US Healthcare - Payer and Provider Market Subject Matter Expert Accomplished IT professional playing the Strategic lead role, managing Healthcare customer engagements, long term partnerships & nurturing emerging opportunities. Confident AI/Analytics lead with innovative thought leadership. Consulting lead working closely with pre-sales team and key accounts. Am a trusted advisor in client relationship management and Business growth. Responsible for customer success and market profitability (P&L). Have laser focus on influencing strategic outcomes with determination. Have been a part of Consulting, Delivery, Pre-Sales and Market initiatives. Seasoned delivery lead who has driven multi-Year, multi-LoB, onshore-offshore model comprising of multi-country engagements in cross-cultural environment. Subject Matter expert / Guiding star on Contract Management and Pricing models. Responsible for budgeting and reviewing invoices for all engagements with me. Global exposure with fortune clients across North America and Europe region. Ability to learn rapidly and grasp new concepts and business models. Strong analytical, planning, presentation, and organizational skills. Results-oriented leader with a can-do, adaptable attitude Passionate about learning, coaching, and mentoring. Motivates and builds high-performance teams
· Strategic Leadership:
· Designed and implemented key initiatives: Responsible for crafting and executing market-focused initiatives that align with the CitiusTech consulting goals.
· Contribute to account intelligence reviews: Participated in the review of account intelligence plans for accounts (within markets) focusing on interoperability solutions and data exchange architecture.
· Collaboration with key teams: Coordinated with the delivery leads and Training team to ensure alignment and synergy across various accounts.
· Crafting consulting unit’s growth strategy: Created detailed operational and business opportunities roadmaps for both Payer and Provider markets, identifying key areas for growth and innovation
· Evaluate new service offerings: Assess proficiency documents, articles and white papers created by consulting team members for publication on the Citius Vision website and internal distribution to all CitiusTech (CT) employees. Maintain the consulting deck by adding the Payvider case studies.
· Identify consulting business opportunities: Analyze Payer and Provider markets from functional and technical perspectives. Share insights and outcomes with the consulting lead, market leads, customer success team and senior management.
· Portfolio Management:
· Conduct training sessions: Delivered a session on "Denial Management" to onshore leads from 3 accounts in provider market covering the entire claim life cycle.
· Research healthcare tools: Investigate tools in areas like Core Administration Processing systems and document GTM strategies for sales teams.
· Create thought leadership materials: Collaborated with the customer success team to develop strategies like the 'Provider Experience' initiative from a payer's perspective for affiliated providers. Authored research papers, including 'Trends of Payer and Provider Market for 2024,' covering regulations and trends such as Gen AI, digital health, value-based care, preventive care, patient engagement, price transparency, telehealth, and population health management. Shared insights with the Market Delivery Lead (MDL) and COO.
· Led the development of key deliverables: Developed in-depth analysis of “Patient Engagement” within the Provider market. This document illustrates enhanced patient communication strategies which can result in an increase in positive patient feedback. Also, it highlights efforts to engage patients and enhance their understanding of care.
· Develop cross-functional teams: Build a team of cross-functional talent, integrating relevant technologies and market knowledge with training programs.
· Facilitate brainstorming workshops: Lead consulting team workshops on planned topics to drive innovation and cost-effective strategy.
SGO, or Strategic Growth Offering, serves as the Health Rules Payor (HealthEdge CAPs) Center of Excellence at CitiusTech, enhancing the HealthEdge-CitiusTech partnership to effectively market, win, and execute service agreements with focused Healthcare Insurance customers. This collaboration aims to elevate the partnership to a strategic level by jointly investing in the development of capabilities, accelerators, and engagements for the HRP tool. CitiusTech and Fluid Edge have identified key accelerators—Smart Start, Configuration CoE, Testing CoE, Training CoE, Tech Services, and BPass—with the potential to transform HRP implementations. The intent is to establish an 'as a service' model for these CoEs.
· Strategic leadership:
· Develop SGO roadmap: Acts as a technology partner for customers by aligning with the delivery vision. Created and implemented account roadmaps across lines of business (LOBs) and developed knowledge roadmaps for accounts. Formulated and executed a three-year strategic plan aligned with SGO goals, boosting market share by 15% and positioning the company as a market leader. Executed strategic initiatives resulting in a 25% increase in annual revenue
· Stakeholder Engagement and Communication: Engaged key stakeholders, boosting collaboration and improving project satisfaction ratings by 20%. Cultivated relationships and developed communication strategies to enhance engagement and achieve strategic goals.
· Conducted comprehensive market analysis: to identify growth opportunities. Led business development efforts, resulting in a 25% increase in new client acquisitions within the 1st year. Expanded market reach by 25% through targeted strategies and partnerships. This helped improving competitive positioning by 10%.
· Role-Based organization: Established SGO with logical goal roadmaps.
· Set up budget: As relationship lead, defined SGO targets, collaborating closely
with sales, account management, and customer success team to set realistic future
targets based on historical data.
· Reporting: Participated in CitiusTech - HealthEdge Leadership meetings, providing inputs to CitiusTech CXO leadership using Power BI tool.
· Managed new client proposals and sales-to-delivery handoffs. Developed RFP solutions using SGO templates.
· Portfolio Management:
· Led consultative business development and client engagement across 15+ Payer and Provider market projects. Managed projects involving claims management (claim lifecycle, EoB, EoP, denial management), product configuration, and Revenue Cycle Management (RCM), including claim validation, adjudication, Utilization Management (UM) in disease and case management, and reporting (communication and letters).
· Responsible for Change Management, Deal Renewal and Contract/SOW/CR preparation.
· Helped clients achieve significant business impact. Contributed to the delivery of a utilization management module for a leading payer's HMO and MA plans. Enhanced patient adherence to treatment plans by 10% and improved health outcomes through analytics-driven risk stratification. Used predictive analytics to identify high-risk patients, reducing emergency visits. Implemented an EHR system, cutting documentation errors by 30% and improving care continuity. Expanded telehealth services, increasing virtual patient consultations by 50% and enhancing access to care. Improved efficiency and coordination through better care coordination, reduced wait times, and streamlined processes.
· Interacted with organizational departments like TLG, Recruitment, PMO, Staffing, etc. Built HealthEdge/HealthRules Practice capability by designing solutions, service offerings, resourcing, training design, and upskilling for the SGO.
· Help clients reducing average patient wait times by 10% by improved scheduling systems. Improved care coordination, resulting in reduction in hospital readmissions. Implemented process improvements that increased patient throughput.
· Gen AI implementation: Executed AI/ML project for extracting benefits from input health plans. Implemented benefits comparison across health plans using Python.
· Financial Management: Managed a $80+ million core budget, achieving a 12% cost reduction and an 8% margin increase through strategic financial planning.
· CSAT: Boosted customer satisfaction by 25% via improved service delivery and innovative feedback mechanisms.
· As a consulting lead, implemented frameworks for delivery, workforce, knowledge, and quality management, and appointed accountable executives.
· Managed PHI delivery with a clean room model and reviewed product implementations for each project, addressing customer satisfaction.
Simplify account : Managed this account alongwith SGO. I was responsible for web development of eProviderSync (Provider data life cycle & contracts management) and eBenefitSync (automate benefit plan design and document generation) modules using .NET,react JS, SQL etc.
Healthcare Management expertise / Experience
Utilization Management, Care Management Contracts Management, Provider Data Management, Revenue cycle Management, Claims Management, Benefits Management, Provider and Network Management, Clinical care and non-clinical operations, Medical Billing, Payment Integrity etc
Healthcare functional expertise: Interoperability, Regulations, Member Enrolment, Facets, Billing or Payments, EMR and EHR, EoB, EoP and Correspondence etc
Healthcare Trends – Deep Knowledge: Value Based Care, Price Transparency, Preventive Care, Payment Integrity, Digital Health, Data Exchange, Payvider, Patient Engagement, Provider Experience and Telehealth (Virtual Care) etc
HealthCare Interoperability: HL7 and FHIR
Healthcare Core Administration Processing Systems Tools: Trizetto Facets, HealthEdge’s HealthrulesPayor etc
Healthcare Care Management Tool: HealthEdge or Altruista’s GuidingCare
Healthcare Utilization Management Tool: Optum’s Utilization Management tool
Healthcare Provider Data Management Tool: Simplify eProviderSync tool
Healthcare markets leadership (other than Payer and Provider): Life Sciences, Med Tech and Pharmacy Benefit Management
Cloud platforms
AWS, Azure, Salesforce and Google (Big Query) etc
Cloud Data monitoring: Azure data factory, Azure & Amazon data Lake, Azure data bricks
Cloud Data integration
Informatica, MuleSoft, Talend and Snowflake etc
Cloud data warehousing: Big Data, Teradata and Apache Hadoop
Analytics: MS Power BI, SAP Crystal Dashboard (Xcelsius), Tableau, QlikView
Artificial intelligence: Generative AI, ML, Deep Learning, NLP and Python etc
Domain: Healthcare, Insurance, Banking, Retail and Telecom etc
Life Cycles: Development, Testing, Support, Migration, Maintenance, BOT etc
Delivery: Product Engineering and implementation, Project / Service Management
Technologies: J2EE, Microsoft, ERP, DWH , Win32 API, Data Analytics etc
Methodologies: Waterfall, V-Model, Iterative, Agile, Dev-Ops etc
Billing Or Pricing Models: Staff augmentation, Time & Material, Fixed Fee, Fixed Price, Managed Services with SLA (Penalty and rewards) etc
Ticket Management: JIRA, Bugzilla and ServiceNow etc
CRMs Managed: Salesforce, Pega Systems etc
Agile methodologies: Scrum, Kanban, XP etc
Application Servers: Apache Tomcat, WebLogic, WebSphere and JBoss etc
Development Frameworks: TDD, BDD etc
J2EE Frameworks: Spring, Struts, Hibernate and JSF etc
Testing Frameworks: Robot, Modular, Data Driven, Keyboard driven, Hybrid etc
IDE: Eclipse, IntelliJ, NetBeans, JDeveloper, Anaconda & Visual Studio etc
Scripting languages: JavaScript, React JS, Node JS, VBScript etc
Test Management: HP ALM, QA Complete, Test link etc
Automation / RPA: Microfocus UFT, Apache Selenium, UI Path and Redwood
Project/Agile Mgmt: MSP, Confluence, Asana and Version One etc
Estimation Techniques: What-If, Top-Down, Bottom-Up, Three Point etc
Relational Databases: Oracle, SQL Server, IBM DB2 etc
Configuration Repositories: GitHub, Apache SVN, CVS etc
Unified Modelling: MS Visio, Rational Rose, Ent Architect, MS Project Plan