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Jeffrey
besje01@gmail.com
508-221-7765
Worcester, MA 01655
Principal
26 years experience W2
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Summary

Healthcare Analytics Expert

Experience
Principal
Information Technology
Mar 2019 - present
  • Working with clients in leveraging Machine Learning and AI in solving business problems in healthcare.
  • Working with a pharmaceutical and medical device company on outcomes and value proposition using Real World Evidence analytics. Consulting biostatistician for a firm.
  • Interim CAO /CTO (Chief Analytics Officer) at a healthcare start-up in Nashville developing web based platform, data strategy and analytics enablement. Summary Experience:
  • 15+ years working as a clinical informaticist including HEDIS, STARS, natural progression of disease models. Have worked with numerous Medical Directors, CNOs, Case Management and other clinicians.
  • 15+ years working in various IT capacities such as BA, project management, managing dev teams, business requirements, functional and technical specifications and solution architect.
  • 5+ years working in claims processing, monitoring and quality. Developed data bots to monitor systems for overpayment, machine learning algorithms to detect hot spots in pending and mispriced claims and a series of KPIs and interactive dashboards to help processes spot bottle necks. Developed automated QA workflow for new Medicare regulations.
  • 10 + years' experience in automation (RPA, clinical analyzers, workflow automation, workforce management dashboards, call center ops, data agents etc.).
  • R programmer with a little SAS and some Python (Keras / Tensorflow/ Web scraping). Have led Python development teams. Extensive experience in statistical and data mining techniques such as Regression (various types), Random Forest, xgBoost, Decision Trees and deep learning.
  • 10 + years working on numerous consulting engagements for VBP, ACO set-up, (Re
  • admissions and HAC), Bundle Payments and PCMH.
  • 15 + years Population Health analytics including pre-sale, sales support, predictive modeling, clinical segmentation, finance lead and outcome measurement / program evaluation.
Solutions Architecture
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Consulting Projects
Information Technology
Sep 2017 - Feb 2019
o Large multistate payer
  • claims quality, root cause analysis and remediation strategy.
    • Academic Medical Center
    • working with CMIO and Clinical Process Improvement Director on using advanced analytics to improve patient care and VBC measures leveraging EPIC reporting structure.
    • Payer
    • developing analytics and automation framework (rules engine and data science) for fraud detection and automation.
    • Medicaid Payer
    • RPA and intelligent automation of back office functions.
    • Project leader for internal software development: 1. Claims quality tool leveraging data science tools and root cause analysis previously delivered to clients. 2. Physician Contract Compliance tool to automate the compliance function for physician practices to include referral networks, Stark violations and False Claim act. Technology consultant for NLP tool for provider contracts. 3. HEDIS / STARS tool for payers and employer groups.
    • Sold to C level executives on automation, technology and analytics in the Payer / Provider team
    • Spoke at a national conference on Machine Learning in Claims Audit. FTI Consulting
No skills were added
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Managing Director
May 2014 - Jun 2017
  • Analytics and technology lead expert for consulting engagements around ACO development, Payment transformation, Population Health and Clinical Integration.
  • Provider
  • developed algorithm for client AMC to help identify factors and attributes leading to increased ER flow.
  • Payer
  • developed a data model for client to assist them in managing claim payments and IBNR accuracy. Identified factors leading to backlog in claims processing.
  • Worked on consulting engagements concentrated on payment transformation, MA risk adjustment, population health and CMS compliance. Client base centered on hospital systems and MA plans.
  • Developed technology partnerships to support FTI in delivering branded software applications to its client base.
  • Created training program for consultants and senior consultants around Python, R, and machine learning
  • I called it 'Py-R-on'.
Project Management
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Director
Apr 2014 - May 2014
Project Management
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Information Technology
Apr 2013 - Apr 2014
  • Worked with clients (internal and external to UHG) to develop technology and analytics based solutions. Worked with off-shore teams to develop and deploy solutions and work with clients to provide high level project management oversight to ensure quality of deliverable. o Projects included:
  • Led a team to develop a pre-authorization program to increase throughput and decrease backlog through advanced system automation.
  • Developed system architecture to deliver on United's Hospital at Home pilot.
  • Developed triangulation strategies between sales organizations, practice, domain functions and delivery units for focused up-selling and cross-selling of analytical services to targeted group of global organizations within the healthcare ecosystem (Pharmacy Retailer, Care Providers, 3rd party Managed-Care & Government Healthcare Organizations).
  • Led off shore teams in expanding analytic toolbox. Examples are EHR, ACA / Exchanges, Tiered networks, Attribution, Population Health, Wellness, NLP, Consumer Analytics, Tableaux. Share VOC comments and keep team abreast of US based developments. Developed growth strategies for off shore team that fits with the Optum Analytics core offerings. Led development team for two key products
  • Stars Suite and CRM Analytics.
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Director, Product Development
Mar 2013 - Apr 2013
Waltham, MA
Project Management
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Apr 2012 - Mar 2013
  • Led product development for new reimbursement solutions (Bundled Payments and New Member Risk products).
  • Worked on machine learning algorhtims to
  • Created knowledge transfer strategy and programs to support Global Payer Solutions colleagues in 100 countries. This allowed to access to best practices of US based solutions and strategies.
  • Developed Pay for Performance strategy and products using IMS data assets.
  • Created consulting proposals and partnership development opportunities.
  • Led development of innovative predictive models using IMS's proprietary data assets.
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Banking/Financial
May 2003 - Apr 2012
  • Worked with clients and in-country business unit leaders in developing and negotiating contract amendments for gain sharing and performance guarantees. Also worked in pre sales contract development on value propositions, pricing and risk arrangements.
  • Collaborate with clients and external researchers / consultants to determine ROI and clinical efficacy of programs. Utilize information such claims data, call center data, health risk assessments, clinical metrics, level and type of intervention and demographics.
  • Developed sales tool to allow worldwide sales force to predict savings and disease prevalence of diverse populations utilizing academic literature, world surveillance information and claim metadata.
  • Significant in-country work (France, Germany and Australia) focused on operations improvement (finance and call center), training of in country staff and sharing of best practices.
  • Finance lead for High Risk / Primary Nurse Model within Healthways. Responsibilities included oversight of financial and reporting for RFPs, pricing proposals and development of economic cost models.
  • Responsible for reporting of contract metrics which includes oversight and management of the development of financial, utilization, clinical, satisfaction, and operational reports consistent with contractual requirements and client demands.
  • Shared responsibility of revenue and cost performance for accounts totaling $20million in annual revenue for domestics key accounts.
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Director, AI Consulting Services
May 2003 - May 2003
Boston, MA
Specialized consulting firm focused on healthcare AI.
Project Management
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Manager, Decision Support and Physician Compensation
Medical Devices
Feb 1996 - Mar 2001
Worcester, MA
/ Fallon Community Health Plan / Optum Health
  • Large multi-specialty medical group practice located throughout Central Massachusetts Manager, Decision Support and Physician Compensation
  • Developed methodology to benchmark physician work levels and measure performance (compensation, revenue, coding and quality) against various national standards. Twenty-five percent of model was pay for pay for performance measures.
  • Developed dynamic reallocation of capitation model (now called ACO structure) that took into account changes in membership, RVUs and cross coverage by other medical specialties. Models reallocated more than $100 million dollars between 20 different departments. Represented Medical Director at site meetings explaining methodology.
  • Developed P&L models for different business lines. Added sensitivity analysis to determine future margins based upon changes to health care benefits, changes in contracts, federal mandates, and technological innovations.
  • Oversaw and was responsible for the reporting of HEDIS utilization measures.
  • Hired, mentored and managed professional staff of ten.
  • Prepared updates and status reports involving physician compensation and incentives to the Board of Directors. Presented at numerous forums to present and explain compensation model to staff physicians and managers.
Project Management
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Edit Skills
Non-cloudteam Skill
Education
University of Rochester
University of Massachusetts
Skills
Project Management
2017
8
Solutions Architecture
2021
1