James WALSH
Spring Hill,TN
Summary
Technology Leader – Healthcare Information Technology, Software Development and Implementation, Strategic Engagement Planning, Program and Product Management Transformational healthcare IT executive with over 20 years of experience driving enterprise innovation, regulatory compliance, and digital modernization across payer, provider, and government sectors. Proven track record of leading large-scale EHR implementations, cloud migrations, and Agile product development initiatives that have generated over $100M in revenue and improved clinical and operational outcomes for 900+ facilities. Adept at aligning technology strategy with business goals, optimizing Medicaid and DSNP platforms, and navigating HIPAA/HITECH, ICD-10, and CMS regulations. As founder of James Walsh Consulting LLC, I deliver strategic advisory services that reduce downtime, accelerate claims processing, and empower organizations to scale with confidence.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Owner
James Walsh Consulting LLC
02.2023 - Current
- Advised Fortune 500 payer on Medicaid modernization, reducing claims processing time by 30%
- Developed cloud migration roadmap for regional hospital network, cutting infrastructure costs by 25%
- Provided consultative services to hospitals with selecting and moving EHR systems saving 30% budget costs
- Ran development shop
- Meaningful use of regulations and expert
- Efficiency developing disaster recovery plans
- Strong background working with startup companies and non-profit organizations
- Creating AI for claiming systems
- Implemented the 2022 bill signed by Governor Bill Lee to create Computer Science in K-12 Schools in Tennessee. Taught the KIRA application over 800 students.
Solutions Services Advisor/ Program Manager
Quorum Healthcare (QHR Health)
06.2022 - 02.2023
- Serving as Solutions Services Advisor to critical access hospitals within the USA. Working with a facility in Lancaster Penn. building a hospital from the ground up, responsible for all IT functions, overseeing the implementation and purchasing of all the hospital systems to include the low voltage wiring, buildout of the MDF/IDF rooms for computer equipment installation, and vendor coordination, working on a full technical assessment of an Ohio hospital IT department. Reviewing all the facilities, and IT functions, from the helpdesk, accounting, projects, software, and supplying a strategic plan for the next year to show monetary savings. Also, assisting a hospital facility in Moscow Idaho, in the selection of a new EMR/EHR and Ambulatory Clinical system.
- Managed the program and process of working with Enterprise applications such as EPIC, CERNER, Allscripts and MEDITECH on obtaining demos for the facility and taking them through the selection process. Worked with a team to redevelop the company SharePoint site. Jira to document bugs, manage processes and overall manage the project. Visio and PowerPoint were utilized to provide updates to management. Working with all the cross-functional areas of the hospitals for EHR selections as well as the CEO and Physician providers. Claims management and programming. Ensuring claims EDI are up to CMS standards.
Medicaid IT Strategy Director/ Program Manager/ Health Plan CIO
CIGNA Healthcare
10.2020 - 04.2022
- IT Director for Cigna Healthcare’s Medicaid Program and working directly with the state of Texas DSNP program in creating and implementing programs from and technology perspective. Working in a combined Agile and Water fall methodology. I worked to move them to a Full AGILE methodology. Managed all UX/UI integrations with Medicaid and Medicare platforms. Managed Scrum meeting with teams of developers on the UX/UI. These programs directly impact the Medicaid population of the State of Texas to manage the care of the less fortunate in each state. Working with EDI transactions such as 834, 271, 835, 820, 837I, 837P, HL7, Azure, cloud applications and many others. Working with many providers to ensure they have the appreciated access to care to treat the members’ needs. Heavy into HIPAA, and HITECH initiatives as well as working with cloud implementations and migrations, testing of software and coding, process development of the data. Work closely with the Centers for Medicare and Medicaid (CMS) on processing claims for members and keeping Cigna updated on CMS changes in rules and regulations. Working with progression of claims and ensuring the data moves properly into adjudication then to the appropriate data tables within each system. Managing the claims processing methodology and making corrections for CMS. Created the disaster recovery plan for the Medicaid program working with many of the officials in the area for coordinating efforts.
IT Director / Program Manager/ HealthPlan CIO
United Healthcare of Tennessee
09.2015 - 07.2020
- IT Director for the United Healthcare State (UHC) of Tennessee Community and State (C&S) program. Working directly with the State of Tennessee in creating programs and implementing them from and technology perspective for the health plan. Working with EDI transactions such as 834, 271, 835, 820, 837I, 837P, HL7, Azure, cloud applications and many others. Heavy into HIPAA, Disaster Recovery, and HITECH as week as working with cloud Implementations, migrations, testing of software, coding, process development and data implementations. Creating claims adjudications programs and processes. Deeply involved with the ICD-9 to ICD-10 migrations of 2015-2016. Working closely with the State of Tennessee on upgrading and testing from an end user perspective on their new eligibility system known as Tennessee Eligibility and Determination System (TEDS). Working closely with the Tennessee MMIS group to create high-level programs for United Healthcare. Worked with the state on programs like Employment and Community First, better known as ECF CHOICES. I work closely with the Centers for Medicare and Medicaid on processing claims for members. Working closely all with the UX/UI teams to create and enhance the Medicare, Medicaid and Dual Special Needs (DSNP) programs. Created all the MIPPA reporting for the DSNP program between each of the different MCO’s and Medicare. Responsible for all clinical systems, and programs, funding and budgeting. I also work closely with other C&S programs across UHC to implement Electronic Visit Verification (EVV) systems, HEDIS applications in HL7 formats and other programs. Currently working with North Carolina, Pennsylvania, Arizona, and Virginia C&S programs to implement medication management. Working with the health plan to maximize the revenue cycle in order to maximize the contracted amounts. Worked with each of the contracting agencies for third party software as needed to complete the contract and implementation. Working with CSP Facets from TriZetto processing claims and ensuring the data moves properly into adjudication then to the appropriate data tables within CSP Facets. Assisted in the transfer from Mainframe Facets to the JAVA client server version of CSP Facets in 2015-16, working closely with development, SMEs, and stakeholders. OPTUM handled all of the programming for this, and I was a part of the team that moved this company to AGILE.
Senior Technical Program Manager
Community Health Systems Inc.
02.2014 - 09.2015
- The Senior Program Manager is responsible for overseeing the successful implementation of the Community Health Systems (CHS) Computerized Provider Order Entry (CPOE) systems through a change management process into CHS tier II hospital facilities. These facilities are working to obtain the Meaningful Use (MU) Stage 2 certifications to receive the MU2 dollars from the Centers for Medicare and Medicaid (CMS). Managed 16 direct report project managers and worked with each of them as well as liaison at the CHS corporate office for the facility. Handled daily standup meeting in Scrum fashion to determine next steps.
- Project completed approximately 30 days prior to estimate completion.
- Working closely with each of the facility CEO’s, and providers daily to complete the operations
- Managed Community Health System program for 84 Hospital full SDLC life cycle implementation of Meaningful Use stage 2.
- Collaborated to design program project plan, charter, and deployment tools. Daily identified and collaborated to assist physicians, administrators, clinical and technical staff to align clinical processes with Meaningful Use Stage 2 objectives, goals, and long-term compliance.
- Daily management of program communications with upper and middle management and worked with other stakeholders to define business process issues, analyze operational efficiencies, implement creative solutions, and measure delivery of results.
- Effectively applied CHS methodology and enforced project standards utilized throughout the fast-paced project.
- Experience with multiple hospital and physician office practice disciplines such as Meditech, Cerner, Medhost (formerly HMS), Cerner, along with many others Proficient in Microsoft suite of products
- Researched the revenue cycle opportunities and how to save money within each hospital
Senior Consultant/Program Manager
Xerox Corporation
04.2013 - 02.2014
- Senior consultant and program manager to a minimum of 7 – 10 hospital business offices to obtain the best revenue cycle and coding platforms for each facility. Worked with many different types of hospital information systems, such as Epic, Meditech, McKesson and HMS. Worked as the engagement manager/program manager over project managers to implement these revenue cycle software platforms. Updated and conversed daily with upper-level management to provide return on investment strategies and ensured that the platforms performed to standards.
- No budgetary responsibility for this opportunity
- Implemented Computer Aided Coding (CAC), and Clinical Documentation Improvement Systems (CDIS)
- Collaborated to design program project plan, charter, and deployment tools. Daily identified and collaborated with administrators, clinical and technical staff to align clinical processes.
- Daily management of program communications with upper and middle management and worked with other stakeholders.
Director of Payer Product Management
United Health Group/OPTUM
06.2011 - 04.2013
- Director of Payer Products for United Health Group over three product lines and two clearinghouses. The teams developed revenue cycle products for payers and facilities. Creating solutions for the transformation of industry standards as required by CMS (Centers for Medicare and Medicaid), HIPAA (Healthcare Insurance Portability and Accountability Act of 1996), and for payers/providers. Consistently working electronic claim transaction processing such as the 834,835, 837, 277CA and many other X12 transactions. Interacted with the company’s legal, sales, business offices operations, and development as well as other operations within to accomplish new business requirements and opportunities. I had a team of developers that were FULL AGILE methodology. Negotiated all the required contracts to bring this product to market, and with the sales team to gain confidence in the hospital facility or facilities. Held daily scrum meetings with offshore teams to create daily routines for developers.
- Budgetary responsibility for over $200,000 in payroll, $250,000 in development and $5 Million in Revenue within the first year.
- Designed applications that increased revenue by 20% and increased customer satisfaction for customer transaction processing.
- Designed new JAVA based platform for transaction processing.
- Collaborated to design program project plan, charter, and deployment tools. Daily identified and collaborated with administrators, clinical and technical staff to align clinical processes.
- Worked with many Third-Party Associations (TPA) such as Great West Health, CIGNA, UNITED HEALTH CARE, TRIZETTO and many more.
- Daily management of program communications with upper and middle management and worked closely with other stake holders.
- Provided management reporting weekly to upper-level management.
- No budgetary responsibility at this opportunity
Implementation Director, Research & Development Director
MediFax EDI - EMDEON Inc. - Change Healthcare Inc.
02.2001 - 04.2011
- Formulated, designed and programmed the system scope and objectives for new revenue cycle products. Provided overall technical and managerial leadership to the IT team to develop and deploy the new applications built in .NET. Trained and maintained the integrated revenue cycle products division for hospitals. This product produced over $100 million dollars in revenue for the company. The group that I commanded were the first in the company to migrate from waterfall development to Agile development. We built out the full Scrum method with daily stand-ups, storyboards, and customer contact directly. Held daily scrum meetings.
- Budgetary requirements of over $750,000 in salaries, and benefits. $1. 5 million in equipment and development costs and generated revenue of over $100 million dollars.
- Managed third party vendors and offshore resources to develop revenue cycle products using the Software Development Life Cycle (SDLC).
- Created the complete UX/UI interfaces for all customers.
- Visited with customers to obtain user stories and translated those to functional development requirements and technical design.
- Created the implementation team, customer service team and went on sales calls to train the sales staff on how to sell the product.
- All products developed were HIPAA certified as well as certified by WEDI SNP, HFMA, HIMSS, EHNAC and CORE
- Products worked with Hospital Information Systems such as Meditech, McKesson, Siemens, Cerner, Dairy land, Epic and CPSI.
- Responsible for hiring all staff on shore and offshore.
- The software handles EDI transactions like the 270, 271 eligibility transactions as well as claims and adjudication transactions such as the 276, 277, 834, 835, and 837 EDI transactions
- Used pure Agile Methodology and Scrum combined in the development environment.
- Hired and trained the customer service and implementation teams.
- Accompanied the sales team on customer calls to provide the technical expertise required to make the sale.
- Developed all departmental standards and was tasked with ensuring standardization within the software.
- Products consisted of both webs based, and desktop applications built on cloud technology and multilayer storage capability as well as designed to allow ease of installation, training, and end user-friendliness.
- Products included Medical Necessity, Advanced Beneficiary Notices, and patient’s ability to pay.
- All Products worked with EHR systems like McKesson’s Horizon Patient Folders, and Siemens Envision systems.
- Platforms are currently running with over 900 facilities to date.
- Negotiated all required contracts and worked with the sales teams to complete contracts that were in flight and gain acceptance of the facility or facilities.
- Led cross-functional teams to drive strategic initiatives and align organizational goals.
Education
BBA - Business Administration With Computer Science
Lamar University
Beaumont Texas12.1991
MBA -
University of Phoenix
Nashville Tennessee01.2008
Skills
- Strategic Analysis and Planning
- Data and IT Governance
- Agile Methodologies
- Product and Program Management
- System Analysis
- Data Center Management
- Change Management
- Negotiation Skills
- Key Performance Indicators
- IT Product Delivery and Senior Project Management
- Budget Strategy and Profitability Improvement
- Claims Processing and Adjudication
- Business Analysis
- UX/UI experience with Medicaid/Medicare
- Electronic Data Interchange
- Team Building, Coaching, and Mentoring
- Cost Control and Compliance
- Use of the Software Development Life Cycle
- Disaster Planning and Recovery
- Cross-functional Collaboration
- Vendor Management
- Patient Experience enhancement
- Benchmarking Business Intelligence
- Electronic Commerce Architecture
- Emerging and Advanced Technologies
- Revenue Cycle Management
- TS Security Clearance – needs to be renewed
- Platforms: Azure, AW, Windows
- Languages: SQL, Python, UNIX, Visual Basic
- Tools: Jira, Tableau, ServiceNow
- Compliance: HIPAA, HITECH, ICD-10
Accomplishments
Driving revenue and outcomes
Strategic Planning and Analysis
Management of Cost Compliance
Program and Product Management
Well known knowledge of SDLC(Software Development Lifecycle)
Systems Analysis and Design
Cross Functional collaboration
Negotiation Skill
Disaster planning and data recovery
Affiliations
President of the 307th Bombardment Group Association – a Non-Profit World War II organization
Certification
- Formal ITIL Training
- United States Army Veteran (1st Lt)
- (Needs Updating -TSSBI) Top Secret Security Clearance
- Formal Scrum Master Training (working on Cert)
Languages
English
Full Professional
Timeline
Owner
James Walsh Consulting LLC
02.2023 - Current
Solutions Services Advisor/ Program Manager
Quorum Healthcare (QHR Health)
06.2022 - 02.2023
Medicaid IT Strategy Director/ Program Manager/ Health Plan CIO
CIGNA Healthcare
10.2020 - 04.2022
IT Director / Program Manager/ HealthPlan CIO
United Healthcare of Tennessee
09.2015 - 07.2020
Senior Technical Program Manager
Community Health Systems Inc.
02.2014 - 09.2015
Senior Consultant/Program Manager
Xerox Corporation
04.2013 - 02.2014
Director of Payer Product Management
United Health Group/OPTUM
06.2011 - 04.2013
Implementation Director, Research & Development Director
MediFax EDI - EMDEON Inc. - Change Healthcare Inc.
02.2001 - 04.2011
BBA - Business Administration With Computer Science
Lamar University
MBA -
University of Phoenix