Operations / Strategic Functions and Analysis Manager / Business Development Executive Senior Project Manager / Business Change Manager Performance-driven and highly accomplished Senior Business Executive offering a results-charged career leading complex, large-scale projects and managing world-class service operations and business processes within the health insurance industry. Expert in analyzing existing operations and implementing the necessary strategies, formal business practices, and technology to improve an organization's operational efficiency, productivity, and bottom-line results. In-depth understanding of IT infrastructure and government regulations. Provide visionary leadership and guidance in turning conceptual ideas into a business reality to achieve administrative savings. Proven leader well versed in unifying cross-functional teams in a matrixed environment toward a common goal. Excel in challenging business environments while creating innovative, cost-effective solutions to solve the most difficult problems facing businesses today that consistently deliver the best possible outcomes. Polished communicator who interacts effectively at all organizational levels and develops top-performing teams. Accustomed to making high-stakes decisions that support critical business functions. Exceptional work ethic. Project & Program Management Strategic Business Planning Change Management Performance & Process Improvement Staff Training & Development Regulatory Compliance Policy & Procedure Development Systems Development & Configuration E-commerce & E-business Escalation & Conflict Resolution Contract Management & Negotiation New Product Launch / Rollout Budget & Resource Management Risk Management & Analysis Team Building / Management Quality Control / Assurance Presentations & Public Speaking Cost / Benefit Analysis PROFESSIONAL EXPERIENCE EMBLEMHEALTH, Albany, NY 2005 - Present [In 2006, Group Health Incorporated (GHI) and HIP Health Plan of New York affiliated as EmblemHealth and provides quality health insurance to 2.9 million individuals.] Operations / Strategic Functions and Analysis Manager Direct all phases of medical claims processing to ensure that production standards, quality, and cycle times are maintained. Develop and implement strategic plans to achieve peak performance and ensure that goals are met in the areas of claims inventory, cycle time, quality, and budget parameters. Co-lead Claims Operations staff comprised of 40+ Claim Approvers and 4 Supervisors. Oversee Strategic Functions and Analysis, including the Analytical staff made up of a Lead Claims Analyst, Senior Claims Analyst, Claims Analyst and Pre-Payment Review Specialist. Serve as member of several Corporate Wide Initiatives: Corporate Medical Policy Implementation Committee, Pend Workflow Automation, Consolidate Gateway, HIPPA 5010, and ICD10 Teams. Evaluate efficiency of existing business process and implement solutions for improvement. Facilitate root cause analysis, project scope and requirements documentation for complex business system solutions. Prepare monthly, quarterly, and annual Executive Summaries that detail performance, initiatives, and overall departmental progress. Develop training plans to ensure staff competencies. Investigate departmental errors found by the Internal Audit Department and provide departmental and / or systemic remediation. * Automated 3rd party processing for Early Intervention Claims, achieving an auto-adjudication rate of 90%. * Streamlined 3rd party business processes for Medicaid Subrogation and Medicare Secondary Payor for both the Medical and Hospital Claims processing platforms. * Implemented numerous departmental business processes efficiencies that provided significant administrative savings. * Played instrumental role in enterprise-wide increased auto claims adjudication, which lowered overhead costs and increased operational efficiency over those claims processed manually.
COMPUTER SCIENCES CORPORATION, East Greenbush, NY 2005 [CSC develops technology-enabled solutions for various businesses.] Technical Call Center Manager Managed 10 members of IT Infrastructure Management Team and Service Delivery staff to ensure that service levels and objectives were met per company's NYS Medicaid contract. Developed and implemented operations improvements to meet defined objectives across multiple facilities. Led activities related to customer requirements, budget challenges, and human resource functions. Created processes for leveraging and utilizing resources to meet customer needs. Established and maintained communication with customers, management, and staff to ensure that service was delivered on time and within budget or contractual obligations. * Co-championed the implementation of the HIPPA 835 RA, allowing pharmacy vendors to reconcile as much as $10 million in account receivables. MVP HEALTH CARE, INC., Schenectady, NY 2003 - 2004 [MVP offers a diverse range of health benefit plans and serves more than 750,000 members.] E-Business Project / Product Development Manager Led MVP's E-Business Team comprised of an EDI Specialist, Web Developers, and offsite contracted vendors. Collaborated with the Legal Department to develop RFPs for outside IT development contractors. Served as Project Lead for all e-business enhancements, including HIPAA mandated transaction sets. Worked on weekly Change Management process to ensure integrity of system. Participated in business analyses, business process requirements definition, system design and enhancements, and procedure development. * Implemented all HIPAA mandated transaction sets within CMS required deadlines and budgets. * Contributed to the design and implementation of MVP's Enterprise Wide Problem Tracking Process. * Presented with Team Award for meeting HIPAA compliance deadline. EMPIRE BLUE CROSS BLUE SHIELD, Albany, NY 1994 - 1997, 2000 - 2003 [EBCBS provides health insurance to more than 5 million members throughout the state of NY and nationwide.] Senior Project Manager, E-Technologies and Partnerships (2000 - 2003) Headed corporate-wide projects dedicated to supporting regulatory compliance and revenue growth. Identified, analyzed, selected, and assisted with the RFPs best-of-breed vendors and partners for e-technology initiatives. Validated corporate-wide compliance of implemented projects, including communication, business processes, and education. Led Evaluation Team for proposed claims adjudication engine. Served on the Implementation Team for the Broker, Member, and Provider portals as well as the 9/11 Business Retention Team. * Completed corporate-wide name change and implemented Upstate Shield Removal Blue Cross Association mandatory compliance requirement. * Received numerous team awards and a leadership award for outstanding contributions to enterprise-wide projects, meeting all deliverables, completing projects within budget, and generating new ideas. Change Management and Development Manager (1995 - 1997) Supported various departments and outside vendors in process design, process improvement, joint-application design, business analysis, and project management. Oversaw weekly implementation, system and user-acceptance testing, user documentation, and project management related to company's Long Range System Planning (CS90 - Source Code. Managed a team of 8 Business System Analysts. Project Manager (1994 - 1995) Created and managed project schedules and deliverables for corporate-wide initiatives.
VALUEOPTIONS, Latham, NY 1997 - 2000 [ValueOptions is the nation's largest independent behavioral health care company that provides services to more than 23 million individuals.] Director of Business Development, Corporate Claims Oversaw the design and development efforts for e-commerce across entire enterprise. Contributed to system design, enhancements, and procedure development. Presided over all reporting requirements for multiple departments. Managed team of 25 Analysts and 2 Managers. Maintained all benefit plan configurations for new and existing clients enterprise-wide. Managed multiple projects simultaneously, including budgets. * Spearheaded Y2K testing initiatives nationwide, which involved coordinating efforts of IT and multiple sites. * Introduced scanning and OCR technologies related to claims adjudication. * Established a Reporting Team to support Claims and Customer Service Management. * Recommended system enhancements and training related to new and existing state legislative guidelines. * Created a tracking system for company's business associates to monitor the status of benefit plans pending Benefit Configuration implementation. * Successfully transitioned Benefit Configuration from Falls Church, VA to Latham NY, which reduced turnaround time from over 60 days to less than 30 days. EDUCATION & TRAINING Russell Sage College, Troy, NY B.S., Business Administration and Education Additional Training: Lean Six Sigma Green Belt Training Change Leadership Training AFFILIATIONS American Health Insurance Plans Project Management Institute National Association of Professional Women COMPUTER SKILLS Microsoft Office, Project & Portfolio Management, Microsoft Project, Visio, Lotus Notes, Client Server Environments, Numerous Claim Adjudication Systems.