Project Manager Implementation

Dr. Amy L. Kramer

803-***-**** ************@*****.***

Candidate Summary

Amy is an accomplished results-driven Healthcare Director with more than 25+ years of experience in health care and insurance programs, ensuring efficient implementation and compliance in healthcare solutions.

She has vast prior experience working and adhering to federal and state norms in the Medicaid and Medicare programs.

She excels in navigating complex healthcare landscapes with expertise including CMS, APD, and RFP processes. She involves meticulous budgeting and accounting to ensure the project's financial health.

She has leveraged MITA frameworks, MDBT methodologies, and MMIS systems, and she drove the successful implementation of healthcare technology solutions.

Her expertise in compliance, vendor management and business and technical requirements ensures seamless integration and operational efficiency, ultimately enhancing service delivery within the healthcare sector.

Key Competencies

MS Project Server

Smartsheet

Asana

Financial Audits and budget management

HIPAA transactions

Claims and Enrollment processes

SalesForce

Visio

Powerpoint

Excel

Word

Data Warehousing systems

Web and Portal Pages

Vendor procurement and management

Medicaid and Medicare program management

RFP processes and cycles

Employment History

Gainwell Technologies Dec 2024 – Present

Director

Account client management for 3 state Medicaid state agency programs representing $260M annual revenue, ensuring quality delivery and operational management of the account including improving operational functions and processes, financials and revenue margin responsibilities while establishing and maintaining strong client relationships

Recruiting, coaching, leadership and management for a team of 25 direct reports operating as a project management office (PMO) and 75 technical staff responsible for all operations of the state agency programs including: EDI transactions for HIPAA transactions (837, 270/271, 276, 277, 834), claims and encounter processing and payment, third part liability (TPL) processes, eligibility and enrollment processes, provider revalidation, pharmacy, and call center operations

Support Medicaid managed care organization (MCOs) through interfaces, file and report processing, TPL provider eligibility verification, provider network and enrollment management

Manage the implementation of CMS mandates affecting Medicaid program requirements, including CMS reporting, audit reportings and filings

Oversee the remediation of security vulnerabilities and patch upgrades to systems across assigned accounts

Implemented process improvements in work intake, management and reporting tools, including through PowerBI to improve client reporting, resource allocation planning, and work progress

Develop escalation paths to support client needs and system impacts including outages

Ensure compliance with SOC and financial auditing, contract requirements including SLAs, KPIs. Identify and pursue time and materials opportunities expanding revenue potential and increasing attention to standard quality metrics

Facilitate offshore and vendor transitions for development and testing while ensuring seamless client experience in quality

Lead the responses in support of DOGE audits and requests for insights into data for fraud research, process efficiencies and effectiveness

Work closely with Sales, Legal, Marketing, HR and vendors to support the accounts Delta Dental Columbia, SC May 2022 – Dec 2024

Portfolio Delivery Manager

Portfolio program manage the Sales, Marketing, Onboarding, Enrollment, and Renewal portfolio and its project initiatives with $23M in annual budget for a $5B leader in health insurance

2024 KPI initiative of $5M to implement a new multi-product offering of dental and vision services in partnership with VSP targeted for mid-sized businesses. Support the expansion of multi-product capabilities for other ancillary health products including change management

Apply agile and waterfall methodologies to drive quality, timely delivery of project requirements, and alignment to strategic goals while managing the financial reporting and resource costs including contractor SOWs and vendor purchase orders

Lead the development of a new cross-functional capability for human capital processes and communications to support sales growth and retain existing business contracts. ($3M pilot effort through Dec. 2024)

Lead a cross-functional SME workgroup in the development and pilot implementation of new processes and communication framework with 4 existing business contracts

Apply agile and Sigma principles to facilitate group discussions and challenge current thinking to co-create solutions with internal and external stakeholders

Develop and present findings and final recommendations to senior leadership for implementation and enterprise rollout.

Directed the contract and product decommission of the California Medi-Cal Dental administrative service operations

Ensured timely and successful transition to Gainwell to assume operations for administration of dental services for the 5 million California Medicaid recipients.

Directed communications and information sharing between vendors, DHCS, and Delta; representing the interests of Delta in these transactions while being mindful of the needs of members and providers

Collaborated closely with Legal and Compliance to ensure alignment to contract terms and working through challenges to requirements

Arranged and led the investigation, research, vendor selection, communications, and legal actions of the company’s MOVEit cyber breach incident with the Legal, Privacy, and Cyber Technology teams throughout the Enterprise including Communications, Customer Service, Billing, and Operations.

Delta was listed within the top 7 companies affected by this breach nationally in June 2023.

Coordinated vendor activities for call center operations and mailing of over 7M individual impacted notifications

Led key discussions for responding to client and vendor impacts, media outreach, internal and external communications, and regulatory filings.

Facilitated implementation of communication, tracking, and organization of information paths including war room communications, updates to boards, outside counsel and vendor information flows, and client and member problem resolution and support.

Led initiatives to ensure compliance with Quality Assurance and Quality Control (QA/QC) standards, enhancing program effectiveness and safety.

Managed the development and submission of Advanced Planning Documents (APDs), ensuring alignment with federal and state Medicaid requirements.

Analyzed and interpreted MDBT data to assess project funding requirements and financial impacts.

Directed the CMS Systems Certification process, ensuring systems met certification criteria and achieved successful approvals.

Led the RFP process, from drafting and issuing requests to evaluating proposals and negotiating contracts, ensuring alignment with project goals and budget.

Created and maintained detailed documentation for project plans, processes, and system specifications, ensuring clear communication and compliance.

Developed and implemented oversight protocols to monitor project adherence to safety regulations and industry standards.

Fluid Edge Consulting Malvern, PA Jun 2021 – May 2022 Senior Director

Led the strategic development of Medicaid and Duals, Duals Demo DSNP service offerings, business development and sales activities

Building market intelligence, and developing marketing content and client lead list.

Created RFP bid responses and competitive bid presentations.

Partnered with vendor companies to leverage complete competitive bids for full-service package offerings.

Managed a team of 5 resources and ensured billable engagement work assignments for staff.

Developed standard operating procedures (SOPs) and process documentation to streamline operations and support project consistency.

Evaluated and aligned project objectives with MITA maturity models to support continuous improvement and strategic alignment.

Coordinated with CMS representatives to address certification requirements, resolve issues, and ensure compliance.

Developed and managed project budgets, ensuring accurate forecasting, cost tracking, and financial reporting.

Coordinated with stakeholders to gather detailed requirements for APD submissions, facilitating timely approvals and funding.

Monitored MDBT updates and revisions to reflect changes in project scope, cost, and funding allocations.

Coordinated with IT and business stakeholders to implement MITA-compliant solutions that improved operational efficiency.

Coordinated with federal and state agencies to ensure APD submissions met regulatory requirements and project goals.

Maintained up-to-date knowledge of CMS certification standards and processes to provide expert guidance and support.

Prepared and reviewed Medicaid Detailed Budget Tables (MDBTs) to ensure accuracy and compliance with federal and state guidelines.

Supported client engagements at AmeriHealth and Kaiser Humana, Louisville, KY Mar 2019 – Jun 2021

Senior PMO Manager

Direct staff manager of 21 program managers, senior project managers, and 4 project coordinators

Managed $37M annually in operational budget

Focus on all aspects of Medicaid functionality from new state market implementation builds to regulatory compliance and operational efficiency

Improved positive engagement, reducing a 60% turnover trend and improved production results over 18 months

Positioned and trained team to new agile transformation

Established key partnerships based on the successful execution and reliability of fundamentally strong PMO activities.

Implemented budget control measures to optimize resource allocation and minimize financial risks.

Developed and maintained certification documentation, demonstrating adherence to CMS guidelines and project standards.

Provided expert advice on MDBT-related queries and issues, facilitating smooth budgeting processes and approvals.

Developed comprehensive certification plans outlining required documentation, testing protocols, and compliance measures.

Facilitated continuous improvement initiatives, utilizing data-driven insights to enhance project delivery and compliance.

Conducted gap analyses to align Medicaid IT systems with MITA framework maturity levels, identifying areas for improvement.

Developed comprehensive APD project plans, including timelines, resource allocations, and budgetary considerations.

Led state Medicaid program implementations including LTSS, CHIP, TANF, ABD, BH, and DUALS Demo products.

Influenced best practices for developing a compliant end-to-end operational and efficient technology-based solution for all aspects of the new market.

Optimized Medicaid efficiencies at the corporate level provided subject matter expertise on implementations and operations and developed standards for Medicaid implementation efforts.

Partnered with IT leadership to define a functional core implementation model to increase implementation successes.

Managed vendor selection and management of vendor implementation of partner services such as vision, dental, and other complementary insurance coverage in markets.

Collaborated with cross-functional teams to define RFP requirements and evaluate vendor capabilities, ensuring optimal selection and project alignment.

United Health Group Feb 2018 – Mar 2019

Implementation Director

Led internal workstream RFP bid development across UHC and Optum and upon successful RFP wins led implementation to support the expansion of the Medicaid program footprint in California.

Decommissioned the program and withdrew all Medicaid operations within the California market.

Oversaw the preparation of narratives and supporting documentation, demonstrating a comprehensive understanding of project scope and objectives.

Developed strategic plans to enhance IT system interoperability and integration

Liaised with accounting staff to guarantee that financial transactions were appropriately documented and compliant with company guidelines.

Aetna, Linthicum Heights, MD Jun 2014 – Jan 2018

Chief Operating Officer

Directed operations of the health plan and staff departments consisting of 65 employees and contractors. Set and implement strategic plans for service level agreements, vendor pricing, success rates for service, regulatory metrics, and contractual requirements through the leadership and management of:

Claims and encounter management (adjudication, pends, outliers, reporting)

Provider network (contracting, relationship management, credentialing, geo adequacy management)

Member outreach, service, and growth through brand awareness, community involvement, and social media messaging

Member and provider service call center service levels and metrics

Member enrollment and eligibility functions.

Grievance and appeals processes and reports.

Technology, infrastructure, and reporting.

State legislation relationship management.

Technology operations and implementations.

Expansion and growth implementations.

Vendor management and oversight (vision, dental, incentives, NEMT, technology).

Ensured thorough documentation of all project phases, including design, implementation, and evaluation, to support transparency and accountability.

Managed procurement activities, including vendor selection, contract negotiation, and performance monitoring, achieving cost-effective solutions.

Education

Indiana University

Business Sciences Bachelor’s degree with High Honors; Religion Minor

Furman University

Project Management Certification Program

Trinity School of Natural Health

Naturopathic Doctor

AAWNP Board Certification, 2024

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