Jessica Claire
Montgomery Street, San Francisco, CA 94105
Home: (555) 432-1000 - Cell: - - -
Highly motivated Sales Associate with extensive customer service and sales experience. Outgoing sales professional with track record of driving increased sales, improving buying experience and elevating company profile with target market.
Work History

Billing NASCO Department ,
  • Guest services
  • Inventory control procedures
  • Merchandising expertise
  • Loss prevention
  • Cash register operations
  • Product promotions
01/2015 to Present
IT Project Manager, II Advance Auto Parts Columbia, SC,
  • Functional Manager of the Core Development, Core Test and Development Operations Teams.
  • Manage core developer activities including code reviews, and support to development teams; DBAs in schema reviews of current development projects/releases.
  • Management of Core Test Team staff and activities related to 508 and performance testing, and metrics.
  • Manage operations team that consists of system administrators, DBAs, release managers, a small help desk, IBM WAS administrators and IBM Message broker administrators.
01/2014 to 01/2015
IT Project Manager, II Advance Auto Parts Gastonia, NC,
  • Provide technical project management support under the CICDIM umbrella for the Center for Medicare and Medicaid Innovation (CMMI) Model Demonstrations.
  • Manage all aspects of the CICDIM SDLC and PMLC from project inception to project close-out.
  • Major projects include: ACO Investment Model under Accountable Care (reference payment aco model), and the Health Plan Innovation Initiatives Model (reference plan innovation), led the Requirements Tiger Team for the CMS Partner Collaboration Site, and most currently building/running the DevOps Team for the Health Services Business Unit.
  • Oversight of Business and System Analysts, and development staff activities as projects require using the XLC framework for development and delivery of project artifacts.
  • This includes but is not limited to all project management artifacts, oversight of business and system requirements as appropriate, oversight of development activities, test case builds and testing activities.
  • Successfully implemented repository for the ACO Investment and the Health Plan Innovations Models in cloud domain (Salesforce).
  • As part of a capture assignment, wrote the past performance section of the RFP that won ActioNet a place on the CMS Strategic Partners Acquisition Readiness Contract (SPARC).
  • Current task - Functional Manager of DevOps building an infrastructure and process to support multiple contracts and development projects under the Health Services umbrella.
  • These include but are not limited to: the CMS Center for Medicare and Medicaid Innovation (CMMI) Consolidated Innovation Center Development and IT Management (CICDIM) contract, National Provider Identifier Clearinghouse System (NPICS), FDA, and the Financial Information and Vouchering System (FIVS).
01/2011 to 01/2014
Project Manager Microsoft Corporation Carpinteria, CA,
  • Provided technical, administrative, and operational leadership to assigned projects including contract and sub-contractor management.
  • Managed multiple projects using SDLC, PMLC and CMMI protocols in a matrix environment.
  • Developed tools and documentation to assist the Project Management Team.
  • Major projects included the development of a data repository in the Integrated Data Repository (IDR) for Medicare Part D, and the build of processes to enhance the Part D Manufacturers Invoice.
  • Creation of technical project plans for four system enhancement releases a year, four Manufacturer Quarterly invoices, and any other system development projects.
  • Oversight of the entire project life cycle from requirements to implementation.
  • Participate in the development of proposals, reports, and administrative reporting.
  • Perform high level technical services on assigned tasks.
  • Conduct planning meetings with the client, CMS (Centers for Medicare and Medicaid Services) and provide recommendations to the client on task/release workload.
  • Attend customer meetings, including facilitation of JADs, and serve as the primary client liaison where needed.
  • Coordinate development of deliverables and products.
  • Maintain current and historical project documents in SharePoint repository.
  • Present regular status reports to communicate to all stakeholders, from staff to the Deputy Director.
  • Review future project requirements and develop strategies for future work.
01/2008 to 01/2011
Corporate Systems Manager Danaher Little Rock, AR,
  • Large Group ASU Manage a staff of 60 associates in the migration of 250 large group accounts from legacy systems to NASCO and Facets products, and the implementation of new account electronic enrollment files and subsequent maintenance/production support.
  • Additionally, was responsible for the oversight of two functional areas, Eligibility and Billing.
  • Develop the Large Group Business Unit Strategic Plan for the Billing and Enrollment areas.
  • Oversight of Large Account Migrations (from legacy systems -EAB and Facets 4.3 to NASCO, MembersEdge, and Facets 4.7 ), as well as the implementation of all new or renewing Large Account EDI, ensuring project deadlines consistently met.
  • Oversight of the Enrollment Eligibility, and Billing Teams for the Large Group book of business.
  • Control resources and workload(s) ensuring timely completion of corporate initiatives and day-to-day deliverables, from requirements through testing of multiple applications to 4 disparate systems, utilizing 26 vendors and 10 layouts.
  • Facilitate the business / IT priority meetings and monitor/control approved work objects for the Large Account/Enrollment lines of business.
  • Work with NASCO project team in development and implementation of all project phases of the Large Account data migrations ensuring project plan detail is refined and executable.
  • Development of the 5 year strategic business plan for the areas in my purview.
  • Report on progress of deliverables against the strategic business plan to executive management up to and including the CEO.
  • Identify and report risks and issues to executive level management.
  • Conduct analysis and formulation of process and practice improvement recommendations.
  • Monitor service level agreements (SLAs), adjusting processes to ensure SLAs are met.
  • Conduct JADs with the client(s) and/or provide support on any day-to-day issue resolution.
  • Coordinate with Claims and Coordination of Benefits areas to ensure accurate adjudication of claims and subrogation claims.
  • Oversight of monthly reconciliation of eligibility data to accurately issue invoices/bills to Large Group Clients.
01/2007 to 01/2008
Sr. Project Manager/Lead Business Analyst Trissential New York City, NY,
  • Medicare Advantage Corporate initiative for the foray of CareFirst into the Medicare Advantage (MA) market, working with Highmark Blue Cross/Blue Shield as the outsource vendor for enrollment and claims processing for the MA product.
  • Oversee the transition of the project to day-to-day.
  • Includes the following areas/functions: subrogration/third party liability, medical authorizations, claims, enrollment, and sales.
  • Facilitate weekly meetings between vendors, and all impacted Highmark and CareFirst operational areas.
  • Facilitate weekly stakeholder meetings between Highmark and CareFirst Executive staff and Compliance Office(s).
  • Report on transition activities and status to executive leadership.
01/2004 to 01/2007
Corporate Systems Supervisor Cushman & Wakefield Inc Stuart, FL,
  • Ops Tech Support/Automated Enrollment Supervise a staff of 13 Business Analysts, responsible for the implementation and day-to-day production support of electronic enrollment.
  • Within the confines of a matrix environment, provide support or lead all corporate initiatives involving electronic enrollment data.
  • Coordination of all commercial electronic enrollment across all platforms (EAB, FACETS, and NASCO), and the renewals of all electronic accounts.
  • Coordination of staff with relation to corporate initiatives and on-going day-to-day production support and account renewal activities.
  • Monitor and report on actual project implementation/renewal results vs.
  • planned results to executive management.
  • Develop business requirements, business system design, and process modeling documents, ensuring all requirements meet test scenario criteria.
  • Coordination of all production moves.
  • Communication and/or Training of operations personnel/end users on expected process changes when an account moves from manual to automated enrollment.
  • Development of Business Analysts in mapping, functional, business and system requirements, testing methodologies, and overall communications with internal and external parties.
  • Scheduling/coordination of renewal files with d2d updates.
  • Participate in weekly calls with IT to prioritize and schedule the promotion of system change requests and new accounts in the automated enrollment job streams.
01/2003 to 01/2004
Sr. Project Manager American International Group Bakersfield, CA,
  • Ops Tech Support/Automated Enrollment Manage a group of 5 Business Analysts in the implementation of electronic enrollment interfaces and of subsequent maintenance of electronic enrollment files.
  • Responsible for regulating all vendor/external party enrollment and reconciliation file transmissions.
  • Operationalization of the HIPAA 834 and 820 datasets.
  • Conduct Project Requirements Reviews.
  • Development of testing methodology and procedures for the team, development of mapping and error tracking documents.
  • Lead JAD sessions for documentation of user requirements.
  • Document user requirements, user acceptance criteria/test scenarios and obtain sign-off at completion of testing phase.
  • Conduct system testing and document results including internal and external user acceptance testing.
  • Control end to end testing process, using SDLC guidelines, for HIPAA 834 and 820 Trading Partners and approximately 50 proprietary layouts to 3 legacy systems.
  • Conduct or oversee all communications regarding requirements, testing and production promotions with internal and external customers.
  • Coordination / management of all production promotions.
  • Regulate the number of trading partners testing the HIPAA 834and 820 transaction sets with CareFirst.
  • Oversee training of end users.
01/2002 to 01/2003
Project Coordinator/Business Analyst Unity Health Insurance Wi, WI,
  • Function as HIPAA liaison for the CareFirst affiliates to ensure all affiliates are HIPAA compliant for the privacy and electronic transaction components of the HIPAA regulations.
  • Review existing processes of the NASCO Business Area and the BCBS Association ITS process.
  • Define business requirements for implementation of the X12 HIPAA Transactions and Code Sets to be received through the CareFirst architecture and routed to NASCO and ITS; negotiate and present recommendations for automated solutions (and manual solutions if necessary).
  • Analyze and interpret the EDI trace reports of 834 submitters and provide the analysis and ongoing support to our third party and direct submitters.
  • Assist with validation of the X12 834 enrollment transactions.
  • Analyze and interpret the EDI trace reports of electronic CareFirst 837I and P Medicare Crossover Trading partner claims submitters and provide the analysis and ongoing support to the Medicare Crossover Trading Partners as well as provide analytical support to the HIPAA Technical Delivery Leads.
  • Assist with the development of HIPAA Transactions and Code Sets Gap Analysis and Business Requirements for internal CareFirst departments and its affiliates.
  • Provide on-going internal and external customer support as related to any and all transactions.
  • Track issues resolution to completion.
  • Develop Ad-hoc reports as needed.
  • Database set up and management for the Business Relationships Team for all incoming client questions related to HIPAA Transactions and Code Set compliance.
  • Assist in development of SOPs for CareFirst and Affiliates for System/Process enhancements for HIPAA TCS and Privacy compliance.
  • Collaborate in development of training aids/tools for Privacy implementation.
  • Participate in definition of business and IT requirements for Privacy implementation.
01/2001 to 01/2002
Supervisor Petco Longmont, CO,
  • Manage staff of 25 associates; oversee all aspects of enrollment and billing to the NASCO platform for CareFirst Maryland and DC.
  • Manage budget in excess of $1,000,000 annually.
  • Support claims, customer service and sales departments by handling problem resolution requests from customer service and/or claims timely and accurately.
  • Attend client meetings with sales representatives, as necessary, to resolve issues, prepare for enrollment set-up or changes for new or renewing accounts, and educate clients on the automated enrollment process when applicable.
  • Provide clients with follow up support to ensure absorption of training and integration of maintenance process of automated enrollment error resolution.
  • Forecast and subsequent management of annual budget, reporting discrepancies/variances on a monthly basis.
  • Identify and execute process improvements for the enrollment and billing functions in my purview, incorporating the training department for development of new materials and classes as necessary to ensure staff developed to meet current and upcoming business needs.
  • Plan 1 - 2 years in advance to meet account renewal or new account service guarantees.
  • Keep accurate statistical records, providing daily and weekly reports of unit productivity / efficiency, and report NASCO accomplishments and outcomes of special projects to Director Level and above.
  • Collaborate with Finance department to report on and resolve accounts receivable issues as related to NASCO, as well as reconciliation of account information to the general ledger.
  • Work closely with technical support staff on resolution of automated enrollment file process issues and identifying improvements.
01/1996 to 01/2000
Claims Supervisor Magellan Behavioral Health City, STATE,
  • Manage a staff of over 40 employees and a membership of over 2,500,000 lives.
  • Establish day-to-day workflow and monitor employee production and quality to consistently meet account performance requirements.
  • Recruit claims candidates and coordinate all phases of training for claims personnel.
  • Establish controls for maintaining claims inventory; thereby, reducing average process time for claims from 45 days to less than 7 days.
  • Work with EDI on resolution of IPDR for two major accounts and also to automate IPDR process for Capital Blue Cross Account.
  • Assist Regional Service Center in GA in reducing average response time for CSR's by setting up an adjudication process at the local level.
  • Work in partnership with SCA consultants and other members of the management team to develop and successfully implement capacity planning strategies. Enforcement of department procedures and policies; with development of policy at the unit level.
  • Collaborate with MIS staff on a regular basis to enhance workflows and reporting requirements.
  • Streamline department reports for associate, supervisory and managerial staff.
  • Analyze and rank the positions within the unit; thereby establishing promotion criterion.
  • Evaluate, document and communicate employee performance on an on going basis and on a formal basis, semi-annually.
01/1989 to 01/1996
Claims Examiner/Supervisor/Manager Admin American Corporation City, STATE,
  • Recruit workforce and oversee all aspects of business operations; including claims and administrative personnel, training, auditing, system network and fiduciary responsibilities.
  • Assist in the development of corporate policy.
  • Implement and enforce corporate policy and policy changes through lectures, demonstrations and performance exercises for the entire firm.
  • Execute daily network back-ups and trouble-shoot any network problems.
  • Implement all new accounts; including set up and maintenance benefit tables and benefit parameters for all clients; execution of all testing of benefits and automated enrollment feeds to external pharmacy benefit managers.
  • Additionally, set-up and maintained the interface with the client re-insurer, mapping client data to re-insurer and pharmacy benefit manager report formats, and oversaw delivery of those files.
  • Educate clients through employee benefit meetings and assist with employee benefit seminars.
  • Coordinate requests for medical and utilizations reviews with sub-contracted utilization review firms and consultants.
  • Develop, execute and deliver client reports as required under ERISA, including those to the account re-insurers.
  • Schedule and supervise all claims correspondence and check runs.
  • Balance monthly enrollment billing against client records.
  • Develop audit procedures for the claims department.
  • Resolved questions and concerns from members, providers and Plan Trustees.
  • Verified benefits and eligibility of members according to the provisions of the contract.
01/1988 to 01/1989
Claims Examiner Blue Cross/Shield Of MD City, STATE,
  • Adjudicated major medical claims for multiple lines of business with an error ratio of less than 2%.
01/1985 to 01/1988
Partner AllClaims Filing Service City, STATE,
  • Set up a partnership in which each owner procured clients.
  • Assisted the over 65 and disabled population with filing medical insurance claims to Medicare and all secondary insurance with both individual and group plans.
  • Kept accurate records of all eligible benefits and any benefit plan changes in order to ensure the client received the maximum benefits available under the CA state insurance laws.
Education and Training
Expected in
Bachelors of Science: IT
- ,
IT Certified Scrum Master (cert) SQL for Access ITIL Foundations Workplace Conflict Delegating for Results SMART Performance Plans Hiring the Best SDLC/PMLC Process Analysis/Re-engineer Microsoft Office Suite CMMI for Development v1.3 Agile for Business Requirements and Product Backlog CMS Expedited Life Cycle (XLS) 2
accounts receivable, administrative, Streamline, Ad, Agile, auditing, automate, Balance, Benefits, Billing, book, budget, Develop business, business operations, business plan, capacity planning, CMS, CA, contracts, client, Clients, client liaison, customer service, customer support, Database, DC, Delivery, documentation, EDI, engineer, executive management, filing, Finance, Financial, Functional, general ledger, help desk, HIPAA regulations, Hiring, html, http, IBM, Innovation, insurance, inventory, IT Management, ITIL, leadership, MA, Director, managerial, market, materials, meetings, Access, Microsoft Office Suite, Office, SharePoint, migration, MIS, network, developer, personnel, policies, development of policy, problem resolution, Process Analysis, processes, process modeling, progress, Project Management, project plans, promotion, proposals, protocols, quality, reporting, RFP, sales, Scheduling, Scrum, SDLC, seminars, service level agreements, SQL, Strategic, SPARC, supervisory, system design, tables, technical project management, technical support, Tech Support, trouble-shoot, validation, workflow
Activities and Honors

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