Carlos Manuel Quintero Jr.
Miami,Florida
Summary
Business Analyst with robust analytical skills and proven track record in driving impactful decisions. Strong focus on team collaboration, adaptable to changing needs, and consistently delivers results. Expertise in data analysis, process improvement, and stakeholder engagement, coupled with keen ability to translate complex data into actionable insights. Reliable and goal-oriented with commitment to excellence in every project.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Business Analyst IV
Centene Corporation/Shared Services (Utilization Management) Reporting
10.2022 - Current
- Work with business stakeholders to understand business processes and procedures
- Conduct business process reviews with key stakeholders and document report requirements
- SME in knowing how existing reports, tools, and software applications support current business processes
- Work with internal development team on new and existing production reports/tools and application enhancements
- Facilitate meetings with Data Analysts to discuss report requirements and ensure final report satisfies all requirements being requested
- Conduct meetings and presentations to share ideas and findings with key business stakeholders
- Demonstrate reports to key stakeholders and gather sign-off before rolling out to production
- Develop ad-hoc reports to support business needs
- Develop production and performance reports and dashboards in ServiceNow for business areas
Business/Data Analyst (Utilization Management)
Humana/Clinical Operations (Utilization Management) Reporting
01.2020 - 10.2022
- Supported the business in development and scheduling of all reports utilized by the Health Services Department
- Worked with a team of Data Analysts & Project Managers on the development of a Microsoft Power BI Dashboard that held all operational and compliance reports for the Health Service Operations team
- Led the HSO reporting team on an organizational wide system migration project from a data and reporting standpoint
- Collaboratively worked with Health Service Leaders/SMEs in gathering report requirements and user stories for all active departmental HSO reports
- Worked closely with the Data Transformation team, IT architects, and business systems analyst in data mapping/validation, User Acceptance Testing, and ensuring all identified release 1 reports by report stakeholders are ready for Project Genesis Go live
Senior Pharmacy Compliance Professional
Humana/Clinical (Utilization Management) Operations
10.2016 - 01.2020
- Reviewed and analyzed local, state, and federal rules and regulations to identify impacts to all pharmacy processes
- Supported the pharmacy department in all regulatory, third party, and accreditation audits including preparation and submission of documentation
- Maintain all active pharmacy department policies up to date and aligned with CMS requirements/new or revised regulatory guidance
- Validated and submitted large pharmacy data sets to the Operational Risk Management team monthly to ensure audit readiness
- Lead preparation efforts for all Pharmacy internal/external mock/live audits including presentation of cases to auditors
- Received a Humana Star Award for successfully leading all efforts on two CMS Audits in 2019
- Worked with counterparts/pharmacy stakeholders on identifying root causes and develop corrective action plans for issues found by the auditor during audits
- Validated & submitted all Pharmacy Department compliance metrics to the Risk Management team monthly
- Facilitated quarterly risk assessment analysis meetings with pharmacy leaders to identify any areas of improvement and/or to mitigate any identified risks/issues by the business areas
- Mapped all core pharmacy operation and compliance processes using cross-functional diagrams using Visio to identify pain points and areas for process improvements to eliminate waste as well as reduce compliance risks
- Worked closely with management to develop, plan, and deliver training for department associates, including creating and maintaining up-to-date training manuals, flowcharts, and desktop procedures
- Supported and maintained a good rapport with business stakeholders across the enterprise, including making and responding to requests, owning, and facilitating regular meetings, and maintaining a communication plan
HEDIS Project Analyst
Humana/Quality Improvement
02.2016 - 10.2016
- Managed the ART (Disease Modifying Anti-Rheumatic Drug Therapy) and OMW (Osteoporosis Management in Women) HEDIS measures
- Worked closely with the Quality Improvement Informatics team as well as all QI Nurses, AEs, and HEDIS Clinical Advising Pharmacists to close all RA/OMW gaps
- Collaborated with the QI Director and Stars Maximization Project Manager in developing new strategies to enhance and improve our HEDIS rates for both ART/OMW measures
- Provided monthly updates to the Quality Improvement/Stars team and leadership regarding current star rating status for both ART/OMW measures
Clinical Pharmacy Utilization Management Lead
Humana/Pharmacy Clinical Programs
03.2015 - 02.2016
- Proficiently supervised a team of 7 pharmacy technicians and served as a SME for the Medicare Part D Clinical Review team
- Conducted daily internal audits on all coverage requests received by the pharmacy operational area to ensure appropriateness and timeliness
- Held weekly staff meetings to discuss any regulatory changes that impacted the business area
- Worked closely with all department leads to ensure organization alignment on any regulatory or operational changes
- Trained/Coached new and current pharmacy department associates
Clinical Pharmacy Utilization Management Specialist
Humana/Pharmacy Clinical Programs
12.2012 - 03.2015
- Conducted drug utilization review (DUR) and resolved drug edit rejections daily as part of the Medicare Part D Pharmacy Clinical Review team
- Received a Humana Shining STAR award for lead production for 12 consecutive months in recognition of hard work and leadership
- Handled all Direct Member Reimbursement (DMR) claim adjudication requests for the pharmacy department
Education
Master of Science - Health Informatics & Analytics
Florida International University
01.2018
Bachelor's degree - Biological Sciences
Florida International University
01.2013
Associate of Arts - Pre-Pharmacy Studies
Miami Dade College
01.2006
Skills
- Microsoft Power BI
- Data visualization
- Waterfall and Agile methodologies
- Reporting and documentation
- Process improvement
- Stakeholder management and communication
- Time management
- Multitasking and organization
- Strategic thinking
- Data analysis
- Requirements gathering and documentation
- Team collaboration
- Microsoft Office Suite
- Project management
- Microsoft Excel mastery
- Business process improvement
- Strategic planning
- SQL proficiency
Accomplishments
- Led team to meet [Number]% of SLAs by streamlining business processes and identifying areas for improvement.
Affiliations
2023 Project Management Institute Member PMI
Certification
- Issued. 2023 PMP – Project Management Professional PMI
- Issued. 2018 Lean & Six Sigma Yellow Belt Certified GoLeanSixSigma
- Issued. 2001 CPhT – Nationally Certified Pharmacy Technician PTCB
- Issued. 2001 RPT – State of FL Registered Pharmacy Technician Division of MQA
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Timeline
Business Analyst IV
Centene Corporation/Shared Services (Utilization Management) Reporting
10.2022 - Current
Business/Data Analyst (Utilization Management)
Humana/Clinical Operations (Utilization Management) Reporting
01.2020 - 10.2022
Senior Pharmacy Compliance Professional
Humana/Clinical (Utilization Management) Operations
10.2016 - 01.2020
HEDIS Project Analyst
Humana/Quality Improvement
02.2016 - 10.2016
Clinical Pharmacy Utilization Management Lead
Humana/Pharmacy Clinical Programs
03.2015 - 02.2016
Clinical Pharmacy Utilization Management Specialist
Humana/Pharmacy Clinical Programs
12.2012 - 03.2015
Bachelor's degree - Biological Sciences
Florida International University
Associate of Arts - Pre-Pharmacy Studies
Miami Dade College
Master of Science - Health Informatics & Analytics
Florida International University
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