Susan M.

Douglas
(c) 617-283-0729 (h) 508-746-5810 * sdouglas123@gmail.com * 15 Curtis Drive, Plymouth, MA 02360
https://www.linkedin.com/in/susan-douglas-healthcareba/

HEALTH CARE SOFTWARE ANALYST with experience in web portal and software development, implementation &
enhancements; process improvement; UI design; project and testing coordination; software support; user and system documentation;
user training.

EXPERIENCE SUMMARY
Medicare Advantage Parts C & D 5-Star Ratings; Claims; Enrollment; Extracts & Services; Member Portal & Tools; Rx; Behavioral
Health; CDHP/PSA; Sales; Marketing; Medicare Supplement Enrollment; Appeals & Grievances; Prospective Fraud & Abuse; EDI;
Provider Directory; Personal Health Record.
• Extensive use of Visio to document current and future processes and system flows & rules
• Extensive use of Use Case methodologies for requirements definition and testing purposes
• Strict adherence to traceability between requirements and design and test cases

SOFTWARE TOOLS
IBM Rational ClearQuest (RCQ); Mercury Quality Center (QC); Visio; Rally; CaliberRM; MS Project; Word; Excel, PowerPoint;
Lotus Notes; SharePoint; WorkSite; Microsoft Visual Studio/Team Foundation Server.

EDUCATION
Suffolk University, MBA, Concentration in MARKETING / Honors: 3.67/4.0, Teaching and Research Fellowship
Boston University, BA, Major in PSYCHOLOGY / Honors: Cum Laude, Boston University Scholarships

EMPLOYMENT
Blue Cross Blue Shield of Massachusetts (KForce), Hingham, MA / September 2013 to June 2017
Business Systems Analyst Consultant
 Medicare 5-Star Performance Management Project
Gathered & documented requirements for a consolidated and actionable Medicare Part C & D Stars Rating solution. Worked with
Business stakeholders and IT to refine scope and define project iterations. Scope included building a data mart to store and
consolidate 5-Star related data currently stored and maintained in disparate systems; building an automated 5-Star dashboard with
more frequent data and calculation refreshes; and to build out a comprehensive Member Gap List functionality and reporting. The goal
for these new tools is to positively and proactively influence the CMS annual 5-Star Medicare Advantage Ratings.

 Shared Accumulators / Maximum Out of Pocket Project

Gathered & documented requirements for back-end and front-end systems and tools to better manage shared accumulators with PBM
vendors. Repository; Inventory Management System; Reconciliation; Claim Recovery/Retrigger; Reporting.

 Appeals & Grievances Application Projects

Wrote requirements and participated in implementation activities for the Medicare and the Commercial implementation of the
MedHOK Appeals & Grievances applications. UI and Workflow; Letters; Print Fulfillment Integration; Fax Integration; Email
Integration; Provider Extracts; Member Extracts & Service; Claims Service; Referral/ Authorization Service; QA and UAT testing
support; Go-Live and Post-Production support

 CDHP/PSA Projects
Gathered and documented requirements and tested for PSA-related software and extract program enhancements for the portfolio of
PSA programs. Bulk of work was in Group, Eligibility and Claims file layout enhancements with the PSA vendor HealthEquity.
Process diagrams; User Interface enhancements for Accounts; Production support; Claims recoveries; End-to-End testing.

Vertex, Norwell, MA / January 2012 to June 2013

Business Systems Analyst Consultant
Customer Portal Project
Gathered and documented requirements for adding product ordering capabilities to the client’s customer portal. Also participated in
testing and production trouble ticket research and resolution. UI design; database specs for inventory.
Harvard Pilgrim Health Care (Perot Systems/Dell), Quincy, MA / August 2005 to December 2011
Senior Business Systems Analyst
 Member Portal Project (myharvardpilgrim.org, myuhc.com, liveandworkwell.com, medco.com)
Collaborated with UnitedHealthcare, OptumHealth, Medco, Ingenix and OptumHealth Bank to build customized member portals and
tools to service members of the Harvard Pilgrim Health Care & UnitedHealthcare joint National PPO products. Scope included
items such as Family Permissions/Privacy, Security/Portal Registration Process, Provider Search, Health Risk Assessment, Content,
Treatment Cost Estimator, Personal Health Record, and Live Nurse Chat.

 Payment Platform
Performed project coordination activities for testing a new payment platform as it related to EOBs, member checks and Health Care
Reform mandates for Joint Venture business with UnitedHealthcare.

 Service Model Project

Created extensive current-state Visio process flows for Member Services and Provider Services in preparation for future-state work
associated with the joint National PPO products running on the UnitedHealthcare platform.

 Oracle Health Insurance (OHI) Implementation

Performed requirements gathering and documentation for new Dental business and system processes, Pended Claim flow and handling
between OHI Workflow IP and EXP Macess, and Claims Operations Reporting for this new system.

 Medicare Supplement Product Implementation

Participated on IT side of project to modify, develop and implement the IT systems to support the Medicare Supplement product launch.
Project point of contact w/ CMS’s Coordination of Benefits Contractor (COBC).

 EDI Enhancements
Project enabled Harvard Pilgrim Health Care to become the first entity to be both CORE Phase I and Phase II certified by the Council
for Affordable Quality Healthcare (CAQH).
Gathered requirements to enhance HPHC’s 271 Benefits & Eligibility EDI transactions with patient financial responsibility
accumulators and other data elements and 277 Claims Status EDI transactions with an increased number of service line status codes
returned in order to make the response more meaningful. Coordinated testing with testing vendor.

Other Projects: Ingenix Prospective Fraud & Abuse; Sales Application Screen Upgrades and Interfaces; Oracle Sales Applications;
Enrollment System; HealthTrio Member Portal testing; Entrendex Paper Claims Upgrades.

Biogen Idec (Keane), Cambridge, MA / October 2003 to August 2005

Senior Consultant
Siebel Life Sciences for Customer/Patient Services, Clinical Provider, Sales & Marketing
Unified the efforts of business, technology and management by visually representing Siebel's patient services workflows using Visio.
This enabled efficient planning for quarterly enhancements, testing and business rules. In addition, it enabled the use of Visio as a
template for new product release rollouts. Contributed to HIPAA and Sarbanes-Oxley compliance initiatives. Developed training
plans for CRM team. Developed test scripts and coordinated testing.
Processes: Patient case management workflow; Nurse Notes; Physician Notes; Medical Information requests; Drug Persistency
Programs; Auto Drug reorder.

Verizon (Ajilon Consulting), Boston, MA / April 2002 to June 2003

Project Coordinator Consultant
Computer Telephony Integration (CTI) and Speech Recognition/Self-Serve Applications infrastructure projects
Built and maintained MS Project timelines for multi-million dollar IT, which required constant attention to critical path tasks and
effective communication across multiple departments and functional areas. These projects provided state of the art functionality
impacting 20,000+ Verizon call center agents, significantly improving call management, customer satisfaction and call center
efficiency and effectiveness in over 90+ call centers on the East Coast.
Cramer Interactive, Norwood, MA / January to February 2002 (Volunteered to learn while unemployed)
Business Systems Analyst Consultant
Siebel Sales Post-implementation Audit
Assessed data requirements and user interface design then provided change recommendations for recently implemented Siebel Sales
application. Developed sales lead management and CRM analytics and report specifications. Documented Marketing Campaigns
module and provided one-on-one training to the Director of Marketing and Director of Sales.

iBasis, Burlington, MA / September 2000 to May 2001

Business Systems Analyst Consultant
Enterprise Trouble Ticketing System for VoIP and Unified Messaging
Worked on project management team that developed a Unix/Remedy enterprise-wide trouble ticketing system. The system improved
trouble ticketing accuracy and effectiveness, analytics, as well as communication between the NOC and Level 2 & 3 Engineers.

Eversave.com, Woburn, MA / February 2000 to September 2000

Business Systems Analyst Consultant
Marketing Communications List Management & Analytics Solution
Worked with the vendor Wired Empire to implement a configured solution to define & pull Marketing lists and to track click-through
rates, opt-ins and opt-outs for this coupon-related Web start up.

TECHMAR Communications, Canton, MA / June 1997 to February 2000

Sales & Marketing Systems Analyst
Response Management Suite of Applications
Supported proprietary NT/VB response management marketing system and ASP web sales and marketing tools. Applications and
databases were customized for clients such as Cisco, SAP America, PictureTel, and Avid. User documentation; release notes;
training; marketing campaign set up such as scripting, sourcing, lead qualification, fulfillment setup, dealer referral, and web lead
distribution, reporting and fulfillment.