Randy Pomeroy Email & Phone Number

Philadelphia, Pa, Us

• Analyzing the existing policies existing policies and procedures and providing the inputs to Executive Management Team to fit into the compass project goals.• Conducting JAD sessions with different Business Users to develop the business requirements for Claim Processing, Program Integrity, eMedia and Reporting• Identifying the impacts and training colleagues on new internal policies /procedures changes.• Performing GAP analysis between Prestige Health Choice and AmeriHealth Caritas for a Data Migration and Conversion.• Defined scope (requirements) and objective based on user needs and thorough understanding of business processes. • Worked with stakeholders on process improvement projects designed to improve results. Gatheredand analyzed information and provided recommendations to address and resolve root causes. • Trace requirements (update and maintaining relationships between requirements components)• Created Workflow Diagrams of the AmeriHealth Caritas applications and proposed solutions using tools like Microsoft Visio • Baseline and manage changes to business case, solution and requirements

Philadelphia, Pa, Us

• Acted as a Business Analyst in various business operations and helped the organization to achieve cost-effective production with increased quality, efficiency and satisfied customer service, documenting the business process by identifying the requirements and also in finding the system requirements• Defined scope (requirements) and objective based on user needs and thorough understanding of business processes. • Worked with stakeholders on process improvement projects designed to improve results. Gathered and analyzed information and provided recommendations to address and resolve root causes. • Evaluated/researched business problems and their relationship to technology. • Organized and presented ideas in a convincing and compelling manner.• Reviewed complex business/systems problems and conveyed information to stakeholders (includes technical teams for translation into solution design).• Identified process, technology and organizational role changes necessary to support business goals and objectives.

East Norriton, Pa, Us

• Responsible for determining testing work effort & testing resources to determine the amount and extent of testing to be performed.• Reviewed requirements and design specifications to identify gaps and ensure documented project criteria are clear, consistent and testable.• Drafted and designed Test Strategy document in accordance to Health Partners guidelines.• Worked as a Lead to assign, oversee and validate results from test team.• Provided LOE to Project management for each release and code drops.• Participate in issues resolution and change control process.• Prepared daily QA status reports for review by project management.• Prepared consolidated results for all validation sessions conducted.• Worked with business stakeholders to ensure that relational star schema designs as well as subject area multidimensional database environment meet their functional expectations• Worked with data warehouse architect and meta data architect to validate and maintain the business relevance of dimensions, facts and attributes along with aggregation and calculated measures plans • Documented and follow-up on identified business validation issues

Hartford, Connecticut, Us

• • Primary function was to act as a liaison between IT, Medical Management Department and the Data Analytics teams.• Annually developed and maintained the Medical Claim Managements Microsoft Project Plan • Developed, documented and maintained Test Strategy, Test Plan & Testing approach.• Responsible for determining testing work effort & testing resources to determine the amount and extent of testing to be performed.• Developed and managed detailed plans for cross functional projects teams and reported the project status• Reviewed requirements and design specifications to identify gaps and ensure documented project criteria are clear, consistent and testable.• Worked as a Lead to assign, oversee and validate results from Business test team• Reviewed complex Provider and Hospital contracts and payments to ensure they were accurately paid• Reviewed complex plan designs to ensure appropriate claims payment and denial were accurate • Participate in issues resolution and change control process.• Managed and maintained the test script repository and UAT templates on the departmental • Uploaded any business related documents to Share Point site • Created weekly status reports for team management on behalf of QA team.• Reviewed test scenarios created by team members.

Hartford, Connecticut, Us

• Create value in projects by analyzing for areas of improvement, efficiency, and necessity, and also • applying an appropriate testing model prior to project implementation. • Acted as a business lead for developing business requirements and related business rules based on the business needs. • Worked closely with the business partners and SME(s) to define the testing, training, implementation, validation of detailed test plans and support of functional requirements.• Performed ongoing research, and supported the departmental MS Access database (RuMOR). • Provided leadership, coaching and mentoring for new members of the team. • Consulted with internal clients on a regular basis to ensure progress is in line with customer's • expectations and to obtain additional requirements needed. • Developed and conducted MS Power Point presentations for internal business areas. • Collaborated Business Subject Matter Expert(s) regarding which CPT-4, ICD-9 codes that should be included in the sweep of the Data warehouse for Disease, Maternity and Complex Medical Management • opportunities projects. • Analyzed and manipulated complex member health data reports in MS Excel

Hartford, Connecticut, Us

• Monitored daily maintenance within the Aetna Quoting System that the Underwriters, Brokers and Sales team would use to ensure system symmetry • Ensured balanced flow between Guide and AQC• Collaborated with Actuaries on State Mandates, Co-Pay, Coinsurance and Deductible Mandates & Plan restricted Mandates • Coordinated structure changes in conjunction with Actuarial team• Managed multiple large Rate Filings in MS Excel files for each state and product offering. • Performed Rate Case Analysis• Ensuring that correct dollar amount was loaded and tested in Rate Quoting application. • Created and maintains all HMO/QPOS/SI products and benefits • Provided accurate and helpful information and guidance to Product Management/Sales, Legal, • SMU, IT, APM, Claims, Actuarial, Underwriting and other internal clients • Worked directly with internal clients to develop specifications to the HMO product systems for AQC with regard to benefits

Hartford, Connecticut, Us

Led user acceptance testing , defect reporting and resolution, and checkout testing.Worked to increase the claims auto adjudication rate by 10%Assisted with the translation of business needs into Business Requirements and Functional Specifications documentation within specified timeframesParticipated in all phases of software testing, (UAT, Integration, System, Regression).Developed complex Functional test plans and User Acceptance test plans and scenarios using member and claim data IE ICD-9 and CPT-4Conducted training sessions. Applied specific functional and/or business expertise to perform assigned tasks and developed specific project deliverablesDelivered project activities on time and within budget; proactively identified and communicated issues that may jeopardize milestones or project budget to Project ManagerAdhered to the APLC (Aetna Project Lifecycle), project management methodology by utilizing internal procedures, tools and identified areas for methodology improvement

Hartford, Connecticut, Us

Performed analysis to assess root cause of moderately complex customer issues for reported system defects and control deficiencies found from system audits Conducted interviews, fact-finding, and independent research to design creative, progressive solutions to system issues and managing the issues to closureSupported business area operations/functions by setting up, modifying, maintaining simple to complex system operating parameters by designing and configuring business rule table entries, and/or complex macros/automated scripts. Provided day to day support of these items to insure they work properly (including the application of appropriate QA procedures) and to quickly fix any identified defectsDocumented business impact of system issueDeveloped and communicated effective short term workaround procedures to address system issues

Resolved Member/Provider inquiries via phone, letters and Internet i.e. Provided claim status information, interpreted benefit coverage, and processed physician changesWorked to enhance customer satisfaction and retention, while balancing interest of plan, sponsor, and memberMaintained individual productivity and quality standards by comparing weekly results against departmental metricsExplained member's rights and responsibilities in accordance with contractEffectively documented all contacts with membersProcessed inaccurately paid claims to ensure appropriate payments are made to Member/Provider

Recruited, hired, supervised, scheduled, and motivated a staff of 30 employeesTrained service staff to enhance customer service and increased revenue through suggestive sellingPlanned menus, estimated food and beverage costs, and purchased inventoryInvestigated and resolved food/beverage quality and service issues, ensuring customer satisfaction and repeat business

Certificate, Real Estate

Certificate, Health & Life Insurance

Education record