Therese Sheehan Email and Phone Number

Provide consulting services to FluidEdge Consulting’s clients. Proficient in Medicare and Group Health Insurance specializing in enrollment processes and related downstream functions. • Project Manager for a project to transition a TPA’s enrollment and billing functions from an AS400 system to a new integrated software platform. • Developed Web Service Business Requirements for clients of a Provider Management system.• Researched and provided recommendations to a PDP for improving reconciliation processes to ensure the Plan remained in compliance with CMS. Reviewed and recommended changes to Policy and Procedure and training required for the conversion to a new processing system. • Developed extensive documentation and analysis for a client’s new in-house Medicare front-end eligibility processing system.

Medicare SME and Lead BSA for a Medicare Advantage Health Plan project to successfully enhance the functionality of an internal database and its interface with a vendor system for the production of annual member notification materials (ANOC/EOC). • Gathered business requirements, developed functional specifications and use cases. • Maintained Requirements Traceability Matrix to facilitate development of any future enhancements.• Identified issues and risks. Coordinated with PM, developers and business owners on mitigation strategies.• Provided assistance to the Q/A team to develop a Test Plan, monitored testing and prioritized defect resolution.• Prepared User Guide which documented existing and new functionality and provided training to users.• Conducted transition meetings (knowledge transfer) with Production Support IT and Business Owners.

Project Manager : Provided strategic consulting, including business plan & implementation strategy for enrollment and finance business areas of a new Medicare Advantage plan offered by a major health plan in the Philadelphia area.Worked with Subject Matter Experts, Business Analysts and Business Owners to manage the project plans, gather requirements and identify and develop the processes necessary tor the implementation.Acted as liaison between business areas and vendors providing services to the health plan (e.g., claim payments, enrollment processing, letters and ID cards) to facilitate gathering Business Requirements and Functional Specifications and developing implementation plans.Maintained issues log to enter issues, develop mitigation strategy and track resolution.

IKASYSTEMS, Southborough, MA 2011-presentSR. MEDICARE PROCESS SPECIALIST• Serve as the primary liaison with Medicare Advantage and PDP health plans, internal development and compliance teams to ensure effective enrollment processing. Lead regular meetings with client to review outstanding issues and system enhancements.•Monitor daily processes for any issues for potential impact to clients' operations or compliance with CMS guidelines. • Identify and initiate process improvements that affect internal and external clients. Develop and implement efficient and functional system design documents based on client requests or regulatory changes.•Provide technical support for releases from pre-release communication through post-implementation. •Gather clients' business requirements and assess progress towards achieving deployment goals.•Serve as subject matter expert regarding Medicare regulations and operational procedures. Remain current in knowledge of Medicare regulations by reading, interpreting and analyzing regulatory bulletins, memos, and other updates.

Analyze data, perform benefit validation, testing and other activities required to successfully implement the transition to a new PBM for the Pharmacy Benefit Management (PBM) transition project. Perform testing with functional areas such as Customer Services and enrollment on new benefit implementation and other system initiatives.

Charged with Business System Support, Testing and Project Implementation teams responsible for implementation and support of new Medicare Advantage and Part D products and services on internal eligibility and enrollment systems. Managed a staff of 20 and managed the annual department budget greater than $800,000:Led the systems support effort to reconcile Medicare enrollment between IBC and Medicare. Recovered over $30M from Medicare.Subject matter expert for corporate projects (e.g., Medicare eligibility conversions to a new Pharmacy Benefits Manager, transition of Medicare ID cards to a new ID card vendor). Recipient of multiple company awards including 'Best of the Best' in 2005 & 2007, Winners Circle Awards in 2002, 2005 and 2006.

Supervised staff of 20 Business System Analysts. Supported Independence Blue Cross Government Programs department in management of Medicare eligibility on department eligibility, corporate enrollment, member services and billing systems. Supported the business areas and ensured compliance with Medicare plan enrollment requirements and reconciliation. Provided documentation and training as necessary for system and process enhancements. Received Special Recognition for outstanding performance on the Pharmacy Benefits Management Transition Project in 2004

Coordinated with vendors to facilitate eligibility interfaces for group health related dental and vision coverage. Maintained ID card functions and processes for over 1 million members. Responsible for maintaining interfaces, documenting processes, and resolving error conditions either through system enhancements or desk procedure. Assisted in the conversion of a eligibility external eligibility systems to an internal enrollment system (MHS).

Implemented and maintained tape electronic eligibility process for group health plan customers, including several national account customers. Wrote specifications and tested programs for customer specific tape processes, reports and for system enhancements required for special projects. Headed operations team that created and maintained eligibility cross-reference files and their system interfaces resulting in improved customer service and electronic claim routing.  Participated on operations team that created and communicated processes that effectively converted group health plans from legacy systems to United Healthcare systems on schedule with minimal impact on customers.

Researched, developed and documented desk procedures for employer group health plan administration. Worked with business partners to develop process improvements to facilitate plan adminsitration. Trained administration, sales and claim personnel nationwide on contractual, financial and communication requirements to successfully transition group health plans from MetLife / Travelers to MetraHealth. Developed and implemented action plans to move MetLife managed care administration system to MetraHealth mainframe application. Results included: faster system turnaround time, significantly decreased system down time, accurate data collection and automation of manual processes for providing data to vendors.Previous positions at MetLife included Account Coordinator for small, mid-size and large groups, commissions clerk, and dental claims processor. Note: MetLife and Travelers Insurance Companies formed a new group health insurance company, MetraHealth, in 1994. Subsequently, MetraHealth was sold to United HealthCare.