Participates in the design, development, implementation, modification and evaluation of health care information systems. Recommends automated and manual solutions to enhance system functionality. Participates in Project teams associated with the development and implementation of clinical systems.Interacts with end-users as required to assist in problem definition and system design. Coordinates and performs education and end-user training programs to assure systems are utilized as designed. Develops end-user documentation or a permanent reference for clear, concise information. Provides implementation assistance for system projects through all phases of the system development life cycle. Assists with system build, data validation and system testing. Publisher of Letters in Letter Admin Systems. Regulatory reports using SQL databases.

Participates in the design, development, implementation, modification and evaluation of health care information systems. Recommends automated and manual solutions to enhance system functionality. Participates in Project teams associated with the development and implementation of clinical systems.Interacts with end-users as required to assist in problem definition and system design. Coordinates and performs education and end-user training programs to assure systems are utilized as designed. Develops end-user documentation or a permanent reference for clear, concise information. Provides implementation assistance for system projects through all phases of the system development life cycle. Assists with system build, data validation and system testing. Publisher of Letters in Letter Admin Systems. Regulatory reports using SQL databases.

Participates in the design, development, implementation, modification and evaluation of health care information systems. Recommends automated and manual solutions to enhance system functionality. Participates in Project teams associated with the development and implementation of clinical systems.Interacts with end-users as required to assist in problem definition and system design. Coordinates and performs education and end-user training programs to assure systems are utilized as designed. Develops end-user documentation or a permanent reference for clear, concise information. Provides implementation assistance for system projects through all phases of the system development life cycle. Assists with system build, data validation and system testing

1. Responsible for coordination of Medical Management activities and documentation for achieving successful compliance of UM NCQA standards inclusive of pharmacy standards and applicable QI standards. Maintains updated roadmap and supporting documentation for Medical Management.2. Responsible for coordination of Medical Management activities and documentation for achieving successful compliance of UM IPRO standards inclusive of pharmacy standards and applicable QI standards. Maintains updated roadmap and supporting documentation for Medical Management.3. Responsible for coordination of Medical Management activities and documentation for achieving successful compliance with our State contract, Medicaid regulations as well as any applicable federal regulations inclusive of pharmacy standards. Maintains updated roadmap and supporting documentation for Medical Management.4. Performs tracking and trending of appeals and denials, and makes recommendations to the Manager of Clinical Programs for process improvements.5. Works with Medical Management Auditor for the development of records and testing tool maintenance for Medical Management audit process.6. Develops and maintains project management tools to assist with tracking and reporting of medical management programs or processes.7. Responsible for assisting the Manager of Clinical Programs with successful implementation of new programs and program changes as identified by the Director of Medical Management or Chief Medical Officer.8. Develops “mission” driven presentations for internal and external committees and departments for clinical program management.9. Acts as a liaison and represents PHP in contacts with providers, members, DMS, and other agencies as needed.10. Performs other related duties and projects as assigned.

Adapt, improve and automate processes and procedures to ensure the Plans compliance with all Health Care regulations around enrolling and maintenance of UFCW Union Employees Benefits.

Accountable for developing and maintaining key relationships and work with assigned areas to optimize business results. • Serve as the expert in clinical data reporting for CMS • Provide regular, comprehensive summaries of critical data to monitor compliance with regulatory and accreditation requirements and processes. • Complete ad hoc searches as required for development of metrics to support regulatory and accreditation requirements and processes. • Represent the Clinical Strategies HGO and HSO regions to internal and external audiences (i.e. auditors) as required.• Coordinate and facilitate Structure and Process measure reporting for CMS, regulatory and accreditation requirements. • Maintain process and technical specifications for all data and reporting. • Review and analyze processes, documentation and data to ensure regulatory requirements are met and to identify any gaps in the HSO’s processes. • Execute audit procedures related to regulatory audits/examinations and special projects. • Develop and maintain key working relationships across HSO regions and other departments to ensure consistent data tracking and reporting. • Identify new and emerging risks, monitor and develop corrective actions to resolve those risks. • Manage process to ensure accurate and timely reporting of internal and external regulatory and accrediting reporting. • Develop methods, systems and criteria for measuring and summarizing data and creating a monthly dashboard. • Serve as communication lead around technical specifications of data and reporting for any audits or inquiries.

Process owner of the Automated Agent Contracting for the Medicare Channel. Subject Matter expert during Spirit Project 12812 (ACE) Automated Agent Contracting Electronically which included testing and implementation. Business Owner of (MRMS)Medicare Relationship Management System for MarketPoint Sales. Adapt, improve and automate processes and procedures to ensure Humana's compliance with all CMS and DOI regulations around agent licensing, contracting and certification. Manage large volumes of Data to provide reporting related to licensing, contracting and certification. Assist with ongoing Quality Assurance efforts. Maintain proactive communication with other departments to ensure efficient, accurate and timely responses to internal/external customer needs. Directly lead and guide seven associates in delivering service and operational excellence through the consistent application of Humana Capital strategies which focus on continuous improvement in the areas of contributions, competencies and performance. Ensure appropriate staffing levels are achieved to ensure resources are managed effectively. Manage and assign balance and flow of work. Ensure associates have the necessary tools to perform their role. Provide guidance and leadership to associates and serve as a mentor for their day-to-day activities. Identify reasons for variation in individual performance and take appropriate actions that will result in improved performance. Analyze data to guarantee key performance measures are met, while aiding in the removal of barriers to success.

Adapt, improve and automate processes and procedures to ensure Humana's compliance with all CMS and DOI regulations around agent licensing, contracting and certification. Manage large volumes of Data to provide reporting related to licensing, contracting and certification. Assist with ongoing Quality Assurance efforts. Implemented an Access Database for Contract Metrics.

Accountable for developing and report metrics for ID Cards, SPAP and Returned Mail using MS Access. Generate comparative analyses of actual results to expected results, perform testing of new applications as they relate to enhancements and system issues. Partner with Information Technology department and business areas during the design of system enhancements resolutions, and throughout the testing process. Resolve system issues as they relate to production processing, report applications and system output.

Responsible for running Geographic Reports for Humana’s Sales Force including Census Overview, Network Geographic Footprint Match, Accessibility Reports, Service Area Zip Code lists and maps, Provider file/directory requests using MS Access. Experienced using MS Access to perform tasks such as: run reports, import & link tables, export data, create queries, manipulate and format data, create tables, and create forms. Also helped as a PSQ Analyst in the same department. Communicate via telephone, email and in person to internal Subject Matter Experts and Humana's Sales Force to provide guidance for Pre-Sale Qualifications. Effectively manage the PSQ Commercial and Group Medicare process from beginning to end. Ensure that Pre-Sales qualifications are thoroughly completed by Sales; routed to the proper subject matter experts (SMEs) in a timely manner; and completed in the required timeframe. Identify barriers in the process and proactively find resolutions to the issues. Meet with associates from the Proposal Center, Sales, and Account Implementation areas to ensure that all customization requests are captured and included in the Pre-Sale Qualification. Keep abreast of company changes and developments, especially as it relates to Humana’s products and services (benefits, administration, enrollment, network, member deliverables and claims). Determine whether to approve or reject the Pre-Sale Qualification based on the information gathered from the Subject Matter Experts. Manage the PSQ escalation process by working with Subject Matter Experts, Sales, Underwriters, Directors, and Vice Presidents to discuss alternative solutions.

Responsible for the Purchasing Procurement for The CGO including the work at home associates. Accountable for budgetary costs for each UDN within the CGO. Planned and built an ACCESS database for the supplies that are ordered in each UDN. Responsible for communications around change in processes of the support staff. Multiple level of involvement on projects distributed by leadership. Assist with catering. Participates in the recruitment process. Coordinates and oversees part of the interview process for the CGO.

Experienced in credentialing verifications in-house and thru the use of a CVO utilizing NCQA and URAC standards including licensure, training, malpractice insurance, claim inquiry, hospital affiliation verification, NPDB (National Practitioner Data Bank) and work history. Experienced in utilizing a state-of-the-art electronic system to manage a large physician database. For over two and a half years I was responsible for the quality reviews for all other credentialing specialists before their files could go to the monthly credentials committee. I submitted reports using EXCEL spreadsheets to the medical director, credentialing director and credentialing manager using the quality review information and an ACCESS database that is linked with Humana Military's electronic database.

USMC Veteran