Scrum Master Business Analyst

Core Skills

Healthcare

IT Implementation

Benefits Configuration

Claims

Medicare /Commercial

Personal Skills

Leadership Communication Team Building

Multitasking

Organized

Background

Certified Scrum Master and Healthcare and IT leader with a wide range of leadership expertise extending over twenty-five years with a focus on the delivery, implementation and business process improvements from an IT and Operations perspective. Experience working on payer and management software applications, such as HealthRules (HRP), QNXT, Amysis portals.

Hands-on experience with designer, manager, claims config, benefit config and provider in HealthRules.

Utilized QNXT Portal to configure benefits during conversion from legacy system.

Managed escalated situations, established appropriate remediation plans, and executed the plan to remedy the situation with troubleshooting fixes.

Assisted with EDI and claims interface for client implementations.

Conducted detailed assessment to gather requirements for pending claims edits that optimized the end-to-end process and improve service levels.

Provided detailed design and business rules to support the requirements in HRP implementation throughout project life cycle up to and through change control.

Considered the business implications of the application of technology to the current and future business environment.

Reviewed system test plans and system tests modules before implementation.

Experience Summary

2023-2024 American Postal Workers Union Health Plan Manager of Business Analyst, Testing and Training team

2020-2023 Impresiv Health Manager Healthcare Services 2012-2020 Dell/NTTA DATA Health and Life Science Delivery Consultant

Detailed Experience on Following Pages:

Education/Certificates

Certified Scrum Master, 2024

Certified Professional Project Manager, 2024

Bachelor of Arts Pacific Coast Bible College

Experience

2023-2024 American Postal Workers Union Health Plan Manager of Business Analyst,

Testing and Training teams

Developed standard operating procedures and guidelines for the configuration and testing teams.

Responsible for oversight of benefit configuration, testing and maintenance within the QNXT database.

Provided metrics for governance meetings.

Developed departmental and unit standards.

Administered salary and performance review program for exempt staff and evaluated departmental performance on an on-going basis. Recommended contingency measures as needed.

Developed staff in their areas of responsibility and created an environment for optimum

performance.

Responsible for the setup and maintenance of the QNXT claims system's configuration, benefits, rules and fee schedules and supported new system releases and new annual benefits.

Developed a thorough understanding of all aspects of the QNXT claims processing system, including claim adjudication, membership and enrollment, eligibility, configuration and benefits, authorizations and payment.

Reviewed and updated any errors in the network data manager system prior to final upload.

Designed provider build, benefit and pricing.

Created and documented test cases performed unit testing for configuration scope of program.

Assisted with EDI and claims interface for client implementations.

Experienced with transactional data including inbound and outbound HIPAA transactions, i.e., 834, 278, 837, 835 as well as proprietary files.

2020-2023 Impresiv Health Manager Healthcare Services

Managed a team of employees by providing goals, feedback, development, and continued learning in HealthRules.

Provided technical leadership and guidance to the team to ensure HRP projects were completed within expectations.

Collaborated with direct team members, Project Managers, and peers to establish monthly delivery forecast that align with established organizational goals.

Managed escalated situations, established appropriate remediation plans, and executed the plan to remedy the situation with troubleshooting fixes in HRP.

Utilized JIRA and Service Now software to track and monitor all team projects and engaged as necessary to remove roadblocks to ensure successful project delivery.

Monitored team member performance and productivity metrics.

Drove the business to continually improve processes and efficiencies, including practicing risk taking as well as creating an environment where employees take risks.

Held team meetings to communicate relevant information to staff, peers, and stakeholders.

Assisted human resources with the on-boarding process for new employees.

Submitted weekly report regarding overall teams’ status, critical issues and roadblocks.

Provided one on one meetings with team members to review project status and discuss issues and concerns as well as highlight achievements.

2012-2020 Dell/NTT DATA Health and Life Science- Delivery Consultant

Supported the following clients:

oAvMed

oWisconsin Physician Services (WPS)

oFEP (CareFirst)

oHarvard Pilgrim

oMcKessen (NDM)

oAffinity Health

oBlue Shield of California

oBlue Shield of Rhode Island

Blue Shield of Michigan

Utilized HealthRules Designer Portal to configure benefits during the AVMed conversion for AMISYS to HealthRules.

Searched benefit plans, located claims and monitored the claims adjudication process within the Designer and Manager modules of HealthRules.

At Wisconsin Physician Services (WPS) conducted a detailed assessment to gather requirements for pending claims edits that optimized the end-to-end process and improve service levels.

Utilized QNXT as part of 6-month requirement gathering process.

Conducted interview enrollment SME to capture the current state processes and identified gaps through requirement analysis for future improvements.

Conducted business process analyses, assessments and preliminary benefits analyses to align information technology solutions with business initiatives.

Provided detailed design and business rules to support the requirements in HRP implementation throughout project life cycle up to and through change control.

Considered the business implications of the application of technology to the current and future business environment.

Reviewed system test plans and system tests modules before implementation.

Created reviews and deliver end-user documentation (user guide, process flow charts, and training materials) and trained for accuracy.

Proficient with executing testing scenarios and cases.

Created end user documents for HRP BPO team.

Assisted with EDI and claims interface for client implementations.

2010-2012 Adventasure, Inc. Senior Medicare Business Consultant

Provided product and solution definition, roadmap creation, testing guidelines, and rollout of solutions and enhancements.

Ensured product development maintained on-time delivery of development milestones and deliverables.

Provided detailed progress reporting and assisted in documentation development.

Conducted comparative analysis against competitors and provided strategic planning of product direction and features.

Served as liaison between groups and divisions, providing business requirements and technical expertise to the product development team.

Worked in collaboration with sales executives, company leadership and strategy team, internal product planning groups, and technical design and implementation teams for the purpose of

product development and implementation.

Conducted training classes regarding implementation of new Medicare and enrollment processes, including lunch and learns chair siding for the enrollment department.

2008-2009 United Healthcare Regional Medicare Sales Manager

Ensured department exceeds expectations enrollment, retention and selling of specific Medicare Advantage health plans.

Conducted quality assurance call monitoring for staff based on member satisfaction of Medicare enrollment.

Monitored Policies & Procedures, guidelines and newsflash to stay compliant with Centers of Medicare and Medicaid, local, state and federal regulations.

Provided support to member relations, Medicare enrollment, retention and sales team with job aids, daily goal settings, training and auditing based on CMS requirements.

Conducted weekly staff meetings to discuss membership enrollment dissatisfaction and retention.

Participated in town hall Meetings to educate prospect and existing Medicare Advantage members with chronic condition plan options.

Reviewed and audited Medicare Advocate’s enrollment activities.

Developed track and trend surveys for marketing team based on Medicare’s enrollment retention.

2007-2008 United Healthcare Enrollment & Reconciliation Supervisor

Utilization coordinator for enrollment department.

Ensured team was meeting quality and accuracy standards.

Audited enrollment applications (paper, telephonic, etc.) data entered by vendor.

Processed re-enrollments and reinstatements.

Researched and resolved enrollment related issues as needed.

Handled Monthly Dual Eligibility Report.

Audited monthly Medicare and Medicaid enrollment low-income subsidy denials for members.

Facilitated staff meetings to remain current with Medicare Advantage health plans.

Provided support within service operations for Medicare members and prospects.

2001-2007 Blue Shield of California Appeals & Grievance Manager

Researched, reviewed, and resolved member/subscriber grievance, appeals and complaints.

Interpreted and explained health plan benefits, policies and procedures to respondents.

Responsible for compliance with State and Federal laws regarding the handling of appeals.

Researched authorizations and appeals with nurse practitioner and physicians within the department.

Ensured compliance with the applicable accreditation agency’s standard section regarding member’s rights and responsibilities.

Served as claims adjudicator liaison for the processing of radiology claims utilizing HCFA and UB92 claim forms.

Provided orientation and training of Medicare Advantage supplemental and commercial plan benefits to entry level coordinators.

1997-2001 Blue Shield of California Senior Billing & Enrollment Specialist

Provided training of Medicare Marketing guidelines and California Department of Insurance statues of limitations to enrollment team members.

Acted as liaison for updates to CMS marketing guidelines and benefit and enrollment materials.

Scheduled, organized and conducted team meetings regarding Medicare and commercial updates to benefit summaries.

Coordinated marketing and pre-enrollment activities according to guideline requirements.

Provided detailed notification to staff regarding payment determination out of network Medicare billing contracts.

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