Jeff Gould Email and Phone Number

• Provide functional leadership in support of the RationalMed product, a highly successful patient health and safety program provided to approximately 350 clients and a patient population of 17 million. Acquired data is also utilized for predictive modeling and to support a number of published clinical studies. • Served as primary contact / subject matter expert regarding data integration requirements, capabilities, and solutions to both internal and external business partners. Active partner in cross-functional teams to include Sales, Client Services, Account Management, the Medical Director, Systems Development, and key Client personnel.• Managed a team of Business Analysts in all aspects of medical, pharmacy, and laboratory result data acquisition and integration. Primary objectives consisted of new business implementations and ongoing support, including data quality issues and resolutions. Consistently delivered appropriate solutions in maintaining the timely and accurate integration of data to the Express Scripts Information Warehouse. • Personally led several successful complex implementations to expand the client base ten fold over the past ten years. The current client base includes 44 of the Fortune 100 companies. • Led and facilitated weekly meetings regarding status, risk, and actionable items and reporting results to senior management.• Ability to balance technically detailed work, with strategic and organizational capabilities of a manager.

• Responsible for the gathering, documentation, and management of the technical aspects of client business requirements.• Supported numerous clients of varying size and market segment. Continually supported Highmark Blue Cross Blue Shield, a significantly complex account, which reflects the company’s second largest client.• Successfully supported the integration of Mountain State Blue Cross Blue Shield into Highmark requiring multiple system enhancements to deliver a seamless transition.• Led design and implementation of a custom design of eligibility loads to support Highmark’s transition to no longer utilize social security numbers as a member identifier. • Managed technical aspects of a significant rewrite of Highmark’s Auto Group Load process in conjunction with their internal conversion to a new benefit administration system.• Supported numerous clients and vendors in converting to the company’s revised outbound claim files necessitated by the implementation of HIPAA and the NCPDP 5.1 claim standard.• Provided business requirements and acted as technical liaison for over 100 custom client requirements.

• Responsible for managing a staff of 24 hospital and medical claim examiners.

• Led project team to automate the conversion of a claim adjudication system.• Developed corporate strategy and led implementation of projects which reduced operating expenses of the Benefit Payment Operation by 40 percent. Projects implemented included electronic data interchange, outsourced data entry, development of client/server applications to automate the adjudication of dental and pharmacy claims.• Represented claims operation on corporate project to initiate imaging, optical character recognition (OCR), intelligent character recognition (ICR), and computer output to laser disc (COLD) technology.• Member of a team established to design a database to be populated from multiple claim adjudication systems.

• Responsible for the enhancement and maintenance of mainframe applications for health claims and hospital pre-certifications.• Designed and implemented operating controls for a 320 person department. Responsibilities included forecasting staffing needs, $90 million annual budget management, and quality control of $400 million in annual claim payments.• Led team of internal associates and external consultants in the evaluation of a replacement claim adjudication system.• Designed operational claim controls – resulting in $80 million in annual savings.• Kept Senior Management abreast of new technologies by researching and evaluating the potential use and impact upon the organization.• Managed a staff of 24 individuals.

• Responsible for the enhancement and maintenance of mainframe applications for health claims and hospital pre-certifications.• Developed membership eligibility interfaces with third party administrators.• Designed and implemented interface of hospital pre-certifications to the claim adjudication system.• Developed and managed Voice Response Unit within the Claims Call Center.

• Responsible for the enhancement and maintenance of the health claim payment system.• Supervised staff responsible for building plan designs within the claim system.

• Assisted in the establishment of company guidelines for claims adjudication.• Researched and responded to inquiries from state insurance departments.

Claims Supervisor.…………………………………………………………………………..1983 – 1985• Responsible for supervision and development of examining staff including training of new hires.• Administered internal health account insuring in excess of 5,000 members.Claims Examiner……………………………………………………………………………1981 – 1983• Responsible for processing health claims and answering client inquiries