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Yyyyyy x. yyyyyy

0000 xxxxxx xxxx , xxxx , xxxxx 00000 xxx-xxx-xxxx ●

Senior Management Executive Healthcare Industry

Claims Operations ~ Quality Assurance ~ Regulatory Compliance ~ Project management




         Excel at driving software development lifecycle (SDLC) via Waterfall and Agile methodologies from initial design through to final release and support.

         Expert knowledge of health plan operations spanning claims, benefits, call centers, providers, enrollment, fulfillment, network development, contracting, appeals and grievances, and compliance.

         Highly skilled in product/program management for software development and implementations across acute, ambulatory, and managed care settings.

         Well-versed throughout design of cutting-edge healthcare analytic tools, medical consumer risk surveillance tools, engagement platforms, and medical management applications.

         Adept at designing intuitive graphical user interfaces and workflow automation features to improve key performance indicators and quality outcomes.

         Proficiency in medical claims management with Medicare, Medicaid, commercial insurances, managed care organizations, Workers Compensation, and auto insurance.


Selected Achievements


         Orchestrated countless projects and implementations valued up to $50M+, specializing in healthcare sector.

         Masterminded software quality assurance program which fueled an increase in quality levels by 45%.

         Employed Agile project methodologies to markedly enhance and streamline product development efforts.

         Overhauled utilization management system which increased production by 25%+ and captured $3M in savings.

         Recouped $10M in three months for Universal Health Care by designing claims QA program which revealed interest payment miscalculations and eliminated process deficiencies.

         Launched formal project management process based on PMBOK and SDLC to accelerate project delivery time by 30% and drastically lower system defects by 45%.

         Drew upon polished interpersonal skills to effectively align and mobilize cross-functional and multi-disciplinary personnel on a global scale.


Professional Experience


Health Integrated Inc., 2015 to 2016

Sr. Director of Medicaid Management Platforms and Products

         Trained, motivated, and coordinated team throughout two-year, $4.5M project from iterative development to deployment across eight lines of business for CaseTrakker Dynamo medical management software.

         Clarified all requirements for solution to track nearly four million Medicare, Medicaid, Dual Eligible Special Needs, and Commercial health plan members.

         Served as SME for solicitation and documentation of requirements based on findings from business units.

         Steered lifecycle management of multiple simultaneous large-scale projects including strategic roadmap.

         Planned, shaped, and facilitated rapid solution development of platform capabilities and integrations.

         Balanced and allocated resources for customer inquiries, projects, and administrative work.


Beacon Health Solutions / HealthAxis, 2013 to 2015

Director, Solutions Delivery

         Applied sharp organizational skills toward overseeing PMO, client relations, programming, software releases, SLA (service level agreement) adherence, and client issue resolution.


Continued ►



Professional Experience continued Yyyyyy x. yyyyyy Page 2 of 2


         Closely monitored solution delivery status and provided regular updates to senior management team.

         Participated in technical pre-sales and initial requirements gathering for new projects/accounts and directed efforts of delivery managers, architects, and analysts to ensure successful payer solutions.

         Determined and structured reliable metrics for measuring program and project progress towards goals.

         Devised best practices and corporate project management standards to achieve consistency.

         Authored RFIs and RFPs, negotiated vendor contracts, and navigated implementations for multiple clients.


Argus Dental, 2013

Executive Director, Operations

         Governed the complete spectrum of daily operations encompassing financial administration, regulatory and corporate compliance, trend analysis, team-building, project management, staffing, and cost control.

         Joined forces with Chief Executive Officer to contrive business goals, projections, and growth strategies.

         Coached, counseled, evaluated, trained, and directed employees in daily tasks and projects.

         Worked alongside senior leadership team to formulate comprehensive business development plans.


Universal Health Care, 2012 to 2013

Senior Manager, Claims Compliance

         Instituted quality assurance program to significantly fortify tracking and resolution of claims errors.

         Created, enhanced, and implemented knowledge management solutions and SharePoint site.

         Trained new hires and existing personnel, recognized excellent staff performance, and provided constructive feedback to elevate morale and team cohesiveness.

         Administered Annual Enrollment Period (AEP) for claims operations, accurately documented policies and procedures, and reinforced internal controls within department.


ikaSystems, 2012

Configuration Analyst / Medicare SME

         Spearheaded system configurations and leveraged project management methodologies and tools to drive initiatives to maximize efficiency and accuracy.

         Advised clients in configuration activities and business rules and processes, and ensured constant adherence to SLAs.

         Provided strategies for mapping client business processes to system functionality, oversaw defect resolution and release management, and assembled documentation such as policies and procedures.


Beacon Health Solutions, 2009 to 2012

Claims Operations Manager

         Led 14 Medicare analysts in processing claims in strict compliance with regulatory and quality guidelines.

         Trained member services and claims staff in ikaSystems software and claims adjudication process.

         Established Quality Assurance program to precisely track, reduce, and amend claims errors.


Amerigroup Advantage, 2008 to 2009

Claims Supervisor

         Shepherded high-performance team of 11 Medicare analysts in claims processing and adjudication operations while enforcing rigorous adherence to regulatory criteria and quality standards.

         Championed efforts to expedite adjudication times for auto claims by 20%.


Education & Professional Development


Master of Business Administration, University of Phoenix, 2011

Bachelor of Science Business / Management, University of Phoenix, 2006

Lean Six Sigma Certification (in progress), Villanova University ITIL Certification (in progress)




Facets, QNXT, ikaSystems, HealthAxis, Homecare Homebase, McKesson, Medisoft, Practice Partner, IDX, Cerner, Gerber, Macess, Amisys, AS400, Redbook, CMS -DDE, SQL, Visual Studio, TFS, and JIRA, EHR, Milliman, Interqual, ZeOmega Jiva, CaseTrakker Dynamo, Tableau, QualtMetrix, Johns Hopkins ACG, CMS GEMS ICD9/10


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