John Spoll
Amarillo
Summary
IT professional with a proven track record of developing software based upon the analysis of critical business functions. Detailed knowledge of Commercial Insurance, specifically workers' compensation and auto liability claim management and related cost - containment, medical bill review and ancillary services. SME is Hour - banking Group Health Eligibility as well.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Senior Director Product Management Medical & TPA
Capital - Rx
08.2022 - 07.2023
- Product Owner/Scrum Team Manager developing Hours - Banking Eligibility, Claims Administration and Medical Bill Review Systems.
- Worked collaboratively with developers, senior-level stakeholders and partners to collect data on deficiencies and provide solutions to long-standing issues.
- Translated information highly technical in nature to investors and senior staff and aligned product strategy with market.
- Identified productivity bottlenecks and devised innovative solutions while remaining conservative with resources.
- Advocated for and advertised products in field.
- Led a Scrum Team
Senior Business Analyst and Product Manager
Conduent Casualty Solutions
01.2020 - 08.2022
- Product Manager of their Citadel Platform which supported Nurse Case MAnagement, Utilization Review feeds and Medical Bill Review
- Analyzed data to identify root causes of problems and recommend corrective actions.
- Collaborated with stakeholders to identify business needs and data sources.
- Developed customized reports, summarizing and presenting data in visually appealing format.
- Provided technical support for troubleshooting analytics and reporting issues.
- Utilized data visualization techniques to present and explain complex data sets.
Senior Business Analyst
Aetna/Coventry (CVS Health)
09.2017 - 11.2019
- Analyzed and documented the critical business functions, supporting business processes, and testing of enterprise software.
- Conducted root cause analysis to pinpoint issues and develop process improvements and implementation capabilities.
- Integrated overall user experience in manual repricing of workers' compensation medical bills.
- Managed the mapping of how the application captured savings to specific financial categories (RARC and CARC), Payment files, EDI Mockups and workflows.
- Subject Matter Expert (SME) on Code Pairs (NCCI Edits), Utilization Review and Workers' Compensation Payment methodologies and systems.
Sr. Business Analyst & Medical Bill Review Manager
StrataCare
06.2011 - 06.2019
- Managed an On-site Bill Review Service Center and performed Business ANalysis.
- Analyzed and documented critical business functions, supporting processes, and testing of enterprise software.
- Conducted root cause analysis to pinpoint issues and develop process improvements and implementation capabilities.
- Integrated overall user experience in manual repricing of worker's compensation medical bills.
- Increased the number of financial categories that captured savings based upon different algorithms.
- Supported leadership team with reporting, analysis, and business presentations to inform divisional strategies.
- Managed team performance by implementing measurable metrics to track delivery of supporting requirement artifacts.
- Worked with team leads and managing leadership, establishing robust talent pool with focus on people and continuous improvement.
Senior Business Analyst
Mitchell International, Inc.
04.2009 - 06.2011
- Wrote technical specifications for their Smart Advisor Medical Bill Review Engine (BRE) for the repricing of medical claims resulting from auto liability claims.
- Reviewed Medicare - based repricing and auto fee schedule directives (CPT, ICD - X, DRG, HCPCS)
- Supported leadership team with reporting, analysis, and business presentations to inform divisional strategies.
- Worked with team leads and managing leadership, establishing robust talent pool with focus on people and continuous improvement.
Senior Business Analyst
Texert
11.2007 - 03.2009
- Wrote technical specifications for their governance risk assessment and loss event reporting tools.
- Created User Guides
- Led cross - functional teams with globally-located teammates
- Supported leadership team with reporting, analysis, and business presentations to inform divisional strategies.
- Managed team performance by implementing measurable metrics to track delivery of supporting requirement artifacts.
Sr. Business Analyst & Project Manager
Corporate Systems
10.2000 - 10.2007
- Wrote technical specifications for their Claim Suite Bill Review Engine (BRE).
- Served as part of their Research & Development Team
- Monitored State and Federal Compliance
- Drafted their HIPAA requirements and served on their implementation team.
- Co - authored their release calendar
- SME in medical bill review, medical case management, FROI, PPO, Internal Tools, CRM, JIRA, Confluence, PDS
- Workload prioritization and refinement
- Managed team performance by implementing measurable metrics to track delivery of supporting requirement artifacts.
- Worked with team leads and managing leadership, establishing robust talent pool with focus on people and continuous improvement.
Regional Business Manager
Concentra Managed Care
05.1994 - 08.2000
- Managed the day-to-day operation of fourteen (14) medical bill review processing sites.
- Court - accepted expert on medical databases and fee reimbursement
- Sat on Connecticut Billing and Payment Committees and Managed Care Alliance.
- Drove year-over-year business growth while leading operations, strategic vision, and long-range planning.
- Chaired weekly meetings with executive leadership to identify opportunities for improvement, establish milestones, and tailor products to individual markets.
Education
Bachelor of Science - Economics And Finance
University of Hartford
West Hartford, CTSkills
- Certified Scrum Product Owner
- Trailblazer - Medicare Certified
- Document Oversight
- Current Trends
- Gap Analysis
- Data Acquisition
- Cross-Training Skills
- Collaboration Software
- Productivity Management
- Channel Optimization
Accomplishments
- Court - accepted expert on medical fee payment methodologies
Certification
- Scrum Alliance - Certified Scrum Product Owner
- Trailblazer - Medicare certification
- ICD - 10 certification (Yale University)
Timeline
Senior Director Product Management Medical & TPA
Capital - Rx
08.2022 - 07.2023
Senior Business Analyst and Product Manager
Conduent Casualty Solutions
01.2020 - 08.2022
Senior Business Analyst
Aetna/Coventry (CVS Health)
09.2017 - 11.2019
Sr. Business Analyst & Medical Bill Review Manager
StrataCare
06.2011 - 06.2019
Senior Business Analyst
Mitchell International, Inc.
04.2009 - 06.2011
Senior Business Analyst
Texert
11.2007 - 03.2009
Sr. Business Analyst & Project Manager
Corporate Systems
10.2000 - 10.2007
Regional Business Manager
Concentra Managed Care
05.1994 - 08.2000
Bachelor of Science - Economics And Finance
University of Hartford
Similar Profiles
JEANETTE OGILVIEJEANETTE OGILVIE
INBOUND CUSTOMER SERVICE REP. at CAPITAL RX PBMINBOUND CUSTOMER SERVICE REP. at CAPITAL RX PBM
William TafoyaWilliam Tafoya
Senior Vice President, Operations at Capital RxSenior Vice President, Operations at Capital Rx
Chawndonna LonginoChawndonna Longino
PA Pharmacy Technician at Capital RxPA Pharmacy Technician at Capital Rx
Amanda FetauiAmanda Fetaui
Remote Pharmacy Customer Service Representative at Capital RxRemote Pharmacy Customer Service Representative at Capital Rx
Noah ReneauNoah Reneau
Cashier - Good4U Crew at Natural GrocersCashier - Good4U Crew at Natural Grocers