Implemented Pay for Performance (Value Based Purchasing) programs for $8 million annual at risk 65,000 covered lives and more than 80 group practices across Kansas. Deployed, communicated, educated, and coached programs into success with pediatric practices, hospital systems, FQHCs (federally qualified health centers), and sole proprietors (single physician practices). Implementation included web-based testing of new monthly scorecards and member care gap lists.Redesigned challenged program focused on behavioral health measures (follow up after hospitalization for mental health diagnosis, diabetes screening for people with schizophrenia or bipolar disorder, and adherence to antipsychotic medications for individuals with schizophrenia). Identified root causes including workflows of program challenges and implemented solutions which restored provider confidence and engagement.Identified through random sampling a 7% systemic data issue that resulted in $1.7M in at risk additional earnings.

Supported the business by recommending system enhancements and solutions for claims, provider secure portal, medical management, and quality departments. Health plan liaison with I.T. for the secure provider portal which has functionality for Medicaid eligibility, authorizations, claims, and secure messaging. Strategist for system enhancements including proposing solutions, evaluating competition and balancing financial considerations. End to end ownership from initiation to deployment and maintenance. Strategically balanced Medicaid and business needs, proposed options, then developed with I.T. an out of the box claims solution for the Kansas Medicaid Health Home program for members with serious mental illness ($7 M in payments over two years). Tested, verified payments after implementation, resolved issues; owned the process from start to finish.Resolved and Negotiated claim settlements up to $1 million in billed charges (not related to Health Homes).

Claims business analyst working with claims configuration including benefits, network status, AMISYS, contracting (Emptoris), remittance systems (Payspan, Emdeon), and Microstrategy/TeraData. Health homes Kansas Medicaid implementation.

Acts as a liaison between clinical and technical departments. Writes business, functional, and technical requirements for case management, utilization management, and disease management programs. Product manager for OPTAMUM (Optimal Product Tracking and Member Utilization Management) proprietary desktop application. Contributor for EAP Expert and web based products (Webpass and Referral Quick). “Alternative Level of Care” researcher and designer, and financial report designer. Report author/designer for productivity reports of CM, UM, and clinical support coordinators. Owner/Designer of the department blog, including news, contests, and tips pages. Visual Studio 2008 advanced user (for screen mockups). Experience with .NET and HTML languages. SQL intermediate user. Advanced user for Word, Excel, PowerPoint and Visio.

Authored business, functional, and technical requirements for “Find a Provider” website, versions 4.0 thru 7.0 (over 400 custom code bases for members, providers, and payers such as Aetna, BCBSCA, Cigna, and WellPoint). Served as business liaison for SDLC process from initiation to implementation to maintenance. Designed user experience for first .mobi site. Authored and reviewed test cases, performed testing, including mobile site testing on several cell phone emulators (iPhone, Blackberry, smart phone, etc.) Received innovation award for contribution to “Physician Quality” product which was based on claims data from multiple payers.

(Jan. 2001 –May 2005) Created SQL Server data reporting which led to improvements in “First Call Resolution,” average handle time, average speed to answer, and customer satisfaction. Post mortem reporting/analysis of product releases. Root cause analysis of call center issues. Designed program which reduced credits for over 20 million subscribers. One of the first testers of the new OLAP tool which was introduced in Customer Service Analytics. Utilized Oracle and SQL to pull data from data warehouse for analysis, ad-hoc reporting, and billing system recommendations. Data mining for defects from legacy to new billing system conversion.