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Work Background
Healthittek LLCHealthcare Data Scientist & AI Innovation Czar
May. 2021United States
FraudLensVP Informatics & Innovation- Data Scientist
Mar. 2018 - May. 2024Arlington, Virginia, United States• After selling company- Remained as Consultant on retainer for next owners. Manage of Health IT developers, managers, technical professionals, Database and middleware team to develop healthcare and dental software to detect and prevent fraud, waste and abuse and analyze healthcare and dental claims to generate savings through expert systems, using AI, algorithms and automated systems including machine learning. To create predictive and prescriptive models.
• Manage all process of new client implementation from setting up requirements for changes and managing development work through SDLC to interoperability for interfacing and integration of systems for bi-directional data exchange using HL7 FHIR API’s and EDI/X12 Implementing system based on requirements, negotiating features, designs and solutions and identifying possible new products spin offs.
• Manage software development complete cycle from planning, design data models, development, implementation, redesign, improvement and optimization of software development, in a variety of schemas to include Waterfall, Agile, Iterative, V-shape and Spiral depending on project and requirements.
• Successfully coordinated infrastructure integration, data selection and gathering, security protocols, data exchange, reporting and analytics, development work, change management and versioning.
• Conducted informatics and in-depth analysis of claims. Working with big data of around 50 to 400 million rows, processing clinical data, claims real time and returning customer with results. Integrating systems between AWS, local servers and data lakes.
Design of data models. Build standards for interoperability, pattern recognition, contextual analyses and developing scalable solutions to healthcare problems.
• Implementations with major payors and TPA’s: medical and dental claims, diagnosis, CDT codes, pharma/medications, DME, providers rosters, NPPE, Clinical data, risk models for population health to create robust models -ML
SVBMHealthcare IT PMO
Mar. 2017 - Mar. 2018Linthicum MD• Expert knowledge of Agile project management • Provide significant leadership in the development and maintenance of the Reporting Strategy and Healthcare Analytics and KPI’s. Including: defining initiatives, developing business case, high level estimates and guiding initiatives through the planning and execution process, expert at facilitating impasses between the technology and the business teams.
• Scrum Master and Agile expert managing multiple mission critical IT projects simultaneously from new claims systems development, system migrations, integration and data analytics, infrastructure deployment and automation. Managed Claims cycle for major payors like Blue Cross Blue Shield, United Health Care. Medstar, Cigna, Aetna and Medicare and Medicaid for a population of 32 million beneficiaries.
• Successfully revamped EDI operations and projects for EDI HIPAA Claims Transactions- Electronic Data Interchange of 5010 X12 EDI transactions including: 834 Patient Eligibility, 270 and 271 Coverage inquiry and response; 837 Professional and Institutional Encounter Files, 999 and 997 acknowledgements, 277 healthcare notifications, 835 Payment Transactions.
• Developed new and improved existing process flows, for full automation of data and analytics of Claims payments, rejections, denials and reconciliations, including mapping, crosswalks, and full reconciliations of data files, reaching overall acceptance rates of 99.8% on first submission. Process improvements and automation of 5010 X12. Electronic Payment analytics. Review and validated data.
• Developed and implemented SLA- Process mappings and Improved data and process flows professional and institutional claims. Developed system for keeping State, plans and Trading partners dashboards and KPI’s including Submission reporting, reconciliation and process for acknowledging, mapping and matching response files. End to end tracking, analytics and SQL queries development.
Tristate Health PartnersData Specialist- Data Scientist ACO
Oct. 2015 - Feb. 2017Hagerstown, Maryland, United States• Developed and implemented Clinical/ Costs/Quality Metrics Data Warehouse for Tracking Patient utilization, cross reference data from hospital, clinics, labs, medications, high utilization of ER, readmissions, and patient risk modelling for ACO and Clinical Improvement processes and reengineering.
• Expert knowledge of Managed Care: Medicare, Medicaid, and Commercial Insurance (Group and Individual). Familiarity with Standard Medicare, Medical Supplements and Medicare Advantage Plans. Knowledge of HMO, PPO, POS Plans, etc. Experience with working with managed care enrollment and claims data, X12 5010.
• Integrated data to prevent over utilization, improving coordination of care and share of information among specialists, PCP, Inpatient, Outpatient, Health Information Exchange and Claims and Costs data from CMS/ Network through integration and interoperability of multiple EMR systems into Data Warehouse.
• Analyzed costs reduction, patient’s clinical risk factors and social determinants of health analytics using multiple data sources. By utilizing data modelling and risk management achieved reduced costs and ACO shared savings. Expert at CMS Claims data files (CCLF), CPT/HCPCS, LOINC codes, ICD 9 and 10 diagnostic and procedures codes, NPPES, HCC risk modelling. Creating complex reports and Power pivot tables, visualizations and trends for decision making. • Managing Big Data systems, integration and trend analytics with longitudinal studies and population data. Experience with EMRs, Healthcare Data Warehouse and Healthcare Informatics: Population Health, Patient Access, Service Quality, Healthcare Outcomes, Patient/Family Satisfaction, T-tests, cluster analysis and correlation and regression, including building models for predictive analytics. Analyzing Readmissions, Average Length of Stay, Total discharged days not billed, Net Days on AR, AR aging.
Health IT TekChief Data Scientist
May. 2015 - Feb. 2018Baltimore, Maryland AreaHealthcare industry subject matter expert, data Scientist leading projects of software development on Computable biomedical informatics. Clinical best practices quality assurance, clinical and dental cross over analytics. Implementing expert systems for detection and prevention of fraud, waste and abuse in healthcare.
Lake Health District HospitalDirector of Information Technology
Aug. 2012 - Sep. 2015Lakeview, ORDirector for Information Technology and Data Mining and management for Critical Access Hospital including Electronic Healthcare Records-EHR, Information systems management for HIS and CPSI systems, Information Security Management. ODBC and OS data Mining for Compliance and Quality Controls. Software Management and Audits, Web Development and Updating for Hospital Websites and Affiliated Clinics in Southern Oregon and Northern California.
ContractsDirector Systems and Clinical Informatics
Oct. 2007 - Feb. 2018• Directed the Implementation of interoperability platforms for Laboratory interface for State reporting and connectivity with 17 different EMR systems. Radiology applications with connection to remote PACS system using DICOM and interfaced to E.H.R creating true end to end data flows for continuum of care.
• Adept at reaching interoperability between stakeholders and gaining buy out from clinicians implementing CDA and CCDA exchanges between hospitals and clinics and HIE. Following the continuum of care for the patients and adapting systems and HIT to allow collaboration among practices, hospital, post-acute care and ACO. Master skills in Data Analytics allowed to prioritize implementation plans and deployments.
• Masterfully performed data ETL: Extracting from heterogeneous sources, Transforming and mapping then loaded for systems migration. Keeping critical data from legacy systems and integrating into new upgraded applications. Putting together reports for Business Intelligence and strategic purposes and quality metrics.
• Conducting statistical analysis and OLAP- Online Analytical Process through ODBC-Open Data Base Connectivity on different systems to integrate data for trends and business intelligence. Mining, managing and retrieving structured data and complex reporting. • Data Dashboards and Quality Measures both for Hospital side and Physician’s side PQRS and GPRO, KPI’s- Key Performance Indicators abstraction and reporting. Six Sigma and Lean projects data management and analysis. Work flow and data flow analysis, data repositories and correlations. DMAIC and DMAVD. Revamped multiple value-based processes and improved quality outcomes 25%.
Panama Canal AuthorityChief of Marketing
Jan. 1995 - Dec. 2001Promote Panama Canal around the World, conduct market analysis for Third Set of Locks Canal expansion project.
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Looking to transition into Tech./. Former sales Representative and have very good Communication skilss @ @NikeStore