Experience

Virginia Premier

• United States
• Insurance
• 300 - 400 Employee

• Manager, Government Programs

  • Apr 2023 - Present

  · Responsible for Federal and State program operations and contract compliance. · Serves as an integral part of department management team to set and implement business goals. · Leads cross-departmental workgroups to assure contracts are operationalized. · Provide oversight for team of contract managers who are responsible for day-to-day interactions with Federal and State regulators. · Uses personal leadership skills to assure departmental objectives are met in matrix… Show more · Responsible for Federal and State program operations and contract compliance. · Serves as an integral part of department management team to set and implement business goals. · Leads cross-departmental workgroups to assure contracts are operationalized. · Provide oversight for team of contract managers who are responsible for day-to-day interactions with Federal and State regulators. · Uses personal leadership skills to assure departmental objectives are met in matrix management environment. · Leads risk and revenue management initiatives

• Senior Compliance Analyst

  • Nov 2019 - Apr 2023

  Richmond, Virginia, United States -Facilitated tracking, resolution and response of an DMAS requests, inquiries or MCO improvement/corrective action plans. -Researched and assisted on Federal and State regulatory requests or potential issues of noncompliance. -Participated in DMAS and other regulatory audits, meetings and initiatives. -Assisted in ongoing Compliance monitoring activities to ensure adherence to compliance, HIPAA and privacy policies and procedures. -Managed the investigation and… Show more -Facilitated tracking, resolution and response of an DMAS requests, inquiries or MCO improvement/corrective action plans. -Researched and assisted on Federal and State regulatory requests or potential issues of noncompliance. -Participated in DMAS and other regulatory audits, meetings and initiatives. -Assisted in ongoing Compliance monitoring activities to ensure adherence to compliance, HIPAA and privacy policies and procedures. -Managed the investigation and remediation of any suspected violations of HIPAA requirements. -Developed, implemented and maintained a system to track and monitor compliance of regulatory deliverables, including reporting, requests and requirements. -Validated monthly, quarterly and annual reports and submit to DMAS via DMAS portal. -Initiated, led or participated in compliance-related or organization-wide research projects and initiatives.

• Business Analyst II

  • Mar 2018 - Oct 2019

  Richmond, Virginia, United States Business Analyst II (3/2018 – 10/2019) Strategic Planning and Business Development and Analytics • Responsible for generating monthly/quarterly metrics for multiple lines of business. Reports include the Newborn Reconciliation Report, Medical Economics Deck, VCC - Virginia Coordinated Care Deck and the Provider Network File. Responsible for updating/maintaining SQL queries to create and maintain the Member Engagement and Provider Engagement Experience dashboards. Execute ad-hoc SQL… Show more Business Analyst II (3/2018 – 10/2019) Strategic Planning and Business Development and Analytics • Responsible for generating monthly/quarterly metrics for multiple lines of business. Reports include the Newborn Reconciliation Report, Medical Economics Deck, VCC - Virginia Coordinated Care Deck and the Provider Network File. Responsible for updating/maintaining SQL queries to create and maintain the Member Engagement and Provider Engagement Experience dashboards. Execute ad-hoc SQL queries to perform data validation and to research discrepancies. • Generate monthly TPA Administrator reports for INTotal Health. Create/maintain SOP’s to document applications for use in cross-training team members. Assist in development of benchmark reports. • Create enrollment, claims utilization, etc., queries for Medicaid Expansion and Marketplace members. • Was assigned to the Gilpin Court Initiative Project which included developing SQL reports for claims and prescription drug utilization, behavioral health issues, major chronic diagnosis, ER utilization, etc. by age and line of business.

• Business Analyst II

  • Sep 2014 - Mar 2018

  Richmond, Virginia, United States Business Analyst II (9/2014 – 3/2018) – Claims Encounters • Executed ad-hoc DBMS and SQL queries to perform data analysis to proactively identify and resolve critical and emerging encounter errors. Performed monthly PricewaterhouseCoopers, PWC, validation and reconciliation. Identified outliers and tracked issues through to problem resolution and post implementation validation. • Created all SOP’s for the VPE/D-SNP line of business. Utilized EDM Next Generation to submit Medicare… Show more Business Analyst II (9/2014 – 3/2018) – Claims Encounters • Executed ad-hoc DBMS and SQL queries to perform data analysis to proactively identify and resolve critical and emerging encounter errors. Performed monthly PricewaterhouseCoopers, PWC, validation and reconciliation. Identified outliers and tracked issues through to problem resolution and post implementation validation. • Created all SOP’s for the VPE/D-SNP line of business. Utilized EDM Next Generation to submit Medicare encounters to CMS. Reviewed and resolved internal scrubs and utilized QNXT to research CMS response file errors. Utilized the IDX system to submit Medicaid encounters to DMAS. • Attended quarterly Vendor conference calls. Worked with vendors to perform root cause analysis to identify and resolve data issues and to also coordinate testing and implementation of change requests. • Created requirements for creation of new SSRS processes and for automating existing manual processes. • Projects included D-SNP Implementation which included data mapping, creating test scenarios and performing user acceptance testing, SharePoint 2013 Upgrade and IDX Upgrade.

• Business Analyst I

  • Dec 2010 - Sep 2014

  Richmond, Virginia, United States Business Analyst I (12/2010 – 9/2014) – Claims Encounters • Was primarily responsible for Medicaid encounter data verification and submission to DMAS. Utilized IDX to extract encounter data to create 837I and 837P EDI files. Utilized Claredi/OTTS to perform HIPAA validation and error correction on encounter data. Performed audit on 837I, 837P, NCPDP and vendor encounter data prior to submission to DMAS. Submitted encounters via Xerox File Transfer System to the DMAS VAMMIS system.… Show more Business Analyst I (12/2010 – 9/2014) – Claims Encounters • Was primarily responsible for Medicaid encounter data verification and submission to DMAS. Utilized IDX to extract encounter data to create 837I and 837P EDI files. Utilized Claredi/OTTS to perform HIPAA validation and error correction on encounter data. Performed audit on 837I, 837P, NCPDP and vendor encounter data prior to submission to DMAS. Submitted encounters via Xerox File Transfer System to the DMAS VAMMIS system. Resolved critical compliance errors. • Reviewed response files, performed in-depth data analysis, researched and resolved data issues, identified error trends, executed ad-hoc SQL, DBMS and ACCESS queries, loaded DMAS response file data to the Data Warehouse. Created Certification letter and Provider file for monthly DMAS submission. • Worked with 3rd party vendors on change requests and error resolution. • Created Member Eligibility report and worked on project to automate report for end user. • Documented the entire encounter data submission/resubmission process and created all SOP’s and process maps. Projects included ICD9 to ICD10 Conversion, HIPAA EDI 4010 to 5010 Migration and IDX Upgrade. • Mentored junior Analysts. Trained new Analyst on current responsibilities when transitioning to new role.

• Claims Systems Configuration Analyst

  • Nov 2009 - Nov 2010

  Richmond, Virginia, United States Claims Systems Configuration Analyst (11/2009 – 11/2010) – Claims Systems Configuration • Was responsible for loading and updating coverage categories in the IDX system, loading par and non-par vendor contracts, entering and updating night jobs rules and real-time rule bank rules, loading fee-schedules, reprocessing claims, and creating cost analysis.



ACS

• Netherlands
• IT Services and IT Consulting
• 1 - 100 Employee

• Account Implementation Data Analyst

  • Apr 2006 - Apr 2009

  Richmond, Virginia, United States • Planned and directed the set-up, implementation and maintenance of new customer accounts for clinical products and internal auditing. • Performed in-depth analysis of new source data and generated database mapping documents and data translation logic for programming team. • Executed ad-hoc SQL queries to research data problems and customer inquires. • Collaborated with business partners, programmers and DBAs to implement data resolutions. • Created and maintained metadata for… Show more • Planned and directed the set-up, implementation and maintenance of new customer accounts for clinical products and internal auditing. • Performed in-depth analysis of new source data and generated database mapping documents and data translation logic for programming team. • Executed ad-hoc SQL queries to research data problems and customer inquires. • Collaborated with business partners, programmers and DBAs to implement data resolutions. • Created and maintained metadata for new and existing clients. • Coordinated and updated data load information for clients and data exchange partners. • Completed post implementation data validation. Show less



Anthem Blue Cross Blue Shield

• 1 - 100 Employee

• Senior Programmer Analyst

  • Jul 1994 - Apr 2005

  Richmond, Virginia, United States • Researched and defined business requirements involving the Amisys claims processing system. • Performed analysis and design, developed code and performed extensive unit and system testing. • Tracked and resolved defects, performed implementation and supported systems and end users. • Conducted database development and maintenance and performed root cause analysis. • Generated data mapping for fee-schedule updating, third party Medicaid claims transmission and data warehouse… Show more • Researched and defined business requirements involving the Amisys claims processing system. • Performed analysis and design, developed code and performed extensive unit and system testing. • Tracked and resolved defects, performed implementation and supported systems and end users. • Conducted database development and maintenance and performed root cause analysis. • Generated data mapping for fee-schedule updating, third party Medicaid claims transmission and data warehouse research. • Constructed application to automate multiple manual processes for physician credentialing which greatly improved usability and information delivery for credentialing team. • Built complex application to update multiple fee-schedules to accurately apply rates during claims adjudication. • Served as technical resource for the Bureau of Insurance (BOI) audit and the HP3000 System Disaster Recovery Project. • Served on Quality Control Committee for 5 years. Championed permanent solutions for production problems and implemented standards and procedures to ensure development of quality systems. Show less



Virginia Blood Services

• United States
• Pharmaceutical Manufacturing
• 1 - 100 Employee

• Programmer Analyst

  • Feb 1991 - Jul 1994

  Richmond, Virginia, United States • Performed detailed analysis of user requests, developed requirements definition, technical design and programming specifications. • Developed/modified code and documented all programming changes. • Performed extensive unit testing and debugging to be fully compliant with FDA requirements. • Provided Help Desk support for hardware, software and system problems and questions.



Circuit City Stores, Inc.

• United States

• Sr. Store Support Coordinator/Analyst

  • Dec 1987 - Jan 1991

  Richmond, Virginia, United States • Liaison between users, vendors, service technicians and technical associates providing information, solutions and escalation of all problems involving the Point of Sale Systems, HP3000 activity for store problems and system aborts and errors. • Followed up on all problems to ensure prompt problem resolution. • Created detailed documentation on Help Desk procedures, problems and resolutions which was subsequently used to create the Help Desk Procedures Manual. • Documented all… Show more • Liaison between users, vendors, service technicians and technical associates providing information, solutions and escalation of all problems involving the Point of Sale Systems, HP3000 activity for store problems and system aborts and errors. • Followed up on all problems to ensure prompt problem resolution. • Created detailed documentation on Help Desk procedures, problems and resolutions which was subsequently used to create the Help Desk Procedures Manual. • Documented all problems including IBM System 36/38, AS/400 and HP 3000 job failures. • Generated ad hoc AS/400 queries and performed database maintenance. Show less