Veterans Preference N/A
Federal Status Health Insurance Specialist GS-0107-14
Health care management professional with close to 30 years of private and public sector experience in leading implementation of legislative directives and program changes to meet organizational goals and developing administrative and technical infrastructure and innovative process redesign to achieve high quality and efficient service delivery at a lower cost. Present a unique skill of understanding the provider as well as the Health Plan (Medicare) needs and developing solutions that benefit both. Works extremely well with numbers with extensive experience in budget development and data analysis. Produce high quality results through extensive business and systems operation, and Electronic Data Interchange (EDI) experience with attention to detail and focusing on innovations while addressing customer needs. Proven ability to conduct research, lead people, build coalitions and facilitate team work to achieve common goals working with CMS components, System Maintainers, contractors and with other Federal agencies, State governments, Professional Societies, and private sector organizations utilizing well developed oral communication and interpersonal skills. Exceed program objectives through critical thinking, excellent analytical, problem solving, and influencing and negotiating abilities. Results oriented and demonstrate resilience in a continuously changing and challenging environment.
Education and Training
M.H.A: Health AdministrationUniversity of Pittsburgh － PAHealth Administration
M.B.A: Accounting/FinanceUniversity of Pittsburgh － PAAccounting/Finance
M.A. and B.A: EconomicsUniversity of Delhi － Delhi, IndiaEconomics
Relationship and team building
Effectively influences others
Critical thinking proficiency
Sound decision making
Claims analysis and review specialist
In-depth claims knowledge
07/2000 to Current
Lead Health Insurance Specialist
GS-0107-14 Centers for Medicare and Medicaid Services 7500 Security Blvd. 40 hours/week Baltimore, MD 21088 Starting Salary: $72,000 Supervisor: Carol Young (410-786-0264) Current Salary: $138,160
Lead implementation of Health Insurance Portability and Accountability Act (HIPAA)
standards making sure that the strategies adopted satisfy Medicare policies and business needs
while being fully compliant with the adopted standards.
Developed and implemented strategies and specifications collaborating with the Medicare Administrative
Contractors (MACs), Shared System Maintainers (SSMs) and other CMS components to implement
Electronic Data Interchange (EDI) transactions per adopted HIPAA standard.
Evaluated, developed and led resolution of complex technical and operational issues identified by analyzing
and comparing actual results with objectives set.
As part of my responsibilities work closely with other CMS
components (e.g.; OFM - HIGLAS, CM, CMMI, CPI, CCSQ and others), MACs, SSMs, contractors,
professional association representatives (e.g.; AMA, AHA, ACLA and others) and HIPAA Standard
Development Organization X12, coming up with best possible resolutions with least cost and least disruption
to Medicare operation.
Co-Chaired a committee that maintains a National Code Database used by the whole industry.
Coordinated and provided leadership to other CMS components and the industry.
Served as change
agent in redesigning the code maintenance process to encourage and increase industry participation when the Code Database is owned by CMS.
CMS Representative to a National Code Committee that maintains a number of codes that are used in
Electronic Data Interchange transactions covered under HIPAA.
Has been very successful in presenting and getting Medicare requests for new codes approved working closely with CMS components requesting the codes as well as the industry organizations that are represented in this Committee.
Represented division and regularly contributed to resolve significant issues before the Medicare Change
Control Board (MCCB).
Identified and resolved issues to help division to complete the Change Request
process more efficiently and on time.
Regularly meet organizational goals through clear verbal and written communication to MACs
and SSMs to implement Medicare policy and procedures.
Achieved results by authoring
and monitoring a number of change requests (CRs) and Technical Direction Letters (TDLs) in the last
CMS representative to national Electronic Data Interchange (EDI) Standard Development
Organization (X12) for developing standards for Electronic Data Interchange (EDI) transactions adopted under HIPAA, Workgroup for EDI (WEDI), and Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) for developing Operating Rules under Affordable Care Act.
Regularly influence and negotiate with these organizations for resolution of issues to meet CMS needs through sound analysis, development of alternatives and written and oral communication.
For example Transaction 835 (ERA) version 5010 added a section for reporting Medical Policy at my request to address the issue of Local and National Coverage Determination and the resulting impact on denial.
Developed written responses to inquiries from members of Congress and author decision papers and talking
points for senior management.
Led CMS wide remittance advice initiatives collaborating and gaining acceptance of providers/suppliers,
clearinghouses, vendors, payers and other organizations to resolve significant issues increasing efficiency and
reducing Medicare and industry cost without sacrificing quality.
Respected and sought after subject matter expert with other CMS components and industry experts on
HIPAA and Electronic Data Interchange issues.
Serve as the technical expert and resource for resolution of
payment and other issues across the Agency.
Team member in developing and maintaining Remittance Advice (RA) Guide for external users in
coordination with another CMS component (CM/PCG).
Developed and led business process improvements resulting in cost reduction and increased efficiency.
Instrumental in planning, developing and monitoring software - Medicare Remit Easy Print - that has
improved efficiency of Electronic Remittance Advice (ERA) and reduced cost in terms of printing and
mailing charges for paper Remittance Advice (RA) accomplishing organizational goal of increasing the share
of ERA and reducing the share of paper RA.
Medicare experienced a 58% reduction in the paper remittance
advice and an increase in the share of Electronic Remittance Advice (ERA) from 30% to 88% between FY
2005 (when MREP was introduced) and FY 2016 as providers transitioned from paper RA to ERA.
Worked closely with other CMS components in developing payment policies and reporting on the Remittance
Advice that is compliant with current HIPAA standard and current Operating Rules under Affordable Care
Act e.g.; Physician Quality and Reporting System bonus payment, Bundled Payments for Care Improvement
Models and payments for other Demonstration Projects.
Analyze issues, develop and present special reports and detailed plans for current problem resolution, quality
improvement and cost reduction as part of my current responsibilities.
Currently represent CMS to the CAQH CORE Code Combination Task Group making sure that Medicare
interests are addressed and raising the Agency awareness about the benefits of standardizing the code use
within Medicare and the industry.
Also led a team on Affordable Care Act (ACA) Operating Rules
development for Phases III and IV working closely with CAQH CORE, other components from CMS
including CM, OFM, CPI and the SSMs and MACs.
Proven success at collaborating and building coalitions with the X12 - Health Insurance Portability and
Accountability Act (HIPAA) standard development organization, health plans, providers, clearinghouses,
Medical Associations, and Centers for Medicare & Medicaid Services (CMS) components - to modify Implementation Guides that become the HIPAA standard once adopted by the HHS Secretary, in ways that help CMS meet organizational goals of better care, better health and lower cost.
For example, in the current standard (version 5010) for one of the HIPAA covered transactions, I was instrumental in getting a new segment (Medical Policy) added that would increase efficiency in explaining the reason for payment denial based on Medicare coverage determination policy and save Medicare by reducing provider calls and manual intervention.
Received Center and Office level recognition from Office of Technical Solutions (OTS), the Center for
Medicare (CM) and Office of Financial Management (OFM) for collaboration and teamwork on joint projects
meeting organizational goals.
Respected leader in the health care industry demonstrated by invitations to speak at Workgroup for
Electronic Data Interchange (WEDI) and X12 conferences and co-authoring White Papers.
For example, I presented one of Medicare initiatives - Bundled Payment Model IV - in June, 2013 at X12 Trimester conference by invitation.
Led a (CMS) cross-component team, multiple MACs, and a system maintainer in developing software
(Medicare Remit Easy Print - MREP) to read/view/print Part B Electronic Remittance Advice (ERA).
Medicare experienced a 43% reduction in the paper remittance advice and an increase in the share of
Electronic Remittance Advice (ERA) from 30% to 73% between FY 2005 (when MREP was introduced) and
Introduction of MREP has been a significant contributor for this transition.
Overall Medicare cost
savings for transition to ERA over this time period is close to $159 million by avoiding the cost of printing
and mailing of paper remittance advice.
Led a workgroup of CMS staff, system maintainers, and multiple MACs to improve non-medical
claims adjudication message code (explaining why a claim was paid differently than it was billed) usage
on the remittance advice contributing to a 32% annual reduction (19M) in call volume.
This was accomplished as part of my continuous improvement project.
In 2012 achieved a 99% reduction in health care provider remittance advice balancing issues (where the total
paid is not equal to the sum of total submitted charges and payment adjustments) through effective management
of and collaboration with system maintainers, MACs and (CMS) staff improving provider ability to automate
payment posting and follow-up action and impacting the quality of CMS Electronic Data Interchange (EDI)
This reduction in balancing issues impacts cost on Medicare as well as provider side as it
helps automation and reduces manual intervention.
With Health Insurance Portability and Accountability Act standard transaction 835 version 5010
implementation, successfully redesigned process to develop standard electronic remittance advice
for Medicare eliminating variations and making the process more compliance driven and cost effective for the
Managed to get 3 new codes approved for the CMS initiative -Bundled Payment Model IV,
working closely with CMS component CMMI and members (e.g.; X12 835 Work Group, American Medical
Association, American Hospital Association, BlueCross BlueShield of PA, AETNA, Mayo Clinic) of a
National Code Committee explaining and convincing the members that although the codes are very unique
and Medicare specific, the national code set should have them in anticipation of cost containment as a result
of Medicare initiative of bundled payment.
Did a presentation on Medicare Bundled Payment Initiative at the
request of X12.
Selected to participate in the Fellows and Continuous Improvement Project programs.
07/1993 to 06/2000
Director of Practice ManagementUniversity of Maryland Pathology Associates － Baltimore, MD
Starting Salary: $40,000
Supervisor (retired): Helene Hess (301) 949-8580 Ending Salary: $66,000
Developed, presented, and implemented short and long term plans for improving efficiency and reducing cost for delivery of laboratory and pathology services.
Worked closely with staff and physicians from the Department of Pathology and a Clinical Laboratory as well as all other departments under the umbrella organization - University Physicians, Inc.
UPI), University of Maryland and the University of Maryland Medical Center.
Represented the Department of Pathology in discussion with upper management of the University of
Maryland Medical Center and UPI to develop innovative solutions to address issues regarding cost, Federal
and State regulations and delivery of health care.
Evaluated, researched and identified issues with current programs and health care models.
presented recommendations for improvement to the senior management.
Once approved, implemented
providing technical assistance to staff as well as physicians in Pathology and other departments.
Served in an advisory role to the Administrator in formulating policies, and developing priorities and
strategies to deliver services at lowest cost without negatively impacting the quality of care and being
compliant with all regulatory dictate.
Negotiated with specialized service delivery providers - laboratory and pathology - to offer specialized
services to help physicians practicing within the Academic Medical Center to deliver high quality care.
Analyzed and evaluated current recruitment and retainment policy, developing short term and long term policies to meet the needs for recruiting and retaining the optimum level of qualified personnel.
Conducted interviews for new hires, assessed staff training needs and arranged for needed training.
Directed staff participation within industry groups.
Provided needed advisory support to employees on work, strategies to maintain compliance with regulations and other administrative matters to facilitate collaboration between departments and achieve departmental strategic goals.
Evaluated employee performance and counseled on administrative matters.
Developed methodology for calculating physician incentive payment, fee schedule, and cost per procedure.
Developed and presented physician and staff training material for the Department of Pathology as well
as other departments.
Led an Internal Audit Team comprising of management and pathologists to monitor progress, evaluate and improve effectiveness of programs, assess training needs and update training material as needed to stay current with Federal and State laws, regulations, initiatives (e.g.; Operation Labscam) and the expected impact on the organization.
Maintained Clinical Lab Improvement Amendments (CLIA) and State certifications,
and College of American Pathologists (CAP) accreditation for clinical laboratory owned by the division
working with CMS (HCFA), the State and CAP.
Working closely with laboratory staff, developed, maintained and monitored CLIA proficiency testing
Led a team to develop, implement and monitor quality improvement policies per Clinical Lab Improvement
Amendments and CAP principles.
Planned, organized and controlled work activities by subordinate employees ensuring success in reaching
departmental and university goals on time.
Negotiated contracts for laboratory and pathology services for various University of Maryland research
projects making sure that high quality services are provided on time and at least cost.
Led operating budget formulation activities, negotiated and finalized budgets.
Monitored, reported and
changed course as needed.
Successfully implemented transition to electronic submission of claims leading a team of clinical, billing and
Prepared presentation material, briefing documents, talking points, performance evaluation reports and
presented to upper Management.
Prepared briefing material for developing new service delivery models improving reimbursement and
reducing cost without any negative impact on quality of care after careful review and analysis of current
practices and presented to upper management.
Successfully led a team to integrate, implement and manage a physician services division that also owned
a clinical laboratory in an Academic Medical Center incorporating pricing, billing, finance, information
services and budget.
Significantly improved operations resulting in 80% growth in net revenue during
my tenure (7 years).
Working with specialized laboratories across the country, managed to offer high quality laboratory and
Pathology services in an efficient manner to meet the needs of physicians practicing in the Academic Medical
Center keeping the operating cost down.
Successful in maintaining a collaborative relationship with other departments, the Hospital and the central
Faculty Practice office staff and coordinated with them to achieve the pathology department as well as the University of Maryland strategic plan.
Met financial targets while maintaining the highest level of patient care.
Independently planned, prioritized, and established work priorities for multiple concurrent projects with tight resources and timelines.
Instrumental in forming a multidisciplinary team and address issues/concerns brought by administrative and clinical staff.
Complaints from staff decreased by more than 90% within one year.
Negotiated with Federal, State and other organizations like College of American Pathologists successfully, maintaining all critical certifications/accreditations and resolving issues.
01/1990 to 11/1992
Senior Budget Analyst/Service RepresentativeChildren's National Medical Center/Children's Faculty Associates
Washington DC 40 hours/week
Developed $400 million operating budget working with a budget team.
Negotiated, finalized and
Monitored and developed corrective actions as needed.
Prepared monthly and year
end budget performance reports.
As a Service Representative, conducted billing and reimbursement analysis and worked with the departments
to help develop policies to continuously improve billing and collection.
Work with Radiology Department to resolve billing and reimbursement issues resulted in 100% increase in
reimbursement within a year.
Developed training material after analyzing department specific data, and presented to staff and physicians to
improve collection and achieve full compliance with Federal and State regulations.
Greater Canonsburg Health System June 1988 - August 1989
Canonsburg, PA 40 hours/week
Participated in the budget team developing operating budget and cost reports.
Negotiated, finalized and
Monitored and developed corrective actions as needed.
Evaluation of patient care models, and developing continuous improvement in health care delivery and/or
reduction in operating cost without any negative impact on delivery of care.
Instrumental in improving the financial status of a Health System with Inpatient and Skilled Nursing Units,
rehabilitation and urgent care facilities by analyzing operational and financial issues and data, and developing
short term and long term plans to improve efficiency and reduce cost without impacting quality of care.
Working in a team, successfully negotiated contract to reduce cost and/or to improve service.
Honors and Awards
CMS ECHIMP Award
CMS Cornerstone Award
OIS Office Director Citation Award
OIS Office Director Cash Award
OIS Office Director Citation Award
Administrator's Achievement Award
Gold Coins from CMM and OFM in recognition for significant contribution
Special Act Award from CMM
Cash Award for Exceptional Performance
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