Summary
Overview
Work History
Education
Skills
Accomplishments
Healthcareindustrysystemskills
Languages
Timeline
Generic

KRUPESH SHAH

Phoenix,AZ

Summary

Results-driven professional with 21 years of experience in the healthcare industry , specializing in business systems analysis, computer information systems, and program development. A collaborative leader with expertise in analyzing business needs, identifying problems, and delivering effective solutions while inspiring cross-functional teams to achieve exceptional results.


Known for dependability and customer relationship management , enhancing business profitability and client satisfaction. Skilled in HIPAA compliance, Medicare/Medicaid plan establishment, and financial standards documentation. Successfully brought large-scale projects into timeline and budgetary compliance at CVS Health.


Marketing expertise includes graphic design, copywriting, and project management, consistently delivering creative strategies that drive results. A fast learner with strong analytical, problem-solving, and communication skills, dedicated to continuous growth and advancing organizational objectives.

Overview

17
17
years of professional experience

Work History

Preventive Action Lead | Sr. Product Analyst

Optum
06.2020 - 05.2024
  • Leadership of Preventive Action Program: Managed the end-to-end preventive action program, spearheading projects to reduce issues and improve turnaround times.
  • Root Cause Analysis: Maintained and updated the Root Cause Master Table to facilitate effective issue resolution.
  • Cost of Poor Quality Management: Oversaw the implementation and monitoring of Cost of Poor Quality standards to drive operational excellence.
  • Dashboard Development & Reporting: Collaborated with the Enterprise Reporting & Analytics team to create real-time dashboards and metrics for tracking service-level performance and business performance metrics.
  • Command Center Coordination: Partnered with Command Centers and resolution teams to develop and maintain the Command Center Playbook, streamlining operations.
  • Issue Resolution Leadership: Monitored issue resolution performance, ensuring SLAs are met while driving continuous improvement initiatives.
  • Project Management: Led high-impact projects focused on preventing recurring issues and implementing sustainable solutions.
  • Stakeholder Relationship Management: Cultivated effective cross-functional relationships to facilitate smooth issue resolution and preventive actions across the organization.
  • Readiness Assessments: Supported evaluations for new products and initiatives, ensuring systems are in place for proactive issue management.
  • Proactive Issue Resolution: Facilitated swift resolution of issues, escalated when necessary, and ensured clear communication with stakeholders.
  • Cross-Functional Collaboration: Partnered with departmental leaders to prioritize and implement preventive action strategies, achieving a 68% reduction in issue turnaround time for the Optum RX platform.
  • Data Analysis & Reporting: Analyzed data to uncover insights for strategic decision-making and generated comprehensive reports for marketing plans and top-level decision-makers.

Sr. Business Analyst

Magellan Health
08.2015 - 06.2020
  • Life Cycle Development & Collaboration: Participated in full life cycle development through requirements analysis, process design, and testing while collaborating with functional teams, IT analysts, and programmers to develop design specifications in line with organizational standards.
  • Liaison Role: Acted as a liaison between business owners, end users, IT, Claims, and Clinical departments to ensure alignment on objectives and effective communication.
  • Reporting & Dashboard Development: Provided reporting support through detailed network matches, provider maps, and ad hoc reports, while creating and maintaining periodic provider and claims-related reports and dashboards, including standard and custom reports, to enhance visibility into operational and network development.
  • Workflow Documentation & Project Management: Developed workflows, system requirements, and process analyses to deliver efficient solutions while managing small to medium-sized projects and system enhancements impacting provider data management.
  • Training & Industry Awareness: Conducted training for new employees and ongoing team members to enhance skills, staying current on software trends and best practices to ensure competitiveness.
  • Client Reporting & Performance Improvement: Managed projects for new clients, generating specific reports and dashboards, and implemented initiatives to improve accuracy and turnaround time for internal network reports.
  • Requirements Gathering & Leadership Support: Engaged with internal customers to gather business needs and translate them into project scope, assisting leadership with reporting and analysis to inform divisional strategies.
  • Data Insights & Governance: Analyzed large data sets to identify trends and provide actionable insights, while developing data governance policies to ensure integrity and compliance.
  • Program Implementation: Successfully implemented the Magellan RX (GoodRx) Discount Program nationwide for network pharmacy chains, ensuring smooth execution and accessibility.

Sr. Client Benefit Analyst

CVS Health
11.2012 - 07.2015
  • Documentation & Compliance: Secured and managed appropriate documentation to meet financial standards and government regulations, ensuring compliance with federal and state requirements in healthcare.
  • Market Segment Support: Provided comprehensive support for multiple market segments across diverse products and complex client plan designs, facilitating tailored solutions that address unique client needs.
  • Research & Analysis: Conducted thorough research and analysis to provide actionable insights to internal partners regarding client benefit setup, enhancing operational efficiency and client satisfaction.
  • System Expertise & Recommendations: Leveraged system expertise to recommend alternative solutions for benefit setup, aligning client intentions with organizational capabilities and operational processes.
  • Client Engagement: Worked directly with clients and participated in client calls, fostering strong relationships and ensuring alignment on benefit plans and services.
  • Cross-Functional Collaboration: Actively contributed to the Health Plans Team, assisting in maintaining relationships with large, complex health plan clients and successfully winning new government business through strategic initiatives.
  • Project Management & Implementation: Managed projects for new benefit clients, successfully implementing Medicaid business initiatives that expanded the organization's service offerings and enhanced market competitiveness.
  • Performance Metrics Development: Developed advanced dashboards and reporting tools to track key business performance metrics, enabling data-driven decision-making and strategic planning.
  • Efficiency & Quality Improvement: Created over 1,000 macros to streamline coding, testing, and quality checks, significantly enhancing operational efficiency and ensuring high-quality outcomes in implementing new healthcare plans.

Client Benefit Analyst

CVS Health
10.2010 - 11.2012
  • Analyze client documentation to interpret client intent
  • Validate testing results to ensure client intent outcome
  • Able to meet aggressive turnaround time standards/client performance guarantees coupled with excellent quality
  • Created new Quality Check points system for Benefits team for more accuracy
  • Responsible of creating more than 1000 macros for coders for faster coding with 100% accuracy
  • Resolved issues and inquiries from plan participants regarding health and welfare benefits and deductions through telephone, email, and in-person interactions.
  • Built relationships with vendors to foster quality service delivery.
  • Analyzed and evaluated existing compensation and benefits programs and recommended improvements.

Client Benefit Specialist

CVS Health
10.2007 - 10.2010
  • Benefit Plan Management: Performed coding for clients' benefit setups, ensuring accurate and timely implementation while adhering to regulatory guidelines and client specifications.
  • Quality Assurance: Utilized quality and testing tools to self-monitor work output, consistently meeting or exceeding turnaround time and client performance guarantees. My commitment to maintaining high-quality standards is reflected in my receipt of Quality Excellence awards every quarter for exceptional benefit coding accuracy.
  • Performance Metrics: Focused on optimizing processes to enhance operational efficiency, ensuring positive claim adjudication outcomes and fostering client satisfaction.
  • Client Communication: Maintained open communication with clients to address inquiries and provide updates on their benefit plans, ensuring they understand coverage, limitations, and the claims process.
  • Collaboration: Worked closely with pharmacists, healthcare providers, and internal teams to resolve any issues related to client benefits, facilitating a seamless experience for all stakeholders and enhancing patient care.
  • Overall, my role combines technical expertise, strong communication skills, and a commitment to quality, enabling me to effectively support clients and contribute to the organization’s success.

Education

Bachelor of Science - Global Business

Arizona State University (ASU)
Glendale, AZ
01.2008

Certificate of Technical Studies - Information Technology

Government of Gujarat
India
07-2001

Skills

  • Business Analysis & Project Management: Proficient in Agile methodology, Scrum framework, critical path identification, and product portfolio management
  • Data Analytics & Technology: Expertise in data modeling, Power BI, Python programming, data quality monitoring, and software development methodologies
  • Healthcare & Compliance: Knowledgeable in Medicare/Medicaid plan establishment, HIPAA compliance, and PBM operations
  • Leadership & Team Management: Skilled in mentoring teams to meet project timelines and objectives
  • Marketing & Strategy: Experienced in creative marketing strategies, graphic design, and campaign management
  • Problem-Solving & Organization: Strong analytical, problem-solving, and organizational skills with a focus on results

Accomplishments

  • Enhanced Operational Efficiency : Spearheaded process improvement initiatives as Preventive Action Lead at Optum, streamlining workflows and improving turnaround times by 20%.
  • Cost Savings Achievement : Identified inefficiencies in client benefit plans at CVS Health, resulting in cost savings of over $250,000 annually.
  • Data-Driven Decisions : Implemented advanced Excel and Visio-based reporting tools to support executive decision-making, improving data visualization accuracy by 30%.
  • Healthcare Expertise : Successfully managed complex cross-functional projects within healthcare organizations, contributing to regulatory compliance and operational excellence.
  • Mentorship and Leadership : Trained and mentored junior analysts, fostering professional growth and enhancing team productivity.
  • Innovation in Problem-Solving : Designed a SharePoint-based knowledge management system, reducing information retrieval time by 40%.
  • Recognition for Excellence : Awarded multiple performance accolades for outstanding contributions to project delivery and client satisfaction.

Healthcareindustrysystemskills

  • Eclipse 3270
  • Rx-Claim
  • Salesforce
  • Laker
  • OnDemand Reports
  • Ombud
  • EZ-Query
  • EZTEST
  • EnterpriseNow (ServiceNow)

Languages

English
Hindi
Gujarati

Timeline

Preventive Action Lead | Sr. Product Analyst

Optum
06.2020 - 05.2024

Sr. Business Analyst

Magellan Health
08.2015 - 06.2020

Sr. Client Benefit Analyst

CVS Health
11.2012 - 07.2015

Client Benefit Analyst

CVS Health
10.2010 - 11.2012

Client Benefit Specialist

CVS Health
10.2007 - 10.2010

Bachelor of Science - Global Business

Arizona State University (ASU)

Certificate of Technical Studies - Information Technology

Government of Gujarat

Similar Profiles

CREATE PROFILE
KRUPESH SHAH