Maulik Prabhakar, MBA, MS, PMP, SAFe LPM, SAFe RTE, CSM, CSPO, ITIL

E-mail: ad1gzl@r.postjobfree.com 551-***-****

PROFESSIONAL SUMMARY:

IT Program, Project, Operations and Risk management professional in Healthcare Payer, PBM and Financial Risk Management industry and has worked with Private Insurance (Blues), Pharmacy Benefit Management (PBM), Medicare, Medicaid and Bank Treasury clients.

Experience in leading large scale, highly visible and complex federal and state mandates implementations for multiple adjudication platforms, jurisdictions and applications using SAFe, Scrum and waterfall methodologies.

Experience is taking failing programs and projects, rebaselining, and executing them to meet external mandated federal/state timeline.

Experience with working with external state agencies/exchanges (Maryland Health Benefit Exchange, DC HealthLink), managing execution relationship and coordination between multiple organizations for complex IT implementations.

Played multiple roles like Program Manager, Release Train Engineer, Project Manager, Scrum Master, Product Owner, Workflow Designer, Project Coordinator, Requirement Manager, Business Analyst, Reporting Analyst, and Quality Assurance Analyst and progressively evolved to lead programs, projects and teams in complex implementation.

Experience implementation SAFe frame work with large application impacts for a large scale programs and projects.

Experience in engaging, managing stakeholders and their expectations, communication, monitoring/controlling program, value stream and projects progress.

Mentored/coached team members and experience in working with on/off-shore team members and built productive working relationship with team members.

Experience in managing program and project level risks, interdependencies, issues and working with multiple domain stakeholders to resolve those.

Experience is leading implementation of Federal Mandates and State mandates like Consolidated Appropriations Act, 2021 (CAA)( No Surprises Act), Affordable Care Act (ACA), HIPAA 5010, MOOP, MD Young Adult Subsidy, Blue Cross Blue Shield Association mandates/upgrades.

Worked on PBM Migration (Benefit & Clinical validation), EDI claims (837 I/P/D) and accumulator, Product portfolio management & Product streamlining, Benefit Coding Applications development, MMIS changes, Enterprise wide process design projects and operationalized with ‘Zero’ defect.

Experience in understanding ‘As Is’ business process, creating ‘To Be’ process, conducting GAP analysis, defining the scope and ability to translate technical concepts into non-technical terms to senior management.

Experience in process design/engineering for cost reduction, increased operations efficiencies and increased data integrity and experience in business process redesign and process streamlining.

Experience with COTS application and customizing based on the business needs.

Created extensive healthcare reporting capabilities for Trizetto Facets Product and Subscriber domain for strategic and operational decision making.

Experience in HIPAA 4010 to HIPAA 5010 Conversion and experience in various versions ANSI X12 4010/5010 and worked on EDI (270,271,835,834,820,278,837I/P/D, NCPDP) transactions under Medicare/Medicaid plans and experience in Claims data scrubbing in Medicaid/Medicare space.

Functional knowledge of Cognizant/Trizetto Facets backend database, Keyedin, Pega System PRPC Product Composure System (PCS), Claims EDI data elements, MMIS, Finacle Treasury, Kondor+, MS office suite, Clarity.

Experience in Portfolio Risk Management specializing in Market Risk Management of a Trading book of the Bank and experience in Interest Rate Products, Forex Products, Risk Sensitivity and Counterparty Risk Management and reporting.

EDUCATION:

Master of Science (Risk Management and Insurance)

St. John’s University, School of Risk Management, Insurance and Actuarial Science

Master of Business Administration (Marketing Management)

Gujarat University, B. K. School of Business Management

Bachelor of Engineering (Computer Science)

Gujarat University, L. D. College of Engineering

CERTIFICATION:

Scaled Agile Framework (SAFe) – Lean Portfolio Manager (LPM)

Scaled Agile Framework (SAFe) – Release Train Engineer (RTE)

Project Management Professional (PMP) – Project Management Institute(PMI)

Certified Scrum Master (CSM) – Scrum Alliance

Certified Scrum Product Owner (CSPO) – Scrum Alliance

Information Technology Information Library (ITIL) Foundation- AXELOS

Financial Risk Manager (FRM): Part 1 – Global Association of Risk Professionals(GARP)

PROFESSIONAL EXPERIENCE:

CareFirst Blue Cross Blue Shield Nov 2019 – Present

Owings Mills, MD

Consultant: Mandates delivery (Program management/ Project management /Release Train Engineer)

Consolidated Appropriations Act, 2021 (CAA) – Program / Project Management

No Surprises Act

The Consolidated Appropriation Act included the language related to the prohibition of Surprise Billing which allows to protect consumers surprise billing medical bills (including both out of network cost share and balance billing amount) when they receive: (1) emergency services furnished by an out of network provider or out of network facility and (2) non-emergency services furnished by out of network provider in in-network facilities.

Provides for patients to be responsible for only in-network cost share amount, including deductibles, in emergency situation and certain non-emergency situation where patients do not have ability to choose an in-network provider (including Air Ambulance)

Prohibits provider for balance billing except in limited circumstances with notice and consent

Providers access to an independent dispute resolution process for providers and plans who cannot reach to an agreement on payment

Implemented and lead 5 closely related projects to implement a large scale, complex and highly visible surprise billing mandate program which had more than 100+ stakeholders across all domains in the multiyear and multimillion dollar program.

Implemented and lead 5 different projects (1) Implementation of new pricing called Qualified Payment Amount(QPA) with network pricing domain (2) Changes on adjudication platform Facets (3) Changes on adjudication platform NASCO (4) Changes on adjudication platform LuminX (5) Changes to downstream applications to consume surprise billing attribute from all 3 platforms.

The program initiated in August 2021 with Federal mandate effective date of 1/1/2022. With such short schedule and with large and complex scope of implementation, worked with senior management, pricing and platform claims SME, developed a contingency based, iterative delivery schedule.

Defined the program benefit management and managed stakeholder engagement for large number of stakeholders across multiple business and IT domains.

Defined and managed program life cycle so benefits are delivered over period of time with reducing manual efforts as IT functionalities continues to be delivered.

Worked with network pricing domain to implement a Qualified Payment Amount (QPA) price which is median of in network provider rate for same services in same service area for Facility, Professional, ASC and DME rate with more than 3500+ rate sheets as Phase 1.

As of part of Federal Mandates compliance go live, Phase 1, lead and coordinated the implementation of ‘Pend claim’ functionalities across all 3 platforms so starting 1/1/2022, all surprise billing claims pended on all 3 platforms.

Worked with Claims SME, coordinated the implementation of a manual adjudication SOP process so surprise billing pended claims were adjudicated with the coordination of network pricing teams with QPA as Phase 2 delivery.

Worked with ITS (Blue Cross Blue Shield Association) Claims SME on all 3 platforms to implement surprise billing functionalities available with ITS 23.0 and 23.5 releases.

Worked with IT teams to develop functionalities to adjudicate surprise billing claims systematically with network pricer QPA as part of Phase 3 delivery.

Worked with claims SMEs to fine-tune claims adjudication logic based on different claims experience on different platforms as part of Phase 4 delivery.

Worked with downstream applications team, Data Service, ITS, Oracle EBS, Reporting etc. so newly introduced surprise billing attributes on all 3 platforms are available to downstream consumers like Finance for their reporting, reconciliation and auditing.

Worked with large number of external vendors to coordinate value delivery of the mandate, which include Cognizant / Trizetto for Facets platforms, NASCO for NASCO platform, Ebix for LuminX platform, Conduent for processing Consent for surprise billing claims.

Implemented functionalities for updating EOB and NOP/Vouchers to provide surprise billing mandate information to members and out of network providers.

Implemented functionalities on Member portal so member can access surprise billing claims data on their claims review under member portal.

Facets platform: Lead implementation for developing a new Facets Extension call ‘QPA extension’ so surprise billing claims are identified through Facets workflow and then out of network rate is replaced to QPA rate so claim is adjudicated with QPA.

NASCO platform: coordinated with NASCO, provided requirements and coordinated testing for the functionalities developed by NASCO for CareFirst.

LuminX platform: coordinated with Ebix, provided requirements and coordinated testing for functionalities developed by Ebix for CareFirst.

Provided leadership across all domains for change in processes, reported progress, issues, interdependencies to ePMO and senior management.

Planned scope, requirements, schedule and cost, monitored progress and communicated those across multiple domains iterative delivery of the value.

Pay Now with State Exchange – Program/Project Management

Maryland Health Benefit Exchange (MHBE) and DC Health Link (DCHL) were requiring that all individual market carries participate in the Pay Now URL functionality. This feature will redirect enrollees of Medical and Dental products from State based exchange (MHBE, DCHL) to issuer’s website for payment. The purpose of implementing this process is to drive consumers to effectuate coverage earlier, resulting into market stabilization and encouraging the consumer to stay with carrier. By providing this capability during the open enrollment period, these initiatives have help minimize the high number of cancelations CareFirst’s Enrollment and Billing department had to do manually, when subscribers do not make their initial binder payment. The program implemented real time Pay Now functionality during 2021, 2022, and 2023 as mandated requirement for CareFirst. This functionality included real time authentication, real time enrollment and real time payment.

This was a multi- year, multi-million dollar and multiple state exchange program which delivered the values for CareFirst’s Enrollment and Billing division for individual exchange market domain.

Worked with MHBE, DCHL and CareFirst’s Enrollment and Billing department for state exchange based products division to define program strategic objectives & benefit management over multiyear program.

Managed multi organizational stakeholder engagement and managed program life cycle for each delivery for each exchange.

Coordinated with CareFirst’s multiple value streams and external credit card vendor (Elavon) to deliver value / functionalities over 3 different years (MHBE Medical : 2021, MHBE Dental: 2022, DCHL Medical and Dental: 2023).

Planned scope, schedule and cost, monitored the value delivery over multiple projects and coordinated and reported with large number of stakeholders.

The functionalities include OKTA authentication, APIGEE and Nexus APIs and Angular UI to provide real time customer experience of exchange product purchase and initial binder payment.

Coordinated end to end testing efforts between large numbers of teams from different organizations before value delivery.

MD Young Adult Subsidy (Release Train Engineer)

Maryland established a Young Adult Subsidy program (HB 780/SB729 of 2021) to support members who are of age 18-34 and have federal income level below 400% of FPL. Maryland Health Benefit Exchange (MHBE) implemented this mandate with CareFirst. Every month, MHBE sent the eligibility file with additional state subsidy information on 834 and CareFirst processed that information and later, MHBE sent the payment through 820 process and then reconciliation occurs. This subsidy mandate impacted around 16 CareFirst IT applications (Facets, Facets Enrollment & Billing surround, Automated Enrollment, MHBE Pay Now, PCF, BIPS, HPX, CDW, CDR, RDS, CDWF, 820 payments, ERMS, MyAccount, Oracle EBS, Data Service reporting). The program was implemented into 3 different phases. Phase 1 was focused on enrollment, Phase 2 was focused on payment and reconciliation and phase 3 was focused on updates to impacted member letter that goes out during renewal and special enrollment period.

Initiated program planning with Maryland Health Benefit Exchange and worked with their IT team to plan high level objectives for different phases.

Based on high level objectives and external timeline, implemented SAFe value stream framework for 16 different teams where their work was planned during a Program Increment (PI) planning event and delivery was provided through Agile Release Train at every PI/Quarter. At that time, CareFirst did not fully implement Value stream framework for its IT departments.

Implemented SAFe subscribed cadence and synchronization so teams could deliver functionalities at every sprint end.

Implemented a scrum based delivery where Sprint backlog was developed, implementations occurred in 2 weeks sprint, System demo was provided at every sprint end to stakeholders and feedback was immediately put into next sprint’s backlog, and retrospect was done.

Managed coordination, collaboration with internal and external stakeholders, provided visibility of progress and impediments to senior management.

Managed their interdependency and risk through internal program board.

Wrote charter, planned and implemented execution, transitioned the functionalities to Day to Day maintenance and closed the project.

FEHBP HMO Dedicated Disbursement Account (Project Manager/ Scrum Master)

Under the provision of CareFirst’s FEHBP HMO contract, CareFirst was required to provide separate financials for HMO contract and Ernst & Young (EY) audit confirmed that CareFirst was not able to timely identify and return FEHBP HMO refunds to US Treasury or properly account for all retention amounts. CareFirst’s finance required a separate checking account to more accurately track the health benefit claims payments for FEHBP HMO group to ensure compliance with federal regulation. The project implemented a dedicated Wells Fargo account for FEP HMO business and financial was separated from commercial account.

Implemented a scrum based delivery framework into CareFirst’s Facets, Vouchers, Billing/Invoicing, DAC and Financial IT teams which have been delivering the projects historically in waterfall methods.

Trained different onshore/off shore teams on scrum based delivery framework for 2 weeks sprint, sprint planning, sprint backlog grooming, execution, system demo and retrospective.

Worked as a scrum master and set up a daily stand up and sprints meetings to increase efficiency of multiple team’s delivery and interdependencies.

Managed stakeholder engagement from large number of CareFirst departments.

Provided project execution status, monitored risks & interdependencies, and reported them to senior management of FEP, Claims & Finance domains.

Coordinated the activities of financial reconciliation before and after the set up dedicated checking account and help finance provide details to Office of Personal Management (OPM).

Anthem Inc. Jul 2018 – Nov 2019

Wallingford, CT

Voyager 2020

Project Manager

Initially recruited to support one of the troubled project in the highly visible Voyager 2020 program where project has started four months ago and planning phase was in trouble. The objective of Voyager 2020 program is to migrate from one PBM(ESI) to another PBM(IngenioRx/CVS) in Anthem. This program is going to make sure all Anthem applications/functionalities are working as expected when the migrations happens on multiple platforms which contains 16,000+ Pharmacy products and 150+ Formularies/UMs across Commercial, Medicaid, Medicare & Exchange line of businesses. There are multiple Anthem applications which are going to be integrated with CVS and all processes will be migrated. The program is going to make sure Anthem is CVS ready and internal/external customers have same experience. The program is having multiple workstreams/projects which are going to interact with each other and enhance all IT applications/functionalities in Anthem when migration happens. Worked as Project Manager for two workstreams, Model Office Benefit Validation and Clinical Validation work stream.

Started a planning phase from zero for a troubled project and brought it back on schedule.

Worked with all stakeholders to complete planning and created visibility of project objectives among Anthem and CVS stakeholders.

Worked with different stakeholders and completed scope, schedule planning for Benefits and claims under model office workstream and formulary and Utilization Management under clinical work stream.

Planned scope, schedule, quality, risk and communication management and estimated resources required.

Designed and documented high level processes for the project execution.

Directed and managed project execution, worked with different business and IT teams and delivered planned work.

Developed and managed onshore and offshore teams with more than 40 members to validate benefit/clinical claims for different line of businesses (Medicare, Medicaid, Commercial & Exchange) for Pharmacy products.

Maintained relationship with business stakeholders, managed expectation of work product, schedule and delivery.

Monitored and control project schedule, scope, quality and risk and initiated change control as needed.

Communicated to project status to appropriate internal and external stakeholders and incorporated feedback to improve project performance/efficiency.

Managed project risks, issues & action items and escalated them to appropriate stakeholders.

Coordinated with different workstreams to reduce risk/interdependencies and created execution efficiencies.

Conducted lessons learned between different phase of the project and learning was implemented to improve processes.

Participated in multiple workshops and brought End to End visibility to team members and improved multiple planning of phases.

Brought efficiency and synergy between two projects in terms of knowledge and resource utilization.

RxSmart – Clinical Automation

Product Owner Jun 2019 – Nov 2019

Anthem/IngenioRx is developing a RxSmart application to integrate multiple pharmacy products/formularies/utilization management validation into RxSmart application. Worked as Product Owner in scrum team for clinical domain.

Worked as Product Owner for clinical validation automation for RxSmart application.

Communicated goal, scope and expectation to scrum team members.

Designed/documented business logic for clinical validation for Formulary (Formulary, Non-formulary, Transition Fill and PA rules) and Utilization Management (PA, PA with Lookback, Quantity & Time, Smart PA based UM rules).

Participated in sprint planning, daily scrum, sprint review and retrospect meeting.

Worked with scrum team in planning / refining product/sprint backlog and clearly laying out expectation.

Worked with Clinical business team, helped in capturing expectation and helped in operationalization of the RxSmart Tool.

CareFirst Blue Cross Blue Shield March 2012 – June 2018

Owings Mills, MD

Project Manager/ Subject Matter Expert/Product Owner/Scrum Master/ Enterprise PCS Workflow Designer /Project Coordinator / Requirement Manager / Business Analyst/Reporting Analyst

470.0 Product Implementation Workflow Jan 2017 to Jun 2018

761.04 Facets Benefit Management Phase 2

Project Manager/Subject Matter Expert/PCS Workflow Designer

The objective of these two projects are to automate CareFirst product design process in Pega Product Composer System (PCS) which includes integrating and automating existing manual business processes for Marketing, Pricing, Mandates, Benefit Contract Management, Quoting and Operations and auto generate CareFirst Product ID which is used by 20+ enterprise wide applications. The objective of the project is to make PCS a single source of truth for CareFirst benefit information and improve data integrity of benefit information across different domains.

Worked as project manager for couple of months and completed entire planning for these highly visible projects in absence of any CareFirst program manager.

Worked as Pega PCS workflow designer and designed end to end workflow integrating Marketing, Pricing, Mandates, Benefit Contract Management, Quoting and Operations departments for these 2.3 million dollars projects.

Automated current manual business processes which were in excel, word documents & share point sites and stakeholder interaction was in emails.

Participated in annual planning for project proposal and developed charter lite for project approval request.

Developed project charter and worked with Project Management Office to get charter approval.

Lead a project initiating and planning processes and worked with 40+ stakeholders in defining project scope.

Planned resource, cost and schedule estimates for planning phase.

Worked with PMO for project funding approval.

Monitored and reported project status for schedule and cost to stakeholders.

Helped new Program Manager in understanding CareFirst Software Development Life Cycle.

Worked with six departments and 40+ stakeholders to design end to end product development lifecycle workflow in Pega PCS.

Lead a team of business analysts and system analysts and worked as Subject Matter Expert.

Channeled all requirements, designed customer UIs, workflows and managed stakeholder engagement and expectation.

Worked with 10+ developers and helped them in designing Pega PRPC Healthcare workflow and provided clarification.

Designed logic to auto-generate CareFirst Medical, Rx, Vision Product IDs which are used across all CareFirst applications and CareFirst vendor applications and worked with stakeholders analyze the impact of removing smart coding.

Designed multiple Pega System’s Applications (Pega PCS, Pega PCF, Pega Broker Express) into one end to end business process.

514.05 Pharmacy - Eligibility and Benefits Management Enhancements Aug 2016 to Jul 2017

Project Manager

The objective of the project is to automate Pharmacy Benefit generation and communication process using Pega PRPC Product Composure System (PCS). Pega Product Composure System is integrated to Rx vendor CVS and is also integrated to other CareFirst downstream consuming applications. Pega Product Composure System is customized to create Rx products.

Responsibilities:

Lead a mid-size project and worked with around 20+ stakeholders in three different departments and integrated project management processes.

During project ‘Initiating’ process, worked with PBM program and lead Rx Benefit Management for Pega Product Composer System (PCS) and CVS integration.

Worked with different program managers to understand high level project scope/expectation. Understood and documented ‘As Is’ manual Process with PBM operations.

Created stakeholder list and initiated project kick off.

During ‘Planning’ process, worked with Pharmacy Benefit Management, Development and Testing team for scope, schedule and cost estimation.

Defined and tracked project milestone while monitoring and reporting project status.

Performed Gap Analysis between Rx CVS attributes and Pega Product Composure System attributes and created mapping documents across multiple internal and external applications. Designed mock ups for business to visualize future state.

Participated in external vendor (CVS) meetings to understand end to end integration requirements and written scope statement.

Wrote Requirement Management Plan.

Worked with different stakeholders across different departments and created Project Requirements Document (PRD).

Designed new automated process which replaced the existing manual process (excel & emails) and new process will integrate with multiple downstream application.

Worked with different team to get approval for Design (SAP2, SAP3), Testing team (Test Plan).

During the Executing process, worked with new development team, coached and mentored team member and helped them in understanding business need, high level scope. Worked with on shore/off shore development team.

Worked with development and testing vendors. Explained the scope/requirement and helped in estimating hours and cost.

Worked with development team daily for code built, validated code in development environment before it is released to testing environment.

Worked with testing team for defect management cycle, business for UAT.

Corradiated with different IT Team (Pega Admin, Websphere admin), development teams to make sure code is deployed without issue and system availability does not impact daily operations.

Escalated project level issues to senior management as needed.

Managed project according to PMBOK project methodology and standard.

Worked with development team and testing team and provided direction, supervision and clarification.

During Monitoring and Controlling process, worked with different stakeholders and managed stakeholder need, in terms of expectation and communication. Provided weekly project performance to sponsor and senior management.

Coordinated weekly stakeholder call for monitoring the progress, managing risk & issues, status communication.

322.0 Account Implementation Automation May 2016 – Dec 2016

Product Owner – Pharmacy Product

The objective of the program was to automate entire Large Group product design and sales process within Pega Product Composure System (PCS) and Salesforce applications. This workstream was following agile project management framework for PCS development and Salesforce Integration. I worked as Product Owner for Pharmacy workstream based on my CareFirst pharmacy product knowledge.

Worked as Pharmacy Product Owner and provided requirements/user stories to scrum team and helped in defining & managing backlog for pharmacy product development and integration.

Participated in sprint planning, scrum, sprint review, backlog refinement and sprint retrospective meetings with Pega PCS and Salesforce scrum teams.

Provided expectation and design documents to scrum teams so team can effectively produce deliverables.

Prioritized and re-prioritized Pharmacy product backlog for each the release.

Interacted with different Large Group operational stakeholders constantly to make sure stakeholder engagement and interest is maintained throughout the project.

Provided leadership to scrum team in terms of how Pharmacy products should work in newly automated workflow.

Contributed as scrum team member and tested deliverables to make sure the deliverables meet expectation and they are in aligned with overall program/project vision.

Trained end users so that sprint deliverables are smoothly and quickly transitioned to operations.

761.03 - Facets Benefit Management Integration and Enhancement Jan 2016 to Sept 2016

Project Coordinator / Requirement Manager

The project has continued based on 28.0 and 761.01 projects and Pega Product Composure System (PCS) was enhanced to support Reporting, Mass update, and Lock down plans functionality to support Small and Medium SBU in reducing the plan set up time and maximizing the operational efficiency with minimizing coding defect.

Responsibilities:

Worked as a Project Coordinator and worked on all project phases starting from initiation to execution.

Worked on the project charter and helped Program Manager / Project Management Office in finalizing / approving the charter.

Created a stakeholder register to identify stakeholders in the initiation phase.

Created a project schedule for multiple project releases.

Worked on project share point site as administrator to manage project documents and made sure all project information is available to stakeholders.

Worked with HP ALM support team to create project shell in Enterprise Application Lifecycle Management (HP ALM) tool and requirements with RTM is available for required stakeholders.

Created and managed risk and issue logs to track both and made sure they are communicated to stakeholders and they are managed.

Created Requirement Management Plan and obtained approval from multiple stakeholders.

Coordinated and lead meetings with multiple enterprise applications owners/SMEs and help them understand the project scope and impact of the project.

Coordinated JAR sessions and created Project Requirement Document (PRD) for multiple releases and for multiple departments. Worked with key business stakeholders to assign priorities for business requirements.

Worked with Project Management Office during Project Requirement Audit and Requirement Matrix for project scored 4.92/5.00.

Coordinated all project discussions and created design documents to help Development and Testing team so that they understand business requirements.

Worked with System Analyst and Testing Lead to plan deployment and testing.

Worked with Business stakeholders and created UAT test cases.

Helped business operations team in writing Pega Product Composure

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