Summary

Industry leading Agile Management professional with more than 9 years of healthcare experience, seeking a wonderful opportunity with a thriving company in the Houston, Texas area.

Experience

Anthem Healthcare Houston, TX

Process Expert II, Government Business Division

9/2017 to Present

Present process improvement solutions for new systems, new accounts, and other operational improvements

Develop and lead project plans and communicate project status

Perform root cause analysis for operations workflow problems and system irregularities

Perform operational readiness tasks, assists with requirements and provides input for test case development and results

Utilize Agile XP methodology for software development to ensure new market transition which includes Medicaid and Medicare

Manage large project teams across multiple markets

Contract negotiation with various Medicaid and Medicare markets and ensuring all aspects are met for state implementation

Create incremental delivery of high-value functionality in the environment where small successes deepen customer and team respect for the unique contributions of all team members

Ensure the emphasis on communication between the team and stakeholders

Provide a safe and courageous environment within the team

Provide the framework that allows teams to address complex adaptive problems, while efficiently and creatively delivering products, services, or results of the highest possible value to internal and external customers

Provide oversight as the business lead for claim implementation new market strategies

Workshare point End to End requests for development resolutions and system configuration analysis for various Medicaid and Medicare markets nationwide

Management of large data sets and creation of a process to properly ensure fulfillment of data migration

Manage and report on the status of key deliverables of claims, milestones, and dependencies

Manage Research operations workflow problems and system irregularities

United Health Group Houston, TX

Network Provider Contracts Analyst- Contract

11/2016 to 9/2017

Monitored activities by tracking the specific terms of each contract, monitored and documented compliance regulations

Developed business requirements for new market development

Utilized Agile methodology for software development to ensure new provider network transition was seamless

Worked in collaboration with the IT team to develop and streamline new processes of contract implementation

Provider network contracting review of Oracle database conversion for new implementation

Conducted, collected and analyzed data from a claim and/or medical record reviews to continually improve the care and service to members and coordinate with the financial recovery areas to retract erroneous or inappropriate payments

Gathered data requirements for technical testing and implementation

Produced monthly and quarterly data analysis reporting and status update to Executive Management and Business and Product Owners

Followed DRG- Data Release Guideline processes company policy and information privacy protocol

Responded to legal violations to determine the cause

Memorial Hermann Revenue Cycle MHMG CBO Houston, TX

Healthcare Data Analyst and Financial Analyst

3/2015 to 11/2016

Maintained and export revenue cycle data and expertise to communicate that knowledge to physicians and other internal customers

Managed large project teams for ambulatory system implementation

Worked directly with stakeholders for incremental updates

Ensured the cross-function of project teams aligned with departmental changes

Managed and creating Custom Insurance mapping with the use of pivot table conversions and analysis

Managed practice utilization and providing quarterly updates for Medicare and Medicaid

Managed Payment Integrity System for variance calculations for Fee/Payment schedules that include proper RBRVS methodologies from all insurance payers

Provided business explanations for monthly reconciliations

Provided daily Ad Hoc analysis within Athena, and PIC integrity system

Managed key revenue cycle performance indicators (KPIs) through data-driven analytics for large, complex sections with a larger number of providers and services to oversee and manage

Executed financial statistics reports for Provider and Practice Dashboards

Produced month-end reports assisting in tracking provider performance and global matrix

Texas Department of Insurance-OIEC Houston, TX

Ombudsman

7/2014 to 3/2015

Maintained full knowledge of the Texas Workers Compensation Civil Code of Texas

Assisted, Advocate and Educate injured workers with worker’s compensation claims as determined by the Division of Workers Compensation

Assisted and gathered all information related to the injury for mediations, court proceedings and appeals

Calculated benefits owed to injured employees and explain the determination of benefits

Negotiated benefits and binding agreements for settlement

Coordinated with State of Texas Workers Compensation for payment management of outstanding claims and previously adjudicated cases

Represented injured workers during hearings with Texas Department of Insurance and assistance with appeals of the state district court

United Health Community Plan Houston, TX

Medicaid Compliance /Contracts/ Financial Analyst

8/2011 to 7/2014

Consultant Medicare members seeking disease management care under the plan and state benefits

Coordination of full transition to full Social Security benefits based on state regulations and advocate for additional services as a follow-up care plan.

Account Manager for End-Stage Renal members on plan with Medicare eligibility and management of Medicaid accounts with a similar diagnosis

Responsible for direct reports of field nursing staff regarding disease management

Managed member data in Access and Excel to integrate systems easily so that a company could connect the financial dynamics of the End-Stage Renal process

Prepared legal documents and member medical history charts for monthly telephonic Fair Hearing calls with the State of Texas

Developed Data Analytics system for Renal/Nephrology Medicare members

Prepared and maintain contracts and describe agreed terms, containing language consistent with healthcare, legal standards and protecting United Healthcare Community Plan

Created and maintain electronic database in Access to accurately track members for Health and Human Services financial regulations

Edited and developing policies for ESRD/ according to HHSC/Maximus standards

Managed adults with disabilities receiving dialysis according to the Department of Aging and Disability

Analyzed, evaluated and makes recommendations concerning the IT audit of company records

Assisted in the budgeting process including claims auditing monthly

End to End process development for disease management and state regulation development for Medicare members

Education

Certified Scrum Master (CSM) Agile Marketing Academy 2020

Belhaven University - Master of Science in Leadership -2019

DeVry University- Bachelors of Technical Management-2013

ABA Dispute Resolution Certification -Mediation Certification- 2011

Center for Advanced Legal Studies-Paralegal Certification- AAS-ABA Accredited-2009

Software Knowledge

Microsoft Operating Systems, Oracle, Agile Methodology, Agile XP, PMP, Kanban, Crystal Reports, NDB, STATA, Oracle, SQL server script editing, Lexis Nexis, Cerner, EPSI, Athena, Epic, Cirrus, Facets, Care One, Carefour, Lawson, CPT/ICD 9/10, SharePoint, Tableau, JIRA, Confluence, Waterfall, Pricing

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