Pamela Sims
Dade City,FL
Summary
Accomplished, solutions-focused professional with 15+ years’ experience driving innovation and improvement for diverse players in healthcare industry. Proven ability to conduct top-to-bottom business and systems analysis and pinpoint avenues for enhancing data management, procedural standards, and patient experience. Respected for capacity to direct cross-functional teams while maintaining effective relationships with technical and business leadership as well as other stakeholders. Advanced knowledge of leading healthcare programs, tools, and systems; adept in conducting testing processes and delivering hands-on training and support for users. Well-educated with bachelor’s degree in biopsychology as well as training in project management, Lean Six Sigma methods, and leadership. Committed to ensuring customer satisfaction by providing exceptional service and unmatched support. Proficient in utilizing customer service best practices and adept at exploring different solutions to address customer needs effectively. Effective and organized with drive for fostering exceptional patient care and overall efficiency. Knowledgeable and dedicated customer service professional with extensive experience in healthcare industry. Solid team player with outgoing, positive demeanor and proven skills in establishing rapport with clients. Motivated to maintain customer satisfaction and contribute to company success. Specialize in quality, speed and process optimization. Articulate, energetic and results-oriented with exemplary passion for developing relationships, cultivating partnerships and growing businesses.
Overview
35
35
years of professional experience
1
1
Certification
Work History
Clinical Applications Manager
MOFFITT Cancer Center
03.2021 - Current
- Drives hospital wide clinical operational support by providing oversight on all activity related to assessment, planning, implementation and post-delivery of complex enterprise-wide cross functional programs, requests, or projects
- Oversight of clinical charge management, production issue resolution, mobile device management, clinical application integration, custom reporting, and software development for electronic health record
- Manage operations of 11-person team of Analysts and Developers including hiring, performance appraisals, and budgeting
- Liaised with hospital and IT functional units to ensure quality solutions, on-going support and fulfill of overall Moffitt technology vision
- Implemented improvements that resulted in 20% reduction in issue SLA for CS Tier2
- Oversaw yearly planning and implementation of Dragon dictation software with 100% adoption from providers.
- Facilitated successful software upgrades by coordinating testing, training, and rollout procedures for clinical staff
- Collaborated with IT department to troubleshoot technical issues, improving system reliability and user experience
Sr. Project Manager
CarePlus/Humana
09.2019 - 03.2021
- Directed planning and implementation of new integrated health plan platform
- Health plan systems and processes improvement initiatives
- Developed solutions design, identified project scope, determined requirements, and created change management strategies
- Authored and implemented project work plans, and liaised with clients, stakeholders, and vendors throughout process
- Oversaw implementation of new member and provider portals and coordinated change management strategies to ensure seamless transition.
Business Relationship Manager/Project Manager
mhk formerly MedHOK inc.
09.2018 - 09.2019
- Directed planning and implementation of on-going software enhancements and monthly application configuration
- Provide oversight for all aspects of production support and value-added vendor integrations and initiatives
- Identified project scope and created change management strategies
- Authored and implemented project work plans, and liaised with clients, stakeholders, and medical management teams throughout process
- Managed project cost within confines of statement of work
- Oversaw transition of new modules from implementation to production support.
Principal Consultant
CAPITAL BLUE CROSS
01.2014 - 09.2018
- Drive enterprise development and improvement through oversight of projects centered on clinical operations, utilization management, provider and network engagement, vendor management, accreditation, and quality and compliance
- Oversee 21-person analytics and reporting team executing full scope of project activities; ensure attainment of budget and schedule targets and swiftly resolve issues and roadblocks
- Managed team operations included hiring, performance appraisals, and budgeting
- Stakeholder relationship management within and outside organization
- Effectively managed team responsible for rollout of Healthcare Effectiveness Data and Information Set (HEDIS) programs impacting commercial and government lines of business on enterprise-wide scale, with results including enhancing medical program efficiencies and provider incentives by 40% and development of new clinical data feeds, improving volume of data drawn from electronic health records (EHRs) by 35%
- Produced $900K savings in vendor fees by leading implementation of new population health and clinical management software enabling elimination of three vendor tools.
Sr. Care Management Consultant/Project Manager
CAPITAL BLUE CROSS/GENEIA
06.2012 - 01.2014
- Directed planning and implementation of clinical systems and processes improvement initiatives
- Developed solutions design, identified project scope, determined requirements, and created change management strategies
- Authored and implemented project work plans, and liaised with clients, stakeholders, and medical management teams throughout process
- Oversaw implementation of new Accountable Care Arrangement (ACA), representing first-of-its-kind agreement between health care system and insurer in state; coordinated customized care plan design and production of clinical management deliverables
- Exceeded expectations in simultaneous management of 12 clinical and corporate projects
- Steered research, selection, and sourcing of new $1.5M clinical performance management tool bolstering outcomes in case, disease, and utilization management
- Reduced costs of care by 25% through collaborative development of Patient Centered Medical Neighborhood (PCMN).
- Managed client relationships by maintaining regular contact and providing timely updates on project progress, ensuring satisfaction with outcomes and fostering long-term partnerships
ELR SME/Data Analyst
PA DEPT OF HEALTH
10.2011 - 05.2012
- In contract engagement, managed system transformation projects to include establishing project plans, creating schedules, and leading all project tasks in coordination with internal/external business partners
- Met objectives for successful transition of 10 hospital systems from manual to batch submission of ELR data to health department in compliance with HL7.
Sr. Applications Systems Analyst/Project Manager
CARROLL HOSPITAL CENTER
02.2009 - 10.2011
- Led implementation of new computer-based hospital applications
- Interfaced with end users to assess and document system requirements
- Led planning and coordination in alignment with project plan
- Configured application for users, implemented testing activities, and provided training and support
- Spearheaded deployment of McKesson Practice Plus physician practice management software within hospital departments, generating 35% gain in procedural efficiencies
- Within hospital call center, implemented McKesson Care Enhance Call management software, yielding improvements in letter generation process and class scheduling of 60% and 40%, respectively, while also minimizing missed calls
- Eliminated paper orders and improved efficiencies by 45% via new computerized physician order entry (CPOE) and EMR.
- Created detailed documentation for both internal reference and client-facing presentations, improving communication between stakeholders
- Provided client support on system operation and troubleshooting
Functional Lead/Release Manager
CGI FEDERAL
10.2007 - 02.2009
- Ensured successful outcomes for design and implementation of modifications to Premium Withholding System (PWS) for Medicare beneficiaries
- Led systems analysis, facilitated change requests, controlled project plans and schedules, and validated business and system requirements
- Monitored contributions of functional project team and led weekly status meetings
- Expertly executed dozen critical updates to Medicare Advantage Plan (MAPD) premium withholding system; achieved 99% error rate on testing of new processes and updates
- Earned reputation for consistent on-time delivery, meeting deadlines in 90%+ of all cases.
Lead Business Analyst
CareFirst Thru CPSI
07.2005 - 10.2007
- Participates as team leader or lead business representative in the design and implementation of new system initiatives
- Completed the planning, scheduling, and coordination of task for Medicare Advantage PFFS and Medicare Secondary Payor Voluntary Data Sharing Agreement projects system project
- Defines, documents, and validates new business and system requirements
- Lead the analysis of existing business processes and systems to recommend process and system enhancements to improve business performance and maximize the effectiveness of available technology
- Develops or collaborates with other staff in the development of user documentation and training for system implementations and enhancements.
Sr. Systems Analyst
Computer Sciences Corporation Thru Tek Systems
01.2006 - 01.2006
- Interacts with client, CMS or other contracted vendors, to complete custom business requirements for MMA (Medicare Modernization Act) changes to Medicare Advantage Prescription Program (MARx)
- Execute ad hoc DB2 queries in QMF
- Utilize DB2 to verify files and complete analysis of production tickets from MARx clients
- Write and maintain Interface Control Documents (ICD’s).
Sr. Business Analyst
Dakota Imaging/WebMD
07.2004 - 07.2005
- Primarily responsible for management of HealthClaim Expert product suites related to product improvements, standardized testing, process flows, and implementations
- Interact with clients to develop custom business requirements, crosswalks, training guidelines, functional specifications, and standardized implementation documents
- Complete analysis and testing to ensure that output files are in correct format of either 837 or NSF
- Perform Project Management duties for internal and external projects
- Developed Estimate Request forms for clients requesting time and cost estimates.
Provider Configuration Analyst III, Team Lead
Kaiser Permanente
06.2003 - 07.2004
- Functions as expert regarding provider contracts and provider payment strategies
- Analyze, create, modify, and test provider contract and capitation records to ensure that system prices accurately and in accordance with contract terms
- Complete analysis of provider contracts to determine best approach for configuring data in DIAMOND and other CSSO systems
- Ensure quality of provider and vendor data loading
- Set up and maintain provider contract and capitation files
- Create ad-hoc provider reports
- Analyze and make recommendations to management regarding required system enhancements and communicate system issues relative to provider contracts
- Supervise and manage day-to-day operations of Provider Data Analyst team
- Mentor and instruct other analysts.
Business Analyst/Project Manager
Destiny Health
07.2002 - 06.2003
- Functioned as a business liaison between the Destiny Health business users and the product and web development areas
- Conducts research with the business user and /or domain and systems experts to thoroughly understand and analyze the business problem to be solved or process to be enhanced
- Produce process models, high-level use case models and documentation describing business processes, system requirements and business rules
- Created and executed test plans and test scenarios to ensure satisfactory delivery of completed project.
Lead Business Analyst
Magellan Health Services
10.2001 - 07.2002
- Served as business liaison to programming department, as well as participated with maintenance and enhancement of software development lifecycle
- Responsible for development of Electronic Data Interfaces (EDI) for membership databases
- Leading various projects, and leading and overseeing creation of requirements documents, mapping specifications, test scenarios, and definition and execution of test plans.
Core Implementation Manager
RewardsPlus
10.2000 - 10.2001
- Coordinates all operational activities required to successfully implement direct accounts with both Voluntary and Core (Health, Dental, and Life Insurances) benefits
- Work heavily with client base and internal departments to ensure that project plans run smoothly and on schedule
- Work with the client to obtain health, dental and life insurance plan information, obtain eligible employee rules and guidelines, and determine the appropriate incoming and outgoing reports and files
- Responsible for overseeing the integration of information obtained from client into web, call center, and IVR enrollment applications
- Coordinated product enrollments including onsite, mail and web for any enrolled products selected by the account
- Responsible for overseeing the development and execution of interfaces to employers and provider for enrollment programs, and web sites for online enrollment.
Systems Consultant
basys inc
08.1996 - 10.2000
- Complete implementations and installations of health care benefits and short-term disability software
- Convert existing plan SPD into design for implementation of benefits on desired system
- Installed and implemented claims exports and imports using OCR, EDI, and provider vendors fee schedules
- Analyzed, designed, and tested customer specific software
- Instructed customers and employees on modules of specialization
- Provided telephone and on-site support to assist in resolution of software and hardware related issues for end-users
- Completed data conversions from foreign systems to unix/unidata database
- Provided system maintenance for customers to include systems disk management, file sizing, fixing corrupted files, and restoring files
- Acted as role model and mentor for new team members.
Lead Full-Service Representative
CareFirst Blue Cross Blue Shield
02.1989 - 07.1996
- Led team of Full-Service Reps and Claims Examiners for government programs
- Managed resolution of complex adjudication and adjustment issues
- Served as mentor for other representatives and examiners
- Managed customers and issues and complaints in high volume call center
- Acts as liaison between Group Administrators and CareFirst Account Management for questions and issues regarding claims payments and benefit interpretation based on group’s schedule of benefits.
Education
Bachelor of Art - Biopsychology
UNIVERSITY OF MARYLAND BALTIMORE COUNTY
Catonsville, MDSkills
- UNIX
- McKesson Programs (Care Enhance Call Center, Practice Plus Physician Practice Management, Practice Partners EMR/Practice Management, Horizon Homecare & Hospice, Horizon Clinical)
- HIPAA Desk
- ClarEDI
- FACETS
- Clinical CareAdvance
- Geneia Programs (Care Optimizer, Care Collaborator, Care Enhancer)
- Cerner EMR
- DB2
- DOORS
- Code Wright
- SQL
- Diamond
- Magic
- KRONOS
- File Aid
- QMF
- Test Director/Mercury Quality Center
- QTest
- Crystal Reports
- Salesforce
- Uniquery
- Unibasic
- JIRA
- Confluence
- SharePoint
- OpenAir
- ServiceNow
- SmartSheets
- MS Office (Word, Excel, Project, PowerPoint, Access, Visio, OneNote)
- Call Management
- Data Entry
- Report Generation
- Building rapport
- Conflict Mediation
- Active Listening
- Prioritization
- Client Relations
- Medical terminology knowledge
- Escalation management
- Call Center Operations
- Problem Resolution
- Customer Service
Certification
- Certified Employee Benefit Specialist (CEBS) Course – ANNE ARUNDEL COMMUNITY COLLEGE
- Project Management Certificate – FRANKLIN COVEY
- Project Management Course – HARRISBURG UNIVERSITY
- Lean Six Sigma Course – MANAGEMENT & STRATEGY INSTITUTE
- Leadership Edge Training – CBC TALENT MANAGEMENT
Timeline
Clinical Applications Manager
MOFFITT Cancer Center
03.2021 - Current
Sr. Project Manager
CarePlus/Humana
09.2019 - 03.2021
Business Relationship Manager/Project Manager
mhk formerly MedHOK inc.
09.2018 - 09.2019
Principal Consultant
CAPITAL BLUE CROSS
01.2014 - 09.2018
Sr. Care Management Consultant/Project Manager
CAPITAL BLUE CROSS/GENEIA
06.2012 - 01.2014
ELR SME/Data Analyst
PA DEPT OF HEALTH
10.2011 - 05.2012
Sr. Applications Systems Analyst/Project Manager
CARROLL HOSPITAL CENTER
02.2009 - 10.2011
Functional Lead/Release Manager
CGI FEDERAL
10.2007 - 02.2009
Sr. Systems Analyst
Computer Sciences Corporation Thru Tek Systems
01.2006 - 01.2006
Lead Business Analyst
CareFirst Thru CPSI
07.2005 - 10.2007
Sr. Business Analyst
Dakota Imaging/WebMD
07.2004 - 07.2005
Provider Configuration Analyst III, Team Lead
Kaiser Permanente
06.2003 - 07.2004
Business Analyst/Project Manager
Destiny Health
07.2002 - 06.2003
Lead Business Analyst
Magellan Health Services
10.2001 - 07.2002
Core Implementation Manager
RewardsPlus
10.2000 - 10.2001
Systems Consultant
basys inc
08.1996 - 10.2000
Lead Full-Service Representative
CareFirst Blue Cross Blue Shield
02.1989 - 07.1996
Bachelor of Art - Biopsychology
UNIVERSITY OF MARYLAND BALTIMORE COUNTY
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