to the CFID department where I created a provider profiling program to identify areas of recoveries.
Independence Blue Cross Philadelphia, PA March 2009 to Dec 2014
Lead Provider Reimbursement Analyst
Develop analytics to price provider utilization using any one of hundreds of fee codes. Work with Informatics department to organize, promote and deliver quality and decision making data. Work with contractors to create reports to help them negotiate rates with providers. I built a professional network summary report that compares similar providers reimbursement against their peers. This report is now being used heavily in our department to negotiate competitive rates with providers. Work on special projects that tested the claim adjudication process on the main frame for accuracy of our claim payment policies. I have found errors that allowed our company to reprocess the claims and seek recoveries. Converted IBC’s professional reimbursement data into Highmark’s reimbursement data. I am pleased to report that claims are paying accurately on the new system. Created the data analytics that was used to create/support our Proactive Tiered product. The expected enrollment on the Healthcare Exchange for Proactive in the first year was 25k members. IBC enrolled over 105k members.
AmeriHealth Administrators Horsham, PA Oct 2006 to March 2009
Query the DataMart to provide information to the Senior Actuary regarding claims experience, contracts, benefit analysis, reserves, lag reports, etc. Work with the IT department to enhance the functionality of the DataMart. Create my own procedures and views when necessary. Take data given to us by brokers, transform it into something compatible with our DataMart (ETL). Interact with the marketing department to provide them with client information. Create filings to the PA Department of Insurance on the health plan offered by Inter County Health Plan. Price benefit plans using Milliman. Quality Check reports issued by the reporting team.
Independence Blue Cross Philadelphia, PA July 2002 to Sept 2006
Maintain and enhance the current Quality Management Provider Improvement systems throughout the regional Quality Management Departments. Design and develop single and multi-user Access database applications. Coordinate findings with designated department contacts. Support other department staff regarding programming, system design, data conversion and other data management duties as required. Developed a database application to retrieve provider and member information from several different servers using ODBC drivers. Created an analytical application to normalize, group, and trend a massive periodical data extract from Merck Medco.
Temple University, Fox School of Business Mgmt, Actuarial Science
Philadelphia, PA 2004-2006 –did not finish program due to wife having twins
Holy Family College, Philadelphia, PA May 1994
Bachelor of Arts in Computer Management Information Systems GPA: 3.1
Night Class for a semester on Visual Basic 5.0
Oracle DBA Administration Classes at Penn State