Proactive, performance-driven professional with 18+ years of progressive expertise in leadership and problem solving for healthcare service companies.

Maintain an impressive record of leveraging resources to meet diverse business demands and deliver cutting-edge technical solutions. Cross-functional communicator easily interfaces with high-profile staff, vendors, and customers. Versatile, innovative, and loyal management professional able to see the "big picture" while staying on top of all the details. Recognized for consistent success in developing solutions to streamline operations and enhance revenue performance.

Most recently worked as IT Manager for a leading healthcare company. Responsible for application architecture & development and business analysis. Acting as primary liaison between business operations and IT PMO on major company initiatives.

Skilled in overseeing the daily operations of the IT development and analysis staff Strong at immediately addressing unexpected events and creating solutions Expert in coordinating IT projects with departmental projects in an Agile Environment Expert in providing the technical experience to streamline operations for maximum efficiency Able to evaluate new technologies that will improve productivity and/or reduce costs Capable of working alone or with team members to solve problems Exceptionally skilled at translating business needs to deliver successful IT solutions

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Healthcare Operations Project Management Client Relations Change Management Quality Assurance Resource Management Strategic Planning Application Architecture Workflow Process Analysis Application Development Database Design Data Mining & Analysis

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Microsoft Visual Studio.NET Microsoft SQL Server Database and Tools (SSIS/SSRS) Microsoft IIS Configuration and Management Open Source Tools (Linux/Apache/MySQL) Microsoft Visio Microsoft Project Microsoft Office Suite (Word/Excel/Powerpoint/Access) Microsoft BizTalk Microsoft Sharepoint Edifecs Adobe Photoshop

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Experienced in all levels of managed care. Work closely with company leadership and provide solutions for CMS measures and compliance. Well educated in STAR measures, Clinical Quality Measures (P4P), Risk Adjustment, Health Insurance Portability and Accountability Act (HIPAA), and Sarbanes-Oxley (SOX) Compliance.

Cal Medi-Connect Duals Demonstration Implementation Core contributor and member of the team responsible for implementing the new Cal Medi-Connect Duals Demonstration Program. Lead the architecture and development of over 30 interfaces and applications to support the seamless and timely flow of information when integrating into existing Medicare Advantage infrastructure. Design processes to enable the business to manage, process, and report on data received in multiple formats, frequencies and from two separate government entities (DHCS & CMS). Work primarily on enrollment processing, provider assignment, continuity of care (COC) and split claims payment. Design the architecture for the processing and management of supplementary duals services such as Long Term Service Support (LTSS) and Behavior Health.

Wellpoint Corporate Integration to CareMore Project Manager for the IT integration team and development of solutions to enable smooth integration and data exchange with Wellpoint after our company was purchased in 2012. Provide guidance on full integration of Operations, Finance and Human Resources. Work closely with executive leadership on both CareMore and Wellpoint sides to make this possible.

Facets Implementation Manage the development/analysis teams through a difficult process of a full lifecycle implementation of Facets (new claims payment system) and migrating the company from EZCap. Developed over 60 interfaces, including a new eligibility management tool using the Facets keyword batch loading process. Also, lead the gathering of business requirements and educating operational leads of the functionalities and limitations between the two systems.

Medicare Risk Adjustment (HCC) Data Mining Complete architecture and development of data mining process identifying Medicare Risk Adjustment Diagnosis for PCP, specialists, groups, procedures and disease groups allowing easy identification of company areas of improvement. Key member of Medicare Risk Adjustment recovery team. Develop and operate applications to effectively identify claims with diagnosis that were not coded to the highest specificity of HCC value, which contributes to the members Risk Adjustment Factor (RAF) Score. Work with senior executives to develop a strategy for increasing revenue from Medicare membership including monitoring both PCP and Specialist encounter data. Design and development of remote Medicare Chart Review auditing tool with ASP.NET. This allows coders in the field to access patient claims data and chronic disease lists while in satellite offices during patient chart reviews. Since early 2013 have been designing the migration to the new CMS Encounter Data Processing System (EDPS).

Provider Ranking (Access Express Portal Extension) Design and development of an interface extension to interact with an industry leading provider portal to categorize, give ranking structure, and enable grouping of PCP providers with a defined prioritization and hierarchy. Along with this, designed a new interface feed to link Access Express to Facets which is not a standard functionality. The Provider Ranking interface integrates with this refresh process to provide the ranking tiers for a provider record inside Access Express.

Claims Automation Process automation for releasing claims to A/P and generating check runs to enable outsourced check printing and mailing using EZCAP using SSIS, VB, and PGP. Author of many scripts for auto-closing encounters, linking authorizations, and pre-auditing claims for coding errors. Generate electronic check and EOB extract to provide to external print vendor allowing batching and bulk mailing of provider correspondence.

Patient QuickView Design and development of web application in ASP.NET with web services to consolidate several core data systems to present a single point of entry to all patient information via a single interface. Data consolidated from multiple platforms for claims system, UM portal, NextGen EMR, Pharmacy, Labs, and Clinical Quality Measurements. Allows the view of entire collection of patient information to be viewable and searchable via single application, improving performance measures from individual contracted providers. This service is extended to external contracted providers and groups as well as integrated to Access Express portal, therefore, extending the view of patient information to all referral requesters and providers.

EMR/EMP Nextgen Implementation Working in coordination with corporate practice management team, designed a migration tool to migrate from MEDIC to Nextgen. Studied the data dictionary of Nextgen system and became expert on the functionalities, features and limitations. Assist the business leadership in mapping out the strategy for managing patient information and processing encounters and payable claims for submission to EZCap (and later to Facets).

Medication Therapy Management (MTM) Working with Pharmacy Director, developed application for the management and reporting of pharmacy data. Application allows us to receive our data from contracted PBM and merge to enrollment system and Rx Redbook to create reportable dataset. Primary function of this application was two-fold, one to allow pharmacy reps to track and maintain outreach to patients regarding their medication therapy management; and the other was to enable timely and accurate statistical reporting to adhere to CMS MTM compliance.

Outsourcing Implementation Lead IT member to the automation team and technical liaison in support of the company's outsourcing initiative to offshore partners. Report directly to senior executives on all strategic and financial decisions. Traveled abroad acting as architect and trainer assisting in the education of operational staff in IT, Claims, Enrollment, and Utilization Management. This outsourcing effort has developed over time into a large outsourcing business that is still growing today.

Credentialing (CPPA) Application Design and development of desktop application to generate, manage and store provider credentialing information. This includes forms for generating completed CPPA credentialing certification (both initial and recertification). A later addition was a web enabled CPPA application allowing providers to complete their credentialing certification online and map data elements to core administrative systems. This application was developed in VB6 with SQL server database.

PhysicianQuest.com Healthcare internet startup in 2000 which was a subsidiary of Network Medical Management. Working with Company leadership to design an online provider portal enabling physicians and staff to have online access to patient data, email, and submit data to parent management company (Claims, auth requests, and enrollment verification). Web application built on Apache/PHP/MySQL platform.

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JRoss Consulting, LLC. Glendora, CA
President	Apr 2014 - Current
Independant Healthcare IT Consulant.

Wellpoint Corporation (CareMore Health Delivery System). Cerritos, CA
IT Manager, Application Development	Feb 2007 - Aug 2014
Lead the IT architecture and development through every major transformation from EMR implementation, migration to a new claims payment system, integration with parent Wellpoint company after purchase, and large implementation project for Cal Medi-Connect Duals Demonstration Program. Manage diverse team of Project Managers, application developers, and Business Analysts, including over 30 offshore personnel. Lead the efforts in business requirements, application architecture and organizational expansion, while also doing hands-on development when additional programming resources were required. Internally managed a seasoned professional development team of 6, which included with me combined for over 125 years of industry experience. Worked diligently to educate and advance the careers of my subordinates, firm but fair and lead by example.

Network Medical Management (Allied Physicians). Alhambra, CA
Manager of IT/Eligibility/Terms & Conditions	Dec 2005 - Feb 2007
Returned to NMM to assist CEO and COO in a organizational restructure after purchase of the company. Served as IT Manager and ultimately becoming Technical Director. Responsible for reporting directly to new board of directors and had oversight of three departments (IT, Eligibility, Terms & Conditions). Worked diligently to streamline processes, system cleanups (both configuration and data integrity), and implemented new policies and processes for more efficient workflows.

Physician Associates. Pasadena, CA
Consultant (Financial Operations)	Apr 2005 - Dec 2005
Lead revenue analysis/recovery team, benefit interpretation, and division of financial responsibilities with health plans. Key member of Medicare Risk Adjustment recovery team. Developed and operated applications to effectively identify claims with diagnosis that were not coded to the highest specificity of HCC value, which controls Medicare reimbursement. Worked with senior executives to develop a strategy for increasing revenue from Medicare membership including monitoring both PCP and Specialist encounter data, development of PCP/Specialist Risk Adjust Diagnosis Reference Cards. Participated in education of both providers and office staff to improve quality of care for our seniors. Automation of Health Plan Benefits, automation of company Division of Financial Responsibility (DOFR) tables. Developed data mining process for identifying Medicare Risk Adjustment Diagnosis for PCP, Specialists, or targeted providers, groups, procedures or disease groups allowing easy identification of company areas of improvement. Developed application to calculate projected Risk Adjust scores to enable more accurate estimation of health plan reimbursement.

Heritage Provider Network/Regal Medical Group. Northridge, CA
Consultant (Financial Operations)	Jul 2004 - Apr 2005
Rebuild of Crystal Report Library to include financial analysis and claims auditing statistics. Additionally, worked on Medicare Risk Adjustment project for disease management and diagnosis coding in regards to senior membership. Created VB application in conjunction with Crystal Reporting to identify, extract and monitor diagnosis codes that were not coded to the highest level of specificity. Developed a Crystal Report Viewing application with both desktop and web-based report viewing which allows the viewing of reports without requiring additional Seagate Crystal Licenses.

Network Medical Management (Allied Physicians). Alhambra, CA
Application Developer/IT Manager	Jun 2000 - Jul 2004
Started as Web Developer and progressed quickly to IT Manager. Responsible to reporting technical information to the company board of directors, and senior management. Responsible for all aspects of internet technology for the company of 120-160 users. Lead a team of eleven IT personnel in a fast paced, very diverse department overseeing such areas as network security, database administration, helpdesk, network administration, programmer/analysts and application development. Responsible for maintenance/security/integrity of EZCAP servers and report servers. Key member of the automation team and technical liaison in support of the company's recent outsourcing initiative to offshore partners. Report directly to senior executives on all strategic and financial decisions that are IT related. In addition, assumed role as project manager for offshore software development ventures. Created numerous database management and extraction tools to monitor progress and accuracy of offshore data processors. Strong knowledge in managed care in the areas of Utilization, Claims, Credentialing, and Membership Enrollment using EZCAP system. Additionally, served as Company's HIPAA Security Officer. Project Manager for all internal application developments in support of company operations.

United States Marine Corps. Honolulu, HI & Okinawa, JA
	Jun 1990 - Jun 2000
Served 10 years in Marine Infantry as primary (secondarily administrative and communications). Spent 5 years abroad at which time attended University of Maryland (Far East Campus), and served 2 years in Marine Force Recon Company. Decorated Marksman, spending 2 seasons in Marine Corps shooting competition, decorated with both team and individual metals at the Marine Corps and Interservice level. Recognized for Overseas service, Navy Commendation, Good Conduct and multiple awards of Rifle/Pistol marksmanship expertise. Graduated from Army Air Assault school, Korean Ranger School and served 2 years as a Primary Marksmanship Instructor. Member of Marine Security Forces in Honolulu, Hawaii, and served headquarter tour of duty in office of Division Inspector. Honorably discharged at the Rank of Sergeant and held top secret security clearance.

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