Lead Data Analyst & Quality Manager
Resume:
ERIC RAES
Sellersburg, ***** IN 502-***-**** *********@*****.***
SUMMARY
Results-driven Lead Analyst with over 12 years of experience delivering data-driven insights and strategic recommendations across diverse business functions. Proven expertise in data analysis, reporting, and cross-functional collaboration to support organizational goals, and improve operational performance. Adept at leveraging analytical tools and methodologies to translate complex data into actionable intelligence. Recognized for strong leadership, problem-solving skills, and a commitment to driving continuous improvement in fast-paced environments.
SKILLS
Data analysis
Risk assessment
Business solutions development
Star Measure Analytics
Critical thinking
Team collaboration
Adaptability and flexibility
WORK EXPERIENCE
LEAD ANALYST 05/2025 - Current (Previously Bright Health-Molina purchased Bright Health 1/1/2024)
Molina Healthcare - Long Beach, CA
Manage data load counts on 5 states for prospective & retrospective monthly analytical runs.
Assist with PO reviews, user story acceptance criteria, and business test case reviews.
QUALITY MANAGER 03/2022 – 05/2025
Bright Healthcare - Long Beach, CA
Led coordination with the HEDIS vendor for monthly data runs, ensuring timely and accurate data processing aligned with project goals.
Oversaw the end-to-end HEDIS project lifecycle, including setup, roadmap development, audit preparation, and successful submission to NCQA.
Maintained comprehensive data sources for supplemental data submissions, while delivering oversight reporting to support prospective quality improvement initiatives.
NATIONAL ACCOUNT MANAGER 07/2022 - 03/2023
Ciox Health - Alpharetta, GA
Directed retrieval activities for the Risk Adjustment project, ensuring timely and accurate data collection, aligned with compliance standards.
Provided strategic oversight to cross-functional teams, including Call Center operations, Health Information Handlers (HIH), and Provider Engagement, driving operational efficiency and service excellence.
Maintained and optimized client playbooks encompassing key performance metrics, project milestones, and contract SLAs to support consistent client satisfaction and accountability.
SENIOR PRODUCT MANAGER 12/2021 - 07/2022
Signify Health - Dallas, TX
Led the creation, maintenance, and successful delivery of clinical workflow requirements, ensuring alignment with organizational goals and end-user needs.
Partnered cross-functionally with Digital and Engineering teams to drive the development and enhancement of mobile and web-based healthcare applications.
Oversaw coding compliance initiatives related to Quality/Stars and Risk Adjustment metrics, supporting regulatory adherence, and optimizing performance outcomes.
STRATEGIC PRODUCT MANAGER 12/2020- 12/2021
Optum - Eden Prairie, MN
Directed the development of business, functional, and technical requirements for Quality Programs and Patient Experience initiatives, ensuring alignment with organizational goals and regulatory standards.
Oversaw the design and delivery of Care Coordination and Quality Program systems, driving innovation in patient engagement and health outcomes through strategic product development.
Supported Stars Maximization Programs by enabling data-driven decision-making and optimizing submission reporting processes to enhance performance across Quality and CAHPS measures.
ASSOCIATE DIRECTOR OF QUALITY PROGRAM MANAGEMENT 10/2016 - 12/2020
Optum - Eden Prairie, MN
Led a high-performing team of Quality Program Managers to deliver exceptional client support, and ensure alignment with organizational goals and quality standards.
Oversaw the execution and compliance of all client-facing requirements for HEDIS, Stars, and CAHPS programs, driving performance improvement, and regulatory adherence.
Directed the development and implementation of complex, integrated Risk and Quality Management solutions, enhancing operational efficiency, and improving health outcomes.
QUALITY PROGRAM MANAGER 10/2015 - 12/2016
Optum - Eden Prairie, MN
Provided key oversight and direction for Optum Quality clients during the life of contract
Maintained client deliverables for HEDIS/CAHPs/Stars based on contract SLAs
Delivered strategic planning, testing, and oversight around system releases
Supported clients with measure rate and prospective gap closure analysis
CLINICAL SERVICES PROCESS CONSULTANT 05/2014 - 10/2015
Humana Insurance Company - Louisville, KY
Assisted with care coordination for members with Medicaid/Medicare Dual program
Monitored inpatient admissions and discharges for members in the Chicago market
Collaborated with vendors and providers to confirm members have active discharge plans
Maintained databases on discharge data for executive reporting
QUALITY SYSTEMS INTEGRATION CONSULTANT 07/2012 -05/2014
Humana Insurance Company - Louisville, KY
Oversaw operational requirements and coordination for vendor system updates, ensuring seamless integration with existing clinical workflows, and minimal disruption to services.
Designed and implemented GAP closure reporting tools aligned with HEDIS and Star quality measures, driving improvements in performance metrics, and compliance.
Delivered comprehensive system training and support to clinical staff, enhancing user adoption, data accuracy, and overall system effectiveness.
BUSINESS ANALYST FOR MEDICARE GRIEVANCE & APPEALS 10/2011 – 07/2012
Humana Insurance Company - Louisville, KY
Managed operational requirements for Grievance & Appeal Teams
Developed Maximus reporting to monitor overturns
Collaborated with Medical Directors to improve Maximus overturn rates
Changed key Grievance & Appeals process based on medical directors' green belt projects
TEAM SUPERVISOR MEDICARE GRIEVANCE & APPEALS 05/2010 - 10/2011
Humana Insurance Company - Louisville, KY
Managed a team of 15 specialists who handled MA Grievances & Appeals, and PDP Grievances & Appeals
Developed and coached specialist on how to properly work caseload
Collaborated with peers on case coding projects to correctly identify the type of Grievance & Appeal case
Changed behavior of specialist by providing adequate resources and training to work case load
TEAM LEAD/LEAD TRAINER MEDICARE GRIEVANCE & APPEALS 10/2009– 05/2010
Humana Insurance Company - Louisville, KY
Managed and supervised a team of 15 specialists, ensuring the efficient handling of Medicare Advantage (MA) and Prescription Drug Plan (PDP) grievances and appeals, driving high performance and adherence to compliance standards.
Designed and implemented a comprehensive training curriculum for the Grievance & Appeals department, enhancing overall team knowledge and operational effectiveness.
Led new hire training initiatives for MA Grievance & Appeals, providing mentorship and support to ensure a smooth onboarding process, and successful integration into the team.
SPECIALIST MEDICARE GRIEVANCE & APPEALS 10/2008 - 10/2009
Humana Insurance Company - Louisville, KY
Effectively managed a diverse caseload of over 100 complex Medicare grievance and appeals cases, ensuring timely and accurate resolution in compliance with CMS guidelines.
Collaborated on multiple case-coding projects, providing peer support and quality assurance to enhance accuracy and consistency across the department.
Cross-trained as a specialist in various case types, demonstrating adaptability, and expanding team capabilities to meet fluctuating operational demands.
MEDICARE CUSTOMER SERVICE SPECIALIST 05/2008 - 10/2008
Humana Insurance Company - Louisville, KY
Handled high-volume inbound calls from Medicare Advantage members, providing prompt and courteous support while addressing a wide range of inquiries.
Resolved complex issues related to billing, claims, and enrollment disputes, with a focus on accuracy, compliance, and member satisfaction.
Cross-trained across multiple service areas, demonstrating flexibility and expertise in handling billing, claims, and enrollment-related calls.
EDUCATION
Webster University - Louisville, KY Masters of Healthcare Administration
07/2012
Indiana University Southeast - New Albany, IN Bachelors of General Studies
05/2005
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