Experience

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  Friendswood arms nursing home

  Jan 1980 - Jan 1983

  Patient care technician

  Provided patient care to geriatric patients

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  Pasedena bayshore hospital

  Jan 1983 - Jan 1984

  Rn

  Floor nurse for Pediatrics

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  American general life and accident

  Jan 1984 - Jan 1986

  Auditor

  Auditor for Worker Compensation, Liability and Automobile insurance policies through American General. Prior to the auditing position worked in file room and responsible for filing and auditing of all insurance files.

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  Prudential insurance

  Jan 1986 - Jan 1991

  Lofa coordinator

  Prior to moving to IT was in Claims as a Claims lead handling COB claims and training new associates. IT started to work on development of a new Provider Contracting System and was moved to assist with project. Worked as the Library of Financial Contract (LOFA) Lead representing the Business side. Developed a National Training Program and performed audits of the provider contract setups for each of the national sites. Performed research on provider trends happening in the marketplace and provided recommendations and observations back to each of the provider Healthcare Sites and Business Units to help improve efficiencies and cut costs. Show less

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  Prudential healthcare

  Jan 1991 - Jan 1996

  Training/auditing coordinator

  Developed, Coordinated and facilitated training for all of Prudential Group departments on the provider contracting system (Library of Financial Arrangements (LOFA)). This training was used at a National Level for all of Prudential's Group Provider Contracting offices. Main responsibilities included the development and training of the LOFA system, Audit of provider contracts loaded in LOFA as well as providing observations and recommendations back to the business entities. Also provided financial statistics of errors configured in system. Show less

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  American heritage life insurance

  Jan 1996 - Jan 1998

  Model office support and system trainer

  Worked as Part of the Group Health Plan Organization and worked in the Model Office/Production Support Office. Responsible for Production Support Issues for both Legacy Claims and Facets Claims. Expertise in Benefit Configuration and setup of the Facets Claims Operating system. Responsible for development of all training curriculum, lesson plans, and training guides for both Configuration Analysts as well as Claims Analysts on Facets. Trainer for Benefit, Provider Demographic, Provider Pricing, Capitation, Commissions, Billing, Group, Sub Groups, Class Plan, Membership, Utilization Management, Customer Service, and Grievance and Appeals configuration of Facets. Trainer for Claims Processing, Customer Servicing Call Logging, Appeals Logging and Utilization Management Authorization and Referral Loading on Facets. System training on Facets Managed Care System. Support role in the Model office (Production Support) handling configuration changes/error resolution and implementation of new benefit products, and provider agreements Show less

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  Highpoint solutions (formally known as tmi, daou, proxicom, and aptiv technology partners)

  Mar 1998 - Oct 2014

  Managing director, payer systems

  Responsible for building out a Payor practice focused around services to support "Configuration" and "Core Claim Systems". Responsibility for Executive level oversight, Healthcare Professional Service resources (Contractors), Budget Planning, Resource Management, Performance Management, Hiring, and Scope Management of Projects. Have demonstrated expertise with Facets (Claims processing system) and experience with various other claims processing systems (QNXT, Health Edge, AcceleHealth, Amisys, etc.). Have been involved with over 50 Facets new implementations and over 20 migrations from one system to another. Responsible for the development of methodology and tools used to support various service offerings including system implementations/upgrades, configuration assessment/audits, operational assessment/audits, claims audits, business process redesign/alignment, healthcare management, testing, configuration and operational trainingExpertise: Developing and execution of strategic plans and goals, oversight/managing/assessing future state and growth initiatives, analyzing/evaluating the needs of Health Plans, payors, providers and hospitals configuration system and or business requirements. Standard Operating Procedures (SOP), User Guides/Business Process/Flows to support each functional area. Known for Root Cause and Lesson Learned initiatives to help reduce re-work and improve overall efficienciesHeld various leadership positions, business management, business operations, information systems, customer service, claim administration, benefit plans, provider contracting, business process redesign, general management and training across all Healthcare lines of business, and Provider Healthcare organizations.HighPoint Solutions formally known as TMI, Daou, Proxicom and Aptiv Technology Partners. Show less

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  Unitedhealth group

  Aug 2015 - Oct 2019

  Director benefit configuration

  Have demonstrated experience with Facets (Claims processing system). Have been involved with over 50 Facets new implementations and over 20 migrations from one system to another. Director over Benefit configuration which entailed end to end configuration of the benefits to support the Health Plans claims operations and Utilization Management system. Requirements, Design, Construction/Build, Testing, Training, Production, Production Support. Responsible for team of over 45 analyst supporting the United Health Care Group Medicaid/Medicare/Dual Enrollment Groups. The Benefit configuration team was leaders in all root cause analysis, issue resolution, Change Management Governance, Communication Governance, Testing (Proof of Concept/UAT/Integrated), and Training. Led development of tools and methodology to support the teams and the best practices. Documentation and Training team reported through to my team as well as the benefit configuration team. Led all joint efforts with other functional teams; Provider, Pricing, Membership, Billing, Commissions, Capitation, Finance, IT.Responsible for Budget Planning, Resource Management, Performance Management, Hiring, Scope Management of Projects. Expertise includes: Developing and execution of strategic plans and goals, oversight, managing, and assessing future state and growth initiatives, analyzing and evaluating. Standard Operating Procedures (SOP), User Guides and Business Process and Flows, for each functional area. Known for Root Cause and Lesson Learned initiatives to help reduce re-work and improve AA. Show less

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  Parrish medical center

  Oct 2018 - Oct 2019

  Clinical quality facilitator

  As the Clinical Quality Facilitator responsibilities include managing numerous quality initiatives with the Florida Health Network (FHN) provider practices. This includes:*. HEDIS/STAR -"Gaps in Care" Quality Management* Medicare Risk Adjustment (MRA) and patient risk score management*. Physician Quality Reporting System (PQRS) measures and reporting* Meaningful Use Measures and reporting*. Patient Centered Medical Home (PCMH)* TeamSTEPPs Master Certified Trainer and implementation managementWork collaboratively with various teams and Provider practices to help with integrated solutions. Resource to assist with project management, education, understanding and establishing of quality initiatives. Responsible for the development of methodology and tools used to support various services handled within the Quality Review Management Department of FHN. Tools included *HEDIS/STAR tracking Measures for PCP and OutPatient Providers, Reporting tools for PQRS, PCMH, TeamSTEPPS, Business Process Redesign/Alignment, Operational training.Expertise: Developing and execution of strategic plans and goals, oversight/managing/assessing the needs of Health Plans, payors, providers and hospitals requirements, Standard Operating Procedures (SOP), User Guides/Business Process/Flows to support each functional area. Known for Root Cause and Lesson Learned initiatives to help reduce re-work and improve overall efficiencies. Show less

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  Clearlink partners

  Oct 2019 - Jul 2021

  Vice president of core system transformation services

  Have demonstrated expertise with Facets (Claims processing system) and experience with various other claims processing systems (QNXT, Health Edge, AcceleHealth, Amisys, etc.). Have been involved with over 50 Facets new implementations and over 20 migrations from one system to another. Responsible for the development of methodology and tools used to support various service offerings including system implementations/upgrades, configuration assessment/audits, operational assessment/audits, claims audits, business process redesign/alignment, healthcare management, testing, configuration and operational trainingExpertise: Developing and execution of strategic plans and goals, oversight/managing/assessing future state and growth initiatives, analyzing/evaluating the needs of Health Plans, payors, providers and hospitals configuration system and or business requirements. Standard Operating Procedures (SOP), User Guides/Business Process/Flows to support each functional area. Known for Root Cause and Lesson Learned initiatives to help reduce re-work and improve overall efficienciesHeld various leadership positions, business management, business operations, information systems, customer service, claim administration, benefit plans, provider contracting, business process redesign, general management and training across all Healthcare lines of business, and Provider Healthcare organizations.. Show less

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  Unitedhealthcare

  Jan 2021 - now

  Associate director
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  Unitedhealthcare community & state

  Jul 2021 - Nov 2022

  Capability manager

  Capability Manager for Implementation of Delegated Contracts. Responsible for the program management of yearly implementation of Delegated Contracts for Community and State (Medicare/Medicaid)