Manager Project

PROFESSIONAL SUMMARY

Experienced MBA Professional, specializing in Health Care Management –

Experienced in handling all Business Requirement Specifications and Use Case Documentation for the Reporting and Adjudication Modules of the Javelina Healthcare Payor System.

Experience in claims Healthcare background (Commercial, Medicaid, Medicare, and Behavioral Health).

Healthcare informatics management experience: Project Management, Independent Contract Consultant (C2C and W2), BI/Data Warehousing Management experience (Cognos), and QA Analytics.

Strong Experience using SQL/SAS, with QA experience developing and maintaining over 60 weekly trend analysis reports for various internal work groups.

Excellent communication and interpersonal skills to maintain effective working environment in any organization.

Local to Glendale, AZ and available for telephonic and in person interview.

TECHNICAL SKILLS

Software applications: Microsoft Office, Lotus Notes, Outlook Express, Cognos, Clear Access, MacroMedia, Acrobat Professional, Mercury TD, Ingenix RCM, Ingenix GeoAccess Suite, EASY Group, Encoder Pro, Episode Treatment Group, ImpactPro, ImpactIntell, NetworksPro, Provider Online Lookup, iCES, Sharepoint.

Case Management applications: Think Med, Click4Care

Platforms: UNIX, Oracle, CMS

Specialization: Reporting Tools, Data Mining & Trend Analysis, Data Migration

Statistical applications: SAS, SQL Navigator, TOAD, SQL Server

Methodologies: Agile SDLC, SWOT Analysis

EDUCATION

MBA, Health Care Management, University of Phoenix – Jul/2004.

BA, General Studies, Western International University – Mar/1998.

OTHER ACCOMPLISHMENTS

-Provided useful information to the Governor of Louisiana pertaining to Radiological Scanning abuse. This information was used in a Gubernatorial Conference, receiving national media attention.

-Met with the Insurance Commissioner of Utah to discuss research pertaining to the benefits of consumer driven healthcare policies.

-Received personal invitation, and met with US Senate Medicare Reform panel to discuss results of a personal research project pertaining to the benefits of a Consumer Driven Health Savings Account.

-Member of BYU Division 1 NCAA Track & Field Teams.

-Dan 1 Tae Kwondo Black Belt.

-Assistant Boy Scout Adult Leader, Troop 399.

PROFESSIONAL EXPERIENCE

INDEPENDENT CONTRACTOR May/15 – Present

Aetna, Phoenix, AZ

Senior Project Manager & Systems Developer

Automated the Claim Query process for claim re-adjudication where claims are paid with errors.

Automated the Provider Interface System.

Built a BI Tool for trend analyses, allowing users to drill down to the claimline level for spikes of interest.

BCBS Advantage, Phoenix, AZ

Senior Project Manager

Mapped the VITAL Case Management Tool.

UNITED HEALTH GROUP Nov/11 – May15

Optum Medical Network, Phoenix, AZ

Manager of Decision Support Analytics

Member of the Senior Leadership Committee, representing Corporate Healthcare Economics, Informatics, Medication Adherence, and Analytics.

Conducted routine analyltic evaluations of the collaborative return on investment for wellness programs within the Medicare Advantage local market with an emphasis on intervention, lifestyle, biometrics, and disease risk.

Researched claims history to identify and improve areas of poor performance within the Care Management structure.

Took initiative to build a premium audits report structure, recovering (on average) $150k per month in retroactive CMS Funds and claims claw back.

Used SQL, SAS, and QA experience to develop and maintained over 60 daily, weekly, monthly, quarterly, and annual trend analysis reports for the various internal and external work groups.

Managed a staff of Direct Reports responsible for day-to-day Report Ad hoc productions.

Offered executive summary level improvement opportunity decisions based on trend analyses.

Discovered and reported a HEDIS compliance issue with the potential of saving corporate tens of millions of dollars.

HWH LIVING LLC Jan/05 – Nov/11

6 Month W2 Contract with MPhasis/HP, Phoenix, AZ: Senior Business Analyst

Responsible for all Business Requirement Specifications and Use Case Documentation for the Analytic Reporting and Adjudication Modules of the Javelina Healthcare Payor System.

Within a matter of days, found over a dozen report reconciliation errors while maintaining report integrity within the other 160 reports developed for Economic Trend Analyses.

Managed the re-design of Javelina CRM Module.

Assisted in the development of the Billing & Admin Module (Broker Compensation Report).

2 Year C2C Contract with Well Point/Anthem and InfoSys, New Haven, CT: Ingenix Software Coordinator, Subject Matter Expert, and IT Sponsor

Directed all Ingenix software QA activities from purchase contract to implementation and maintenance.

Directed the Infosys off-shore coordination efforts.

Directed asset management efforts for the entire Well Point Enterprise (over 30,000 users and 20 applications – Ingenix’s largest client).

Coordinated training, new user and upgrade installs, and application repair efforts.

Created user networking functionality through the implementation and maintenance of Share Point.

Maintained user compliance and departmental charge back information.

Utilized Business Process Modeling to identify best business practices.

18 Month W2 Contract with University of Phoenix, Nashville, TN: Facilitator

Facilitate the learning experience of healthcare administrative students at the University of Phoenix.

Member of Academic College of Healthcare Executives.

Certified to instruct and tutor the following courses: Accounting, Finance, Quality Management, Marketing, Business Trends, Evaluation Methodology, Economics, Financial Resource Management, Financial Management, Measurement Standards, and Informatics. All courses were taught with an emphasis in the Healthcare industry.

HWH LIVING LLC (Continued)

9 Month W2 Contract with MedSolutions, Franklin, TN: Healthcare Economics & Informatics Manager

Utilizing SQL Server and Cognos VII and VIII, identify radiological management needs for prospective clients. Build presentation documents for marketing review. Created a Radiological Abuse Report that ultimately received national media attention.

3 Month W2 Contract with Blue Cross Blue Shield of Vermont, Berlin, VT: Senior Health Data Programmer/Analyst Contract Consultant

Led the Group Reporting & Employer Analysis Team, offering employer group solutions to counter rapidly rising healthcare cost trends. Utilized SAS, SQL, Access, Excel, PowerPoint, and healthcare analytic skills to build automated reports. Utilized Business Process Modeling techniques to identify best business practices in terms of the build and implementation of each solution.

12 Month W2 Contract with United Health Group/Ingenix, Salt Lake City, UT: Senior Data Manager & Resell Network Manager Contract Consultant

Led the Project Management Team for the Ingenix Network Performance Evaluator, a tool used to compare Property & Casualty network performances based on cost, quality, penetration, accessibility, network disruption, and client disruption. Reviewed all network resell and direct contracts.

Automated invoicing cycle, reconciliation and payment process for both receivables and payable.

Utilized Business Process Modeling techniques to identify best business practices in terms of the build and implementation of this tool.

Developed 16TB Data Warehouse.

3 Month C2C Contract with Hill AFB (Government Contract), Hill AFB, UT: Senior COGNOS Contract Consultant

Lead the implementation of a COGNOS 8 Business Intelligence Reporting Tool at Hill AFB. The company lost the government contract shortly after beginning the project.

6 Month C2C Contract with United Health Group, Edina, MN: Systems Developer Contract Consultant

Product developer of the Ingenix Rules Creation Manager (iCES tool).

Utilizing Mercury Test Directory, claim payment policies are coded for processing, and tested for business compliance.

Created a Cardiac Monitoring Rule and twenty-six Obstetrician Sub-rules with minimal errors discovered during testing.

Developed upgrades to the Therapeutic Injection, Care Plan Oversight, Stand-by Services, IV Conscious Sedation, and Tele medicine policies.

Utilized Business Process Modeling techniques to identify best business practices in terms of the build and implementation of this tool.

THE REGENCE GROUP Sep/99 – Dec/04

Regence Blue Cross Blue Shield of Utah: Health Information Analysit II

Lead Product Manager of a COGNOS driven Web-based Medical Director’s Report. The purpose of the report was to identify per member per month costs for our various products broken out by service type.

Introduced and developed the monthly COGNOS Cost-Utilization Medical Director’s Report.

Participated in a four State committee, integrating the design of the report to fit the needs of Utah, Oregon, Washington, and Idaho.

Lead Product Manager of the Provider Profiler Tool, with an objective to ensure specialists were available to members within an on demand radius.

Overall responsibility of the Physician Data and Requirements Analyses, Pricing Fee Schedule and Provider Profiling (Ingenix Geo Access) reports, and Medication Adherence Reports.

Extracted data into a corporate-wide Physician's Reimbursement Schedule.

Analyzed and extracted material system errors where claims were overpaid on an annual estimated basis of nearly $18 million.

Analyzed a database which saved the company over $33,000 in a single fraud & abuse case.

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