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HIPAA Subject Matter Expert

SUMMARY

• Has over 20 years experience in the health care industry with a primary focus on public health care programs and systems. Has extensive hands-on and management experience in a variety of projects involving the customization, design, development, implementation, and testing of automated systems to support public health care programs as well as day -to-day business operations. Well versed in the Project Management Methodology used by the California Department of Information Technology (DOIT) in overseeing IT projects. First involved in Health Insurance Portability and Accountability Act (HIPAA)  over three years ago. Has been involved in the assessments, problem resolution and design, and remediation/implementation.

PROFESSIONAL EXPERIENCE

Visionary Integration Professionals, Inc.

1990 - Present

• For the State Government Programs Division of Delta Dental Plan of California, responsible for the HIPAA compliance of the following programs:  Alameda Alliance for Health, Santa Clara Family Health Plan, Geographic Managed Care, California Healthy Families, and Florida Healthy Kids.  This involved all rules with a focus on those that are final. Responsible for developing, maintaining, and tracking the project plan and activities for these programs as well as coordinating with the entire Delta organization. The initial Assessment phase and Problem Resolution and Design phase have been completed. The current phase is implementation for the Transactions and Code Sets and Privacy rules. Currently revising and developing policies and procedures impacted by HIPAA. Involved in developing the system design specifications for each of the transactions.
  
  Also responsible for training as it related to Transactions and Code Sets and provides input to Privacy training. This included determining the delivery medium, establishing objectives, curriculum, scripts and visuals.
   
• Under USAID funding, responsible to provide technical and management consulting services for the Republic of the Philippines' National Health Insurance Program (NHIP). The services included comparing the Health Care Sector Reform Agenda (HCSRA) developed by the Secretary of Health to the technical requirements incorporated into a Request For Proposal and then making recommendations to the Secretary accordingly. Published a set findings and recommendations for review by the Secretary in Manila. Provided direction to the Technical Evaluation Committee in re-developing their requirements to meet the goals of the HCSRA. Also developed a query tool for use by NHIP staff in tracking the outcome of each recommendation. Recently been asked to assist in the implementation plan, development of benchmark tests for the bidders, and in evaluating the submitted proposals for their compliance to the technical requirements.
   
• Under contract to PROPARTNERS, Inc., supported Delta Dental Plan of California in a number of areas including management of the proposal production process for new business, evaluation and identification of new markets, and assisting in the response to the Request for Proposals, specifically those areas dealing with HIPAA compliance. Most currently, been involved in Delta Dental's HIPAA compliance project. This involved developing the project plan for all phases including Assessment, Problem Resolution and Design, Implementation/Remediation, Client Acceptance and Certification. The project plan was developed and tracked using both MS Project and ABT Project Workbench. Designed solutions to address the gap analysis (Assessment) performed for the Privacy, Security, and Transaction and Code Sets Rules. This included a full review of policies, procedures, development of training materials, and EDI design documents. Initiated the gap analysis of new rules, followed by development of the solution(s) to ensure compliance, implementation, operational readiness testing, and ultimately certification if appropriate.
   
• In support of Vision Service Plan, performed analysis and made recommendations for more comprehensive data collection and reporting methodologies for Health Plan Employer Data and Information Set (HEDIS) measures and for the Administrative Simplification EDI standards as a result of HIPAA. At this time the HIPAA rules had not yet been finalized, so was tasked with analyzing the areas impacted by HIPAA, making recommendations based upon the preliminary rules, developing a project plan, and preparing staff to commence work once the final rules were published.
   
• Led the data management and system test activities for the California's Medi-Cal Management Information System and Decision Support System (MIS/DSS). The data management activities included the analysis, receipt, data mapping, and conversion activities for the Department of Health Services MEDS eligibility data feeds, the EDS Provider Master File, and claims and encounter data from both state fiscal intermediaries as well as individual county programs. Developed a system test tracking tool, still in use by MEDSTAT for tracking each and every test executed including test scripts, expected vs. actual results, the name of the tester, date completed, and any testing anomalies. This tool includes a series of reports that are used to track metrics and productivity of the testers as well as automating the reporting of test results for the System Test Deliverable to the State.
   
• Was retained by Mercy Care Plan in Phoenix to assist in system test activities including the development of system test plans, identification and analysis of enhancements, and the execution of specific tests for a client implementing the EDS MetaVance managed care system. Specific subsystems included provider and eligibility. Developed a series of MSAccess queries and event procedures based upon the client's design and code specifications. These procedures, once validated, could be run and rerun using the same input data as the MetaVance test system. Then another set of queries, also developed was run to compare the results of the system test to the results of MetaVance. This automated validation process significantly speeded up the testing phase, and ensured that 100% of the records being used could be verified row by row and column by column resulting in highly thorough testing, particularly when large volumes of data were involved.
   
• In support of the Geographic Managed Care for Medi-Cal eligible in Sacramento County, assisted in the implementation for a northern California health plan. This included developing the implementation plan, developing the specifications for the file conversions, system testing, training claims processing staff, and all associated deliverables to the Department of Health Services.
   
• As part of the Vital Records Improvement Project, was responsible for system and acceptance testing the IBM and State of California joint effort to automate the collection and reporting of birth, death, dissolution, and other vital records for the entire state from the year 1905 to present. This was a multi-platform system utilizing Intelligent Forms Processing (IFP), Intelligent Character Recognition (ICR), OS/2, PCs/LANs, and IBM Mainframe.
   
• For GTE Health Systems, was retained to perform requirements analysis and technical design for an Integrated Health Data System (IHDS). The IHDS was a relational database designed to house information from medical claims, HMO/PPOs, pharmacies, disability claims, workers compensation settlements, accident statistics, and employer health risk profiles for benefit plan administration.

Electronic Data Systems Corporation

1979 - 1990

• Eleven-year career with EDS involved a number of assignments. Following is a description of some of those assignments beginning with the most recent:
   
• Under the CHAMPUS Reform Initiative (CRI) contract, designed, developed, and tested system enhancements. This included assisting the client in designing more efficient procedures for processing claims, and developing and administering a transaction generator used for automatically processing claims that previously suspended for manual review.
   
• Under the State of California Department of Health Services' Medi-Cal contract, managed the suspense/resolution unit, involving a staff of over 100 on two shifts, for inpatient/outpatient, professional, pharmaceutical, vision, Medicare crossovers, and long term care claims. This included designing numerous system enhancements including an Automated Error Correction System (AECS) to meet cycle time requirements mandated by the state. AECS was so successful; it was later utilized by EDS and Foundation Health to improve processing for the CHAMPUS Reform Initiative (CRI).
   
• Was responsible for managing the operations of the Child Health and Disability Prevention (CHDP) contract for the State of California Department of Health Services, including front-end claims processing, provider relations, medical review, and system maintenance. Identified system enhancements to eliminate payment of duplicate and fraudulent claims and to speed the claims processing cycle time. Assisted in integrating CHDP into the overall Medi-Cal program.
  In support of Redwood Health Foundation (RHF) in their Medi-Cal program, was responsible for the program code maintenance and implementation of enhancements to the automated system used by EDS to support three counties in California namely Lake, Sonoma, and Mendocino.
   
• As part of the State of California Department of Social Services (DSS) In Home Supportive Services (IHSS) program, performed state training for staff using the newly developed the case management and payroll systems. The IHSS program provides in home care to the blind, disabled, and elderly low income as an alternative to nursing home care. Also tested system changes, developed training materials, and supported the state and county offices in their day-to-day operations.

EDUCATION

• Healthcare EDI Standards, Washington Publishing Company and EDI Partners
• Advanced HEDIS, National Committee for Quality Assurance (NCQA)
• Graduated Systems Engineering Development Program, Electronic Data Systems (EDS)