Project Management
Resume:
Shawn Jones
Levittown, Pa *****
**********@*****.***
SHAWN JONES
SUMMARY:
Senior-level database and development analyst with over 10 years of
professional experience in the analysis, design, development, execution,
and delivery of highly complex, customized technology solutions.
. Expertise in diverse development platforms accompanied with
multifaceted programming capabilities with a strong emphasis on
Microsoft-based technologies - including SQL Server and the .net
framework.
. Firm hands-on experience in Software Development Lifecycle with an
experienced approach in SCRUM and AGILE.
. Solid analytical and project management background in formulating
technology solutions for healthcare industries - including a strong
knowledge of Facets Software (version 2.96-5.01), HIPAA 834,835 & 837
(270/271,276, 277, X12) compliance file formats, 5010 formats, ICD-10
and Medicare/Medicaid environments, Healthedge 4.31-4.6
. Skilled team leader; adept in training, coaching, and motivating
members to support broad ranging development, functional, and
operational needs.
. Smart working and focused with exceptional analytical, organizational,
and interpersonal skills.
TECHNICAL SKILLS:
Languages: MS SQL Server 2000, MS SQL Server 2005 (test environment),
Sybase 12.0, Oracle 9i, Access, Informix, FoxPro, TSQL,
PL/SQL, DTS, SSIS (test environment), Visual Studio.NET, ASP, Visual
Basic, Visual Interdev, C, C#, Visual C++, XML, Windows/UNIX Socket
programming, Delphi, Pascal, Perl, Assembler.
Software: FACETS (versions 2.96, 4.11, 4.21, 4.31, 4.51,4.7,5.01),
DataStage 7.5, Microsoft Office, dBase, Excel, Rapid SQL, TOAD,
Crystal Reports XI, CPS, Qiclink
Platforms: Windows NT, Windows 2000, DOS, AT&T/Unix, Sun/Unix, HP/Unix,
Linux
PROFESSIONAL EXPERIENCE:
Facets Configuration Consultant
Excellus BCBS of Roch, NY
11/2013-2/2015
. Analyze current products and recommend configuration for changes
necessary to meet HCR regulations.
. Configure benefit products within Facets 5.01 to meet new sales
requirements and promulgate changes throughout development
environments.
. Product
. DEDE
. LTLT
. SERL
. SEPY
. BSBS
. BSDL
. PDBL
. Recommend business processes to make configuration of benefit packages
more efficient throughout development lifecycle.
. Liaison with Technical and System testers to ensure correct
understanding of system coding and aide with testing scenario
development necessary to effectively test configuration.
. Troubleshoot Facets 5.01 to locate any inefficient configuration
(Product/Membership build) and make necessary recommendation toward
solution in system configuration.
Facets Technical Consultant
Highpoint Solutions,Inc
9/2013-11/2013
. Assess Facets configuration for VNSNY of New York
. Interview key resources to determine actual Benefits and Product
configuration Facets 4.71 and develop recommendations on more
efficient configuration for Facets5.01.
. Recommendations given to Upper management on more effective Business
process and communication opportunities to effect overall
configuration strategies within the company.
. Developed an assessment package which could be followed to achieve HCR
product changes within the new Facets environment.
Principal Consultant
NTT DATA, Inc.
10/12-9/2013
. Manage activities of the Configuration Competency center.
. Lead team of configuration analyst developing Healthedge product in
Provider Contract pricing configuration for Fortune 500 client.
. Developed mentorship programs of the configuration team including
pricing and processing rules configuration of the HR system. Developed
various system architecture to achieve client goals surrounding
provider contract pricing goals.
. Report activities directly to PMO and align development strategy with
corporate implementation planning.
. Manage budget constraints and report resource efforts to manage
overall project efficiency.
. Document and review findings with customer to facilitate solution
design for the business configuration of Health Rules product.
. Configure the system that will include information like benefit plans
and provider payment provisions.
. Work with customers to define and build complete test cases.
. Act as a customer advocate; work closely with all stakeholders,
articulate customer's business.
. Lead and manage a team of customer resources while configuring Health
Rules product.
. Participated in delivery of commercial software, either externally
procured or internally developed, including participation in a SDLC,
within the healthcare payer space.
. Developed business processes between configuration teams and QAT to
ensure timely transfer of test environment data to QA environment for
additional quality measures on client configuration.
. Initiated standards such as second level peer review of Provider
Contract configuration and Unit Test result review of the same
contract configuration. This enabled Quality Assurance teams to have
more effective lead times in preparing test cases.
Hs2 Solutions, Inc. (AON/Hewitt-Motorola)
March 2012 -9/12
Benefits Configuration Analyst
. Develop benefit product configuration for multiple Motorola Client
countries
. Document requirements and troubleshooting techniques for Employee
Benefit Election system.
. Develop Benefit Rules Calculation based on a country on country
requirements basis (Israel/India/China)
. Managed development of 834 transaction set for Benefit Election
System.
. Develop Web Portal visualization and calculations from host
(Motorola) database.
. Document and report status of configuration efforts and relay to
Senior Management
. Lead team of configuration analyst during troubleshooting and
requirements gathering sessions
. Communicated system requirements to country representatives in
India/Israel and China in their respective time zones.
. Project management of tasks necessary to develop in-house Motorola
benefits system and relay development needs to IS team.
BCBS of Rhode Island
Nov 2011-
March 2012
Trizetto Facets Benefit Configuration Analyst
. Analyze exiting client healthcare products and advise on methods to
configure products in Facets environment 4.71.
. Develop Facets Trizetto Benefit configuration for client healthcare
products (Commercial, Medicare, Medicaid) in version 4.71
. Develop tools in MS Access/Sybase to help client quickly access
information from Facets databases. Data then used to ascertain the
validity of claims payment and membership ad-hoc reporting.
. Lead project QA Analysis team in validating current configuration
while training client staff on current Industry testing methods.
. Lead team of client associates in building Benefit configuration in:
1. Service Payment Application
2. Deductible Rules Application
3. Limit Rules Application
4. EOB Information Application
5. Auto Payment Level Application
6. SERL
7. Product Variable Component
8. Unit Testing/Claims
. Developed processes to account for thorough documentation of all
configuration developed utilizing Worksite and SharePoint applications
UNITED HEALTHCARE (UMR)
March 2010 - Oct 2011
Sr. Project Manager
. Contributed to the successful achievement of the Affordability team
goal to improve medical costs
. Successfully deployed projects in accordance with rollout schedule
with minimal disruption using established Road to Deployment, UHC
Operations and Medical Cost Management Team processes
. Utilized business analysis, project management and Six Sigma
techniques to drive root cause identification and solution
implementation
. Use project management tools (i.e., project charters, task lists, risk
management plans, communication plans, benefit models, change
management plans), and software (Microsoft Suite) necessary to be
successful
. Coordinate and complete projects across various functional areas.
. Presented and communicated project progress to core team, work team,
senior leaders in a fashion that makes it easy for the audience to
understand, using the most effective way (right graph, right content,
right formatting) to display work.
. Trained essential resources on newly implemented Enterprise software
using Procedure and Policy techniques.
. Provided subject matter expertise in areas including project
management, project scope definition, cost/benefit analyses, data
mining, risk identification, project methodology, resource allocation,
facilitation, and other areas of expertise based on professional
knowledge and background.
. Generated status reports and metrics as required. Ensuring projects
are completed on time and in control.
. Engaged other key matrix partners / subject matter experts to define
project scope, perform levels of analysis, strategy development, and
project implementation.
. Managed Systems analysts/IT Analyst in the development of HIPPA
compliant EDI Gateway.
. Managed development timetable for enhancing EDI format file deployment
of 837 (claims), 834 (Enrollment/Membership), 835 (Claims Payment
Advice), 276/277 (Claims Acknowledgement), 270/271 (Eligibility) and
X12 EDI file format (837) transaction set.
. Managed development of EDI transaction file formats from four
different healthcare platforms (QuickLink, Facets, QNXT, CPS)
. Engaged IT and Systems analysts in developments sessions on best
practice techniques to mine source data from healthcare platforms in
HIPPA compliant format.
. Developed dependency matrix to facilitate EDI file development and
project development timetable.
UNITED HEALTH GROUP, Moline, IL
January 2010 - March 2010
Facets Technical Consultant
. Facets Provider Implementation technical consultant
. Advised Business/IT staff on best practices for Facets Implementation
. Advised Business/IT staff on best practices for Provider Matching
logic implementation and coding
. Advised Business/IT staff on areas of Provider data cleanup and data
mapping principles
XL HEALTH, Baltimore, MD
February 2009 - July
2009
Quality Reporting Analyst/Facets Configuration and Report Development
Consultant
Organized JAD Sessions to achieve the following:
Developed and Implemented quality reports to determine differences between
client Datawarehouse environment and Facets 4.51.
Documented data integrity issues and coached client through Facets data
mapping to Datawarehouse environment.
Instructed client on Facets 4.51 mapping to Data Warehouse environment in
following Facets modules:
. Enrollment/Membership
. Provider
. Claims
. Billing
. GL/Financials
MVP HEALTHCARE
May 2008 - January
2009
Facets Configuration/Testing Analyst
Configured Facets 4.11-4.51 applications and utilized AGILE (SDLC) to
develop the following applications:
Membership,
. Medicare/Medicaid/Commercial
. Eligibility
. Group
. Rate Date
. Accumulators
. Policy/Info
. Related Entities
. Class
. Plan
. Billing entity
. Premium details
. Component Details
Configured the above applications developed as part of Benefits
configuration per client specifications. Aligned appropriate membership to
applications based on member benefits, demographics and billing
constraints. Benefits/Product,
. Configured Class/Plan
. Subgroup/Group
. Billing Entity
. Deductible
. Limit Rules
. Out-of-Pocket
. Accumulators
. Payment Rules
Configured the above applications based on client benefit specifications
as they applied to the applicable product design.
Networx Pricer (Facets 4.51) Provider Contracting/Pricing
. Networx Pricer 4.31 and 4.51
. Configuration of contract terms in accordance with Hospital contract
rate sheets and relevant lines of business.
. Implemented and configured qualifier groups in Networx Priceras
needed based on hospital contract
. terms.
. Tested and Analyzed Inpatient/Outpatient Exclusions/Case Rate/ Per
Diem and Services sections of Networx Agreements for correct pricing
logic based on operational business rules.
. Developed Complex Qualifier Groups to facilitate contractual variants
and business logic.
. Conducted Unit testing on claims for over 100 hospital contracts by
developing line by line procedural claims scenarios to test proper
claims adjudication and verify pricing as outlined by hospital rates.
MEDECISON INC December
2007 - April 2008
Senior Business/Systems Analyst
Care Management/UM Management Software
. Maintained extraordinary ability to keep current knowledge of
MEDecision products including features, functions, and customizations.
. Supported of specific product functions by taking on the
responsibility of being a specialist for a product or product
category. Involves being the lead on product discussion and mentor to
others in Professional Services as requests or issues arise within
their specialty
. Gathered and analyzed requirements and develop functional requirements
specifications for customer specific projects in JAD Sessions. This
includes the ability to provide analysis for custom and model products
as required, and the ability to provide guidance to stakeholders on
devising effective and efficient approaches to achieve the project
objectives
. Implemented MEDecision's install process including documentation for
items such as project plans, product configurations, and training
materials.
. Directed meetings as the liaison between MEDecision's technical staff
and the client to answer questions and provide clarification on
product specifications.
. Support of Development and SQE processes to facilitate efficient high
quality software deliveries to our customers.
. Trained clients to use MEDecision's products.
. Provided live and continued support on the software application and
document problems and questions as the key functional business
communication point between MEDecision and assigned customers during
the project life cycle.
. Participated in the analysis of system interfaces including patient,
provider, and extract specifications and record layouts as the lead
analyst. Requires detailed understanding of MEDecision data within
these records and experience with legacy systems, which would
facilitate the data translation process.
. Promulgated the utilization review, case management, and disease
management functions so as to advise clients of the optimal workflow
as it applies to their MEDecision solutions.
. Ascertained current changes in the Managed Care Industry and made
recommendations based on current client business processes.
. Created client status reports and facilitate client review meetings on
a regular basis
. Conducted project management and planning activities including
facilitation of group meetings, management of project plans, regular
project status reporting and post project review reporting. This
includes the ability to participate in large and small projects as
defined by MEDecision's project management process.
. Demonstrated ability to drive business and produce project estimates
or statements of work in conjunction with current client projects.
. Understand and developed the client's reporting needs.
. Participated on committees or work groups to represent the
Professional Services staff in product design, specifications, or
customer documentation.
. Participated as a leader within the Professional Services
organization. Includes identification and resolution of process
issues, training other personnel on existing processes, and assisting
management to create efficiencies and contributed in a positive manner
toward morale.
. Used ChangePoint software to log issues, research problems, and record
time in accordance with company policy.
INDEPENDENCE BLUE CROSS BLUE SHIELD, Philadelphia, PA
May 2007- August 2007
Senior Business Analyst
. Developed enrollment business processes, which verify pharmacy
(Commercial and Medicare part D) and IBX membership in a mentoring
environment for current IBX business analyst staff.
. I mentored IBX Enrollment staff on AS400 environment database
management, advising personnel on best practice adhoc enrollment
querying techniques against an Advanced MHS database.
. Developed operational processes for IS and Enrollment staff, where
essential download of Advanced MHS member data could be assimilated
into high level reports such as HIPPA and ERISA compliance reporting.
. Developed detail oriented documentation process by the creation of an
2003 MS Access database application; where IS Development and
Enrollment operations staff will be able document inter-department
system upgrade requests.
PHP LANSING, MI
September 2006 - April 2007
Senior Business Analyst
. Developed analytical, logical, physical, dimensional and statistical
Data Models for data warehouse and data mart development and
testing.
. Performed Integration, system, unit, regression, backend, user
acceptance and quality assurance testing, using manual and automated
testing scripts.
. Tested and analyzed and validated front end and backend Facets data
loads to protect data integrity standards and assessed the maximum
proficiency of SQL updates versus manual Configuration.
. Facets Claims Adjudication Process lead transactions test analyst for
PCA and Variable Component builds, EDI interfaces and downstream
Eligibility and Billing component configuration builds.
. Prepared Facets test plans for Billing, Enrollment, Capitation,
Commissions and Claims testing during the Configuration phases in
Systems Integration and User Acceptance testing environments.
. Validated Configuration efforts in Facets 4.31 database testing
environments and documented all changes, fixes or missing components
that differed with client functional designs.
. Key resource for extracting/migrating data out of legacy/disparate
systems (Facets 4.21, MS Access, customer/external sources, etc) into
the Facets 4.31 production environment for new lines of business.
Also responsible for business analysis and identification of essential
data elements - these duties include: creating requirements/project
plans, developing mapping strategies to Facets data tables
(source/destination), and generating ETL solutions using TSQL
scripting, DTS, stored procedures/triggers/queries, batch processing,
BCP utilities, UNIX scripting, etc
. Reviewed client's current business operation specifications and
translated the requirements to Facets Configuration specifications.
Facets applications included:
. Provider Pricing
. Member Enrollment
. Billing
. Claims Adjudication
. Medicare Billing Processes and Reporting
. Commissions
. Capitation and GL functions
. PCA and Variable component builds
. Product and Benefit Configuration
ESSENCE HEALTH CARE March
2005 - August 2006
Systems Analyst
. Lead the project management team through all phases of SDLC utilizing
AGILE.
. Advised and analyzed Facets development and configuration in versions
4.11 and 4.21 upgrades during JAD Sessions.
. Created departmental processes for more efficient uses of the product
based on Configuration.
. Main client contact in Configuration support and new development
providing peak performance standards in the following areas:
. Provider Pricing
. Member Enrollment
. Claims Adjudication
. Medicare/Medicaid/Commercial Billing Processes and Reporting
. Systems Interface Integration
. Enrollment and Eligibility
Analyzed edited stored procedures in SQL, Sybase, and Oracle to achieve a
higher percentage of claims adjudication by reducing the number of manually
pended claims.
. Main Configuration consultant for development of new Medicare line of
business.
. Identified previous configuration errors and constructed new
configuration in the following Facets applications for correction:
. Provider Pricing
. Service Rules
. Service Payment
. Product
. PCA
. Variable Component build
. Service Limits
. Service Definitions
. Procedure Conversion Table Configuration/Revenue Conversion and
Auto Room Type Configuration
. Advised client on improving the pricing configuration to reduce
claims backlog and manual claims processing.
. Provided clear and concise documentation for future
configuration projects.
. Rewrite complex business logic for member and provider eligibility
process. Eliminated using keywords and bypassing MMS batch process.
Improve member eligibility accuracy and reduce monthly inbound member
eligibility processing time from ~18 hours to ~8 hours.
. Wrote HEDIS report process to output ~15 millions claim detail,
member, provider from large scale FACETS database.
. Wrote process to correct 3 years FACETS member and provider
eligibility data needed for HEDIS member, provider, and claims
reports.
. Implement FACETS xml billing batch operations for custom
calculation.
. Modified custom interest calculation for claim check batch.
. Wrote inbound claim auto-adjudication using UNIX scripts and
Sybase stored procedures.
. Wrote Claim Remittance Advice to be sent to providers and
billers.
. Wrote General Ledger process Improve accountability for Medicare's
payments to physicians, hospitals, and other providers servicing
Medicare beneficiaries.
. Configuration, test, debug capitation batch process for new Line
of Business
SAMARITAN HEALTH SERVICES
March 2005 - July 2005
Facets Product Lead
Configured Facets Medicare product in the following components:
. Service Definitions
. Deductible Rules
. Limit Rules
. Provider Agreements
. Variable Component
. Service Rules
. Service Payments
. Medicare Rates
. Subscriber Rates
. APCC Rate Configuration
Implemented Best Practice Training for client personnel.
Designed and developed training and documentation to facilitate reporting
needs across all lines of business (Commercial, Medicaid and Medicare).
AMERIGROUP, INC.
November 2004 - March 2005
Facets Consultant
. Analyzed provider contracts for Configuration in Facets 4.11.
Contracts types included
. Hospital
. Professional
. Ancillary
. Implemented provider contracts and built provider fee schedules by
analyzing provider rates for configuration continuity. This resulted
in greater UM pricing integrity.
. Configured Facets provider applications for flexibility in future
upgrades to existing contracts and fee schedules.
KEYSTONE MERCY HEALTH PLAN October
2002 - October 2004
Business Analyst Specialist II
. Coordinated and documented business requirements of the stakeholders
and communicated these requirements to the system programmers on the
team.
. Assisted Project Managers with Unit Testing and User Acceptance
Testing to achieve the best possible project results on behalf of the
stakeholders. Coordinated the implementation of each project from
beginning to end phase (Migration to Production Environment).
. Performed data analysis for internal departments for all lines of
business. This included: Creating MS Access databases for data
analysis, creating Crystal Reports, querying Facets databases for
requested information and coordinating meetings to discuss new issues
or workflow processes.
. Managed project resources to achieve successful implementation as
measured by project management and stakeholders. Coordinated
resources for project plan, and mediated configuration issues between
functional teams
. Participated in the interview process of new team members, provided
guidance and support for team members.
. Actively participated in design, development and implementation of
Facets. Attained expert knowledge of Facets pertaining to functional
areas of responsibility. Achieved global understanding of Facets for
all functional areas.
. Used accurate and appropriate data capture to properly configure
Facets to administer the business of KMHP and other lines of business.
. Configured provider contracts for appropriate lines of business.
Implement provider agreements based on per case/per diem, provider
profile limits and tier them in accordance with Facets build.
. Engaged client on logical ways to build products based on provider
network, contracts held with provider network, member demographics,
and existing contractual obligations (i.e. State regulations, Benefit
plan). This included arranging members into class and group
structures based on benefit, and building shell member/provider
configurations to test final claims adjudication rates.
EDUCATION:
. Computer Information Science DeVry University, North Brunswick, NJ
2005
. Associates Liberal Arts Leeward Community College, Pearl City, HI 1995
. Facets 2.61a and 4.11 Product Configuration Training 2003 and 2004/5
(TMI/Daou)
. Facets 4.7.1 Trizetto Configuration Training 2010
. Certified Health edge Consultant 2013
. Ongoing QicLink and CPS process education through Project FOCUS
migration EDI Consolidation work stream responsibilities.
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