Mechanicsburg, Pennsylvania, United States
Experienced Senior IT Executive with a demonstrated history of working in the Hospital & Health care industry. Executive Core Qualifications include Leading Change, Leading People, Results Driven, Business Acumen, Building Coalitions. Professional and Technical Qualifications include Strategy, Communication, IT Acquisition, Procurement, Best Practices and Emerging Technologies, Enterprise Architecture, Process, Fiscal, Budget, Performance and Vendor Management, CyberSecurity, Information Assurance, Risk Management, Service Operation, and Continuous Service Improvement. A strong business development professional with a Doctor of Education (Ed.D.) focused on Organizational Leadership from Grand Canyon University.
• Responsible for all the Compliance standards with Federal and State regulations including reporting and operational standards. • Led the strategic review of claims systems and participates as a core member of the IT Management leadership team. • Serves as a leader of the IT Management team responsible for delivering cost-effective technology solutions. • Accountable for analyzing, developing, implementing and optimizing the use of Information Technology in all IT processes.
• Was responsible for design/creating maps, type trees, message broker flows and test data to test the UCCI/Highmark/Mountain State Claims System and also to test the Foresight/TIBCO Instream SOA for 5010 claims for 834 pre-enrollment, 835 ERA, 837P, 837I, 837D, 999, 277CA. • Was responsible for analyzing the Instream Error Report for 837/835, APF for HIPAA Level 1-5 edits and 999 acknowledgment. • Was responsible for creating the WMB 5010 Queues for UCCI (United Concordia for Dental claims) and Highmark, Mountain State Professional and Institutional claims. • Was responsible for creating 837D, 837P and 837I and 835 test data, analysis of 835 ERA (Electronic Remittance Advice) in B2B and Stratus, OSCAR and RENO Mainframe systems.
• Was responsible for providing architectural and technical support for PA Department of Public Welfare (Year 2009; Year 2005-2006) for HIPAA 4010/5010 and ICD9/ICD10 Projects. • Was responsible for providing System and Program documentation for the Total Claims Processing System (TPS). • Was responsible for creating and applied training programs for clients and employees. • Was responsible for Analyzing, designing, coding, debugging, testing and implementation of ITS Home and Host Application Modules, Front-end, Payment Resolution Application and Financial modules for the BCBS healthcare insurance claims. • Was responsible for Quality Assurance and Estimation of work efforts for the Modules involved in the ITS, Payment Resolution, Front End and Financial Application areas for the BCBS healthcare and insurance claims.
• Was responsible for the delivery of HIPAA re-mediated programs against HIPAA Transaction Sets - 837P, 837I, 837D. • Restructured the architecture of three HealthCare Claim Processing Engines (BCL: Mainframe, QMACS: C++ on UNIX and LATRON (Mainframe Dental Claims) and Eligibility Engine. • Was responsible for Payment resolution system, Membership & Enrollment and Financial System areas. Also responsible for providing System and Program documentation for HIPAA 4010 standards and ICD-9 code changes. • Was responsible for coordinating activities, providing directions and scheduling • Was responsible for generating project metrics for the NASCO Metavance Project. • Coached and mentored 12 individuals on the NASCO Project team. • Adhered to CMMI/Level 5 model, PMI policies, procedures, and methodologies. • Was responsible for HIPAA rollout and created Customer Service Requests (CSR). • Developed detailed plans and schedules, including goals, risks, and resource allocation.