ตัวอย่าง Resume งานบริหารโครงการ (PMO) ฉบับที่ 203

Professional Summary

Organized professional with 19+ yrs. of experience into IT enabled services in US Healthcare Insurance domain. Payer business (16 yrs.) experience into Claims, Rework, Appeal, Provider, Benefit Config etc. and Provider RCM (10 yrs.) into Frontend and Backend processes Strong track record executing in multiple working domains like Analytics, Automation, Process Excellence, Compliance, Project Management, Training & Quality facilitating successful performances.

Highlights

• As Analytics Lead has engaged and delivered numerous solutions for both Payer and Provider work streams to reduce cost of operations, improve accuracy of transaction processing, Interest avoidance, Penalty avoidance, reduce write-offs for Provider, Improve speed of cash for RCM etc.. Below are some of major solutions developed during tenure with Optum. And there are many more which are actively contributing to KPI improvement. Billing Audit Tool - 100+ different types of defect determination on Pharmacy Claims Billing and report for same day remediation to decrease Claim Denial, Improve collections and speed of collection in RCM. Data Mining and Analytics Tool - GUI based tool which supports Payment Integrity team to identify Overpayment opportunities and fix the issue upstream to avoid rework and Provider abrasion. Clinical Research & Pharmacy Benefit Automation - E2E Pharmacy appeal handling by integrating multiple data source on 1 platform and using AI/ ML capability in enabling Pharmacists take faster decision on Upheld/ Overturn of Part D appeals. System Error Audit Logic Tool - AI/ML Deterministic rules hosted on Big Data Infra/ Cloud Infra to identify, report and get the defects remediated same business day stops incorrect payment to provider and thus improves payment accuracy, Provider NPS. Cash Posting Cognitive Automation - RCM Cognitive Automation solution to extract bank statement from portal, digitize the structured / non structured data templates, parse to required format, run business rules to identify exceptions and payments. Bucketize the transactions into different exception handling bucket for next best action and process all eligible automation transactions. RCM Workflow Tool - Aggregate payer EOB using API services from different Payer groups. Analyze the EOB and accordingly create strategy to maximize AR collection. Use AI/ML rules to identify non workable inventory for AR and triage them to relevant buckets for further action. Cloud Infra Set Up for Pharmacy Operations - Strategic initiative to reduce cost of infrastructure for hosting all automation solution and other important tools. Benefit Configuration Automation Tool - Using OCR and Document indexing capability identify the benefit config changes, compare with existing values, update changes, generate exception report of fall out to be handled manually. Patient Profiling Tool - Developed tool to perform sentiment analytics and historical behavior study to assign score to each Patient and thus able to highlight high risk buckets which can translate to Patient recovery delays or leakage.

Experience

Education

• MBA: Finance And Marketing, 05/2018 · IMT Ghaziabad Ghaziabad
• Bachelor of Arts: Maths And Economics, 07/2001
• University of Delhi - Delhi · 10+2 (Science): 06/1992 · Kendriya Vidyalaya - Bokaro Steel City · 10: 06/1990 · Kendriya Vidyalaya - Bokaro Steel City
• PMI ACP certification - Credential ID - 2645321 (Yr. 2019)
• Masters in Data Science - Simplilearn (Python, R & Tableau) (Yr. 2018) · AHM 250-AHIP (Yr. 2017) · Six Sigma Black Belt - RABQSA & Benchmark Six Sigma (Yr. 2012) · PMP Training - QAI (Yr. 2012

Skills