Cesar Morales
Vineland,NJ
Summary
Knowledgeable [Desired Position] with proven history of leading high-performing teams and executing strategic initiatives that drive organizational growth. Successfully directed cross-functional projects that resulted in significant process improvements and operational efficiencies. Demonstrated leadership and communication skills in fostering collaborative environments and delivering impactful results.
Overview
39
39
years of professional experience
1
1
Certification
Work History
Director, Application Development
AmeriHealth Caritas
Philadelphia, PA
08.2014 - Current
- Oversight of vendor development team to ensure quality, compliance, and continuous improvement of LTSS platform.
- Spearheaded migration of a custom application to AWS Cloud improving system scalability, performance, and cost.
- Developed and executed a forward-looking technical roadmap to transition to next-generation LTSS system.
- Long-Term Services Support Program
- ACA Market Implementation
- Successfully delivered first ACA Exchange launch in 2020 achieving quality outcomes and compliance readiness.
- Served as IT Lead for first ACA Exchange implementation in NC and DE.
- Partnered with stakeholders to drive system design, integration, and operational readiness.
- Provider Credentialing and Contract Management
- Managed infrastructure for provider credentialing systems, ensuring compliance, accuracy, and timely processing.
- Directed multiple successful upgrades and enhancements of the McKesson Contract Management platform.
- Collaborated with cross-functional teams to improve credentialing workflows, enhancing provider onboarding efficiency and data integrity.
- Financial Products (Third-Party Liability, Payment Integrity, Newborn State Reimbursement)
- Supported newborn state submission system (EDI 820) responsible for generating over $500M in annual revenue.
- Supported Payment Integrity solutions responsible for generating over $200M in cost savings/avoidance.
- Supported infrastructure of provider credentialing system (Symplr) utilized to track and monitor provider credentialing and contracts.
IS Manager, Electronic Data Interchange
AmeriHealth Caritas
Philadelphia, PA
10.2005 - 07.2014
- Successfully led industry wide HIPAA 5010 upgrade (healthcare transactions 837, 835, 834, etc.)
- Conducted 'Get Ready for 5010' educational webinars to raise HIPAA 5010 awareness across the enterprise.
- Led development effort in establishing AmeriHealth Caritas’ first online provider portal (Navinet).
- Contributed to several industry white papers (WEDI) published in 2011 on HIPAA 5010 testing strategies.
IS Manager, Encounters
Keystone Mercy Health Plan
Philadelphia, PA
12.2001 - 10.2005
- Responsible for day-to-day operations of encounter data submission process.
- Enforced regulatory compliance and coordinated communication of key initiatives across multiple entities.
- Led end-to-end redesign of Encounter process instrumental in improving overall process performance.
IS Product Lead
Keystone Mercy Health Plan
Philadelphia, PA
12.1999 - 12.2001
- Provided technical leadership and future direction on all phases of Facets claim management system:
- Led development of Facets Coordination of Benefit (COB) extension
- Actively participated in identifying operational opportunities and areas of improvement
- Led Peer Review sessions to dissect technical designs and architecture impact
IS Lead Business Systems Analyst
Keystone Mercy Health Plan
Philadelphia, PA
12.1998 - 12.1999
- Led claim conversion of (10M+ claims) from legacy to new claim adjudication system (Facets)
- Subject matter expert of Facets healthcare claim adjudication system
- Established QA testing best practices and programming standards for Sybase programming staff.
Senior Programmer / Analyst
Keystone Mercy Health Plan
Philadelphia, PA
12.1996 - 12.1998
- Provided development support for all core claim modules using Pick Basic language, Visual Studio and Unix
- Led development of first EDI capability to accept claims electronically using standard EDI X12 format.
Multiple positions with increasing responsibilities
Keystone Mercy Health Plan
Philadelphia, PA
12.1994 - 12.1996
- Member Education – Conducted periodic member educational workshops in English and Spanish.
- Member Services Representative – Fielded calls from members via toll free Member Services line (English and Spanish).
Claim Supervisor
Prudential Insurance Company – AARP Operations
10.1991 - 12.1994
- Supported Medicare supplement claim processing in accordance with established claim policies and procedures.
- Coordinated day-to-day activities.
- Supervised and developed claim staff.
Multiple positions with increasing responsibilities
Prudential Insurance Company – AARP Operations
01.1987 - 10.1991
- Claim Examiner
- Member Education
- Member Services Representative (Spanish/English lines)
Education
BS - Management Information Science
University of Maryland, UMBC
Skills
- Oversaw various healthcare transaction formats
- Sybase SQL proficiency
Websites
- http://www.linkedin.com/search?search=&keywords=PA+Health+and+Life+Insurance+Licensed+Agent+%28previously+held%29&sortCriteria=R&keepFacets=true&goback=%2Enmp_ 1_ 1_ 1_ 1_ 1_ 1_ 1_ 1_ 1_ 1
- http://www.linkedin.com/search?search=&keywords=Certified+Professional+in+Healthcare+Information+and+Management+Systems+%28CPHIMS%29&sortCriteria=R&keepFacets=true&goback=%2Enmp_ 1_ 1_ 1_ 1_ 1_ 1_ 1_ 1_ 1_ 1
Accomplishments
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Resolved product issue through consumer testing.
- Achieved [Result] through effectively helping with [Task].
- Achieved [Result] by completing [Task] with accuracy and efficiency.
Certification
- PA Health and Life Insurance Licensed Agent
- Certified Professional in Healthcare Information and Management Systems (CPHIMS)
- Healthcare Compliance Professional
- ITIL Foundation Certificate in IT Service Management
- HIMSS (Healthcare Information and Management Systems Society) member
- WEDI (Workgroup for Electronic Data Interchange) member
Languages
Spanish
Native or Bilingual
Timeline
Director, Application Development
AmeriHealth Caritas
08.2014 - Current
IS Manager, Electronic Data Interchange
AmeriHealth Caritas
10.2005 - 07.2014
IS Manager, Encounters
Keystone Mercy Health Plan
12.2001 - 10.2005
IS Product Lead
Keystone Mercy Health Plan
12.1999 - 12.2001
IS Lead Business Systems Analyst
Keystone Mercy Health Plan
12.1998 - 12.1999
Senior Programmer / Analyst
Keystone Mercy Health Plan
12.1996 - 12.1998
Multiple positions with increasing responsibilities
Keystone Mercy Health Plan
12.1994 - 12.1996
Claim Supervisor
Prudential Insurance Company – AARP Operations
10.1991 - 12.1994
Multiple positions with increasing responsibilities
Prudential Insurance Company – AARP Operations
01.1987 - 10.1991
BS - Management Information Science
University of Maryland, UMBC
EXTERNAL PROFESSIONAL ACTIVITIES
- Independent Real Estate Investor/Property Management
- Big Brothers Big Sisters (Mentor and Board Member)
- Technology Career Advocate/Coach (radio/TV guest speaker)
- CAM Technology Scholarship Founder
- Program Advisory Committee Member for CCTEC (Business/Technology)
- Community Hero Award (Bridgeton Chamber of Commerce)