1. AETNA BETTER HEALTH® OF PENNSYLVANIA
Jamie Swartz
Information Systems Coordinator
Total Health Care Experience: 14 Medicaid Experience: 12
PROFESSIONAL SUMMARY
Health careprofessional with extensiveexperience in multipleoperational areas as well as
multi-industry experience. Have 10+ years of experience in both Commercial and Medicaid
managed care. Have strong background in quality improvement, process improvement,
project management, NCQA/HEDIS®/CAHPS®, policies/procedures,regulatory reporting,data
systems, data management and analysis.Strongteam player and individual contributor with
the ability to simplify/streamlineoperations to supportbusiness needs.
Highlights includedevelopment of several tactical business tools migrated to other Aetna
Medicaid plans and also used enterprise-wide. Most recently developed a Managed Long Term Care (MLTC) case
management tool used to successfully run the MLTC program for the Delaware Medicaid Plan. Developed
reporting oversightprocesses recognized as best practiceby Delaware State Regulators and EQRO auditors.
In 2015, selected as one of only eighteen Aetna Government Programs employees to participatein the inaugural
program group for Accelerated Leadership Development. This elite group is recognized as high performing/high
potential leaders within the Aetna organization and will bekey in Aetna’s future business success.
EMPLOYMENTHISTORY
Aetna Better Health of Pennsylvania 01/2015 – Present
Director, Business Project Program Management, 2015 – Present
 Have strong knowledge and understandingof key systems and processes,includingbutnot limited to:
o Trizetto QNXT™ operatingsystem - IODB
o MedAssurant/QSI HEDIS® system
o External State Data Files/ImportProcesses
o External Vendor Data/Encounters/Import Processes
o Internal Actuarial Services Database(ASDB)
o Internal DYNAMO CaseManagement system
o Internal PPM/CORE population health management tools
o Various internal BusinessDeveloped Applications (BDAs) to manage processes,includingbutnot limited to:
o Member Service Verification
o Provider Credentialing/Recredentialing
o Appeals/Grievances
o Quality of Care Issues/Concerns
o InpatientDischargePlanning
 Position provides oversightand direction to staff responsiblefor all statereportingrequirements. This includes butnot
limited to:
o State-mandated Ops reporting:
o Ops 5 – Provider Network Reporting
o Ops 15 – Community Based and Traditional CaseManagement Reporting
o Ops 10 – PCP Assignment Reporting
o Other state-mandated reporting as required
o Ad-hoc data requests to support:
o Internal plan reportingneeds and processes
o External data requests from multiplesources
o Internal and external audits
o NCQA accreditation
 Position oversees and works with staff directly responsiblefor,but not limited to:
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2. AETNA BETTER HEALTH® OF PENNSYLVANIA
o Internal/External Information Technology/Informatics duties and projects
o Serving as main plan contactfor all internal and external systems/IT-related issues. Investigates,triages
and provides resolution
o Overseeing and facilitating multipledepartment filetransfer processes (outbound and incoming) between
plan and State and plan and Vendors
o Performing Q/A review on multipleoutbound state submissions
o Receiving and converting numerous state files into consumabledata to drive contractually-obligated
processes
o Assistingwith delegate vendor filetransfers to/from DentaQuest, Superior Vision and CVS
o Serving as liaison between corporate IT resources and State IT resources for projects and IT-related issues
o Ensuring IT projects and planned activities remain in compliancewith contractual obligations
o Working with IT/plan representative to develop Business Requirements Documents and obtain plan sign-
off/approval
o Assisting/coordinates User Acceptance Testing (UAT) for multipleplan projects and QNXT
upgrades/changes
o Assisting/coordinates deployments of new processes/BDAs
o Assisting/completes plan Information Technology Work Requests (ITWRs) – oversees master ITWR listand
works with staff to ensure ITWR completion by required deadlines
o Plan production resourcefor ProReport/Patient Centered Medical Home reporting
o Overseeing data storage/data management of local plan drives
o Overseeing/administrator local plan HUB
 Directly servingas projectmanager and/or providing data support/analysis for numerous health plan initiatives and
projects,includingbutnot limited to:
o Provider Data Set Up/Termination Standards Review
o Contract Alignment Review/Monitoring
o CMS/State Pediatric Dental Rates
o Non-Emergent Emergency Department Utilization Reduction
o Children’s Hospital of Pennsylvania (CHOP) Asthma Inpatient/Emergency Department Utilization Reduction
o Lancaster County General Hospital Emergency Department Utilization Reduction
o Esperanza FQHC Population Health Management
o Vitas PalliativeCareImprovement Program
 Participateon several plan-level workgroups/committees:
o Service Improvement Workgroup and Committee
o Quality Management Committee
o Strategic Action Items (SAIs)
Senior Manager, Business Project Programs- Aetna Medicaid, Delaware Physicians Care (DPCI) 2008 – 2014
 Responsiblefor state-mandated monthly QCMMR (Quality CareManagement Monthly Reporting) key metrics reporting
for DPCI. Developed data collection and operational process recognized as a bestpracticeby EQRO auditors.Produced
numerous ad-hoc state data requests includingcomplex reports/analyses.Had oversightof or personally produced
internal ad-hoc data requests to support all areasof plan operations.
 DPCI team member and used as a SME to supportvarious State of Delaware project/programs includingtheDelaware
Health Information Network (DHIN), State Health Innovation Plan (SHIP)/CMMI Grant Technical Advisory Group and
DMMA/DOJ Inpatient Mental Health Services Project
 Served as a SME on cross-functional teams,committees/workgroups focused on health plan initiatives and activities.
Focuses of initiatives/activities were to increaseHEDIS® scores,member (CAHPS®) and/or provider satisfaction and
maintain plan regulatory compliance.Have extensive experience as a HEDIS® project manager and state-mandated
performance improvement projects.Have extensive experience in data extraction from multiplesources to perform
deep-dive reviews/analyses to identify issues/opportunities for improvement. Experience with both the plan
accreditation processes URAC and NCQA®. Provide data/technical writingsupportfor multipleNCQA® standards
analyses.
o Worked collaboratively on a two-person team to develop multiplebusiness developed applications(BDAs) to

3. AETNA BETTER HEALTH® OF PENNSYLVANIA
improve workflow/function and greatly streamlined processes.NotableBDAs included:
o Fax Tracks - BDA was used to model Medicaid enterprise-wide, web-based solution to capture and track prior
authorization requests received via fax to ensure completion timeframes were met as well as compliancewith
internal auditrequirements.
o Managed Long Term CareRemote CaseManagement BDA – BDA was developed to allowto staff to work
remotely disconnected from network. BDA reduced member interview/needs assessmenttime by 50% and
allowed for rapid onboardingto meet contractually required enrollment/assessmenttimeframes. Key
functionality and automation developed in BDA arenow being reviewed for incorporation into Medicaid
enterprise-wide casemanagement system.
o DPCI Appeals and Grievances BDA and correspondingQuality of Care grievances BDA to improve operational
efficiencies and compliancewith contractual requirements.Both BDAs migrated to other Medicaid business
units.
o CredentialingBDA to capture provider plan/credentialingapplication information and setup data exchange
process with Aetna CVO to allowfor timely processingof new providers for addition to the servicenetwork and
to ensure timely credentialing/recredentialingof activeproviders.BDA migrated to other Medicaid business
units.
o Member Service Validation BDA.BDA designed to pull claims based on determined criteria/stratification and
produce member notifications to validatebilled services.BDA also allowed for member response tracking,
potential fraud identification,referrals to internal fraud department (SIU) and produced required state and
internal reporting.BDA migrated to other Medicaid business units.
 Took ownership of DPCI Policy and ProcedureCommittee. Established SharePoint sitefor management of plan
policies/procedures and correspondingtemplates and trackingtools.Set up monthly meetings, policy reviewschedule
and trackingtools to ensure annual reviewof required documents. Facilitated and served as Committee Chair for three
years and continued on as a participatingSME.
 Redesigned DPCI Service Improvement Committee. Committee focus was on member, provider and internal/external
serviceimprovements. Reviewed and analyzed annual NCQA/CAHPS® Adult and Child Member Satisfac tion surveys and
was primary resourcefor development and implementation of the annual NCQA/CAHPS® Survey Action plans as partof
the serviceimprovement process.Facilitated and served as Committee Chair for six years.
Coventry Health Care/Coventry Health Care of Delaware, 2001 – 2008
Senior Health Care Analyst – Quality Improvement, 2006-2008
 NCQA/HEDIS® ProjectManager for 2006,2007 and 2008 for both Commercial and Medicaid products.All audits
ending in successful outcomes.
 Responsiblefor all clinical and serviceQuality Improvement Activities alongwith oversight of all preventivehealth
initiativesand programs.
 Responsiblefor developing strategic tools to drivemember outreach and improve plan performance for the Medicaid
program.
 Assisted in accreditation auditprocessas well as regulatory auditsby multiplestate governments.
 Lead/facilitated multipleworkgroups and committees critical to plan operations and for maintainingcompliancewith
accreditation standards.
Supervisor, Pharmacy Service Operations, Year 2004-2006
 Embraced the challengeof runningpharmacy operations with no previous pharmacy benefit management
experience. Responsiblefor the day-to-day operations of the Pharmacy departments for two Coventry Health Care
plans coveringCommercial and Medicaid managed careprograms.
 Successfully managed Pharmacy operations staff to ensure processingtimes were met and department and plans
remained regulatory and contractually compliant.
 Responsiblefor all Pharmacy projects and initiatives.Skill setused to evaluate current processes and implement
improvements. Also determined gaps in departmental functions and implemented processes/procedures to
strengthen short and long term projects.
 Liaison to employer groups/members havingPharmacy benefits. Facilitated numerous onsitemeetings with employer
groups as well as conducted member trainingon appropriatebenefit utilization.Directpointof contact for employers

4. AETNA BETTER HEALTH® OF PENNSYLVANIA
and brokers with pharmacy benefit issues.
Department Specialist, Quality Improvement, Year 2001-2004
 Entered into dynamic department with no previous managed care experience and used strong skill setand self-starter
attitude to quickly learn both Commercial and Medicaid managed care programs.
 Provided all administrativesupportto QI staff usingmultipleMicrosoftand internal programs.
 Supported NCQA/HEDIS® projectmanager and learned NCQA/HEDIS® auditprocess.
 Supported QI staff and other Plan personnel in preparation for two URAC accreditation audits.
 Responsiblefor oversightof all member preventive health mailings.
 Participated on and/or supported several internal workgroups and committees.
FiberVisions Incorporated, 1997 – 2001
Executive Administrative Assistant, 1998-2001
 Worked directly for entire senior management staff - included President& CEO, VP of Human Resources, VP of Legal,
Director of Financeand the President & General Manager of this separate jointventure entity.
 Performed full rangeof administrativesupportincludingtyping,graphics presentations,reports,
international/domestic travel,expense reports, schedulingmeetings/conferences. Also responsiblefor management
and maintenance of office space.
 Had daily interaction with internal and external customers.This included domestic and international locations in
Europe, South America and China.
Administrative Assistant 3, 1997-1998
 Worked directly for the VP of Human Resources,VP of Legal, VP of the Americas and the Director of Finance.
 Performed full rangeof administrativesupportduties,maintained all officesupplies.Processed all Accounts Payable
for this location.
 Back up support for the Executive Assistantposition.
EDUCATION
Degree (e.g., Masters, Bachelors) – N/A
Delaware Technical and Community College, Newark, DE – Stenography Program Graduate- 1988
BACKGROUND (LICENSES, CERTIFICATIONS, SPECIAL SKILLS, ETC.)
Licenses
Certifications