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Click here or scroll down to respond to this candidatePROFESSIONAL SUMMARYA degreed Managed Health Care Professional with extensive experience in the health care industry. Holds a rich, unique and well-rounded range of executive level managed healthcare experience that encompasses all major aspects of todays managed care business.PROFESSIONAL EXPERIENCELegacy Health, Portland, Oregon CURRENTHospital Security, DPSST certifiedAdvancedHealth, Coos Bay, OregonChief Operating Officer 12/2020 2/2023Oversee the daily functioning of the organization and assigned departments. Claims, Customer Service, Provider Service, Health Information Management, Pharmacy, Utilization Management and Behavioral Health teamsMaintain organization stability and have the ability to predict future logistical needsRecognize trends in data to plan future projects and monitor the daily operations of assigned departmentsPlan, develop, organize, implement, direct and evaluate the organizations relationship with partner organizations, including boards, delegates and other community-based organizationsParticipate in the development of the organizations long-term and annual business plansEvaluate and advise on the impact of long range planning, introduction of new programs, strategies and regulatory action on plan operationsProvide, operational assessments, future capital/budget performance and trends in order to assist the board and CEO in performing their responsibilitiesEnhance and/or develop and implement policies and procedures for the organizationProvide strategic input and leadership on decision-making issues affecting the organization, including the valuation of potential alliances, partnerships, new business opportunities, and acquisitionsEvaluate the organizations structure and implementation of continual improvementsEnsure compliance with company policies and procedures as applicable to areas of responsibilityCareOregon, Portland, OregonVice President of Health Plan Operations 6/2016 1/2020Reason for change: Organization Re- alignmentOversight of Claims, Customer Service, Enrollment, Payment Integrity and Member Engagement for Medicaid and Medicare enterprise businessBusiness Development and IntegrationAt an enterprise level, reviewed and enhanced business operations as needed. Ensured new business considered the needs of the entire organization as new opportunities were presented. Spans the organization and was consultative in nature.Provided consulting services for claims management, encounter data oversight/management, provider/member relations, provider contracting, practice management, systems implementation, process flow, staff management, government programs, Medicaid, Medicare, commercial, sales, change management, project management, P&L management, matrix and non-matrix environments, regulatory oversight, RFP creation / review, committee creation / oversight, E2E auditing and many other operational skill sets. Educated practices and plan staff on STARS, HEDIS, and CAHPS initiatives.Boston Medical Center HealthNet Plan, Boston, Massachusetts 10/2015 6/2016Vice President of Customer OperationsReason for change: Organizational Re-alignmentReporting to the Chief Operating Officer this position was responsible for Customer Service in multiple markets, Claims Operations and member plan enrollment for Medicaid, Medicare and commercial lines of business. This position had oversight responsibilities for multiple business contracts, owned new business implementations and business enhancements and was responsible for maintaining / evolving operational key indicator metrics and general business structure and team evolution. Working with all other departments on shared initiatives to achieve plan success.Trizetto, Phoenix, Arizona 7/2015 10/2015Director of Medicaid and Medicare Program ConsultingReason for change: Better opportunityResponsible for aftermarket consulting services for Medicaid, Medicare and Commercial managed care products utilizing Facets, Qmacs and QNxt products. Acted as a customer advocate and assisted in cultivating new business opportunities with new and established clients. Supported all STARS, HEDIS and CAHPS initiatives.Healthcare Consulting 8/2013 7/2015Reason for change: Better opportunityProvided consulting services for claims management, encounter data oversight/management, provider/member relations, provider contracting, provider credentialing, practice management, systems implementation, process flow, staff management, government programs, Medicaid, Medicare, commercial, sales, change management, project management, P&L management, matrix and non-matrix environments, regulatory oversight, RFP creation / review, committee creation / oversight, E2E auditing and many other operational skill sets. Educated practices and plan staff on STARS, HEDIS, and CAHPS initiativesUnited HealthCare, Phoenix, ArizonaDirector of Provider Relations / Market Service Lead 4/2008 -8/2013Reason for change: Organizational downsizingImplemented a nationally recognized provider service program responsible for saving the organization millions of dollars in administrative costs. Had oversight of 20 Provider Advocate associates that enhanced the overall provider relationship experience with United healthcare in the Medicaid, Medicare, Commercial and Military and Veterans lines of business.Manage the Physician Advocacy programs in Arizona and UTAHEducated practices and staff on STARS, HEDIS, and CAHPSRealized a United provider experience satisfaction rate increase of approximately 15% over a 5-year period,Contributed to 75% reduction in provider reworkOffer claims, administrative, policy, process, EDI/EHI and financial education to physician community consistently.Increased team productivity metrics to 95% through administration efficient work modelsWork with Medicaid, Medicare and Commercial lines of business to ensure optimal provider serviceWork with all other internal business partners to ensure issue resolution pathways were open and easily accessible.Coordinate community education eventsWork within the organizational matrix to better all aspects of provider service (contracting, credentialing, utilization management, marketing and more)Strategize for yearly and long-term planningWork with sales teams to close small, large and Jumbo accountsSchaller Anderson Healthcare, Tempe, Arizona 10/2005 12/2007Director of Provider Relations, Operations and Medicare OperationsReason for change: Corporate buyoutHad direct progressive oversight of all provider relations, operations and new Medicare special needs population business. Included all aspects of staffing, quality improvement and daily operations and maintenance in accordance with business goals. Responsible for plan start up activities. Ensured 100% compliance with all audit activities for existing business.Directed all contracting and service activities of the Provider Relations department which resulted in annualized savings of ~$1/2M annuallyResponsible for participating in organizational audits to ensure organizational compliance with regulatory agencies.Responsible for maintaining appropriate local and multi plan level credentialing processesResponsible for managing Medicare Part D PDE error reductions that saved the organization $1M plus dollars.Responsible for analyzing and reporting departmental data and identifying network trends.Oversight of the member/provider services functions.Interfaced with management and staff to facilitate SAH goals and objectives.Oversight of the companies facilities operations, including operating leases, facility management, mailroom, general reception and security for employees and the general public.Oversight of operations related to the Regional Offices and responsible for the coordination of specific issues with other SAH managers related to provider relations, human resources and case management.Coordination of reporting functions within SAH and between SAH and SAI, SAA, outside entities.Coordination of department specific Key Indicator metrics and service improvement teams that yielded~$300K in annualized savingsEducated practices and plan staff on STARS, HEDIS, and CAHPS initiatives.Work with sales teams to close small, large and Jumbo accountsThe Maryland Department of Health and Mental Hygiene (DHMH), Baltimore, Maryland 2/2002 10/2005 Chief, Division of HealthChoice Management and Quality AssuranceReason for change: Better opportunityChief of department responsible for managing a multi-million-dollar Medicaid managed care program. Oversaw all managed care contracts and sub-contractor contracts for the state of MD Medicaid business.Oversight of State contracts with vendors for, Evaluation and Quality Review Organizations (EQRO), Health Employer Data Information Set (HEDIS), Consumer Assessment of Health Plans (CAHPS) and The Maryland Insurance Administration (MIA)Ensured 7 active MCOs provide the 460,000 Medicaid recipients enrolled in managed care appropriate health careWorked with encounter teams to manage the daily interactions with the states encounter data vendorEnsured MCOs complied with state encounter data submission processInterpreted regulation and provide clarificationMonitored MCO network adequacyMonitored PBM activityDesigned and implement operations, procedures, and protocols necessary to effectively monitor the Quality Improvement Program for the HealthChoice managed care system.Organized and Maintained the DHMH Quality Assurance Liaison CommitteeResponsible for solvency of multi-million-dollar Medicaid program budgetCIGNA HealthCare (Sales), Silver Spring, Maryland 6/2000 1/2002 Client Strategy SpecialistReason for change: Better opportunityManaged the sales relationships with key clients such as the Kennedy Center, The National Education Association and varied international embassies. Responsible for client persistency with an annualized 20% profit margin. Maintained service excellence for all new and existing clients.Interacted as main liaison between Health Plan and Employer Groups for problem resolutionManaged day to day needs to Employer groupsFacilitated open enrollment meetings/Health Fairs/ Q&A sessionsAssisted with the maintenance and future financial viability of first year accounts and renewalsDeveloped proactive goals and initiatives for account growthEnsured that efficient levels of communications are established between other CIGNA matrix partners and employersEstablished and maintained effective communications between Employers and Brokers to ensure optimal satisfaction for clientsEducated practices and plan staff on STARS, HEDIS, and CAHPS initiatives.Responsible for maintaining group persistency and new salesMaryland Physicians Care Medicaid Managed Care Organization (MCO), Woodlawn, Maryland 1/1997 6/2000Manager of Customer ServicesReason for change: Better opportunityCreated and managed the day-to-day service aspects of the MCOs 270K member and 20 customer service representatives. Guided the overall development, implementation and maintenance of the plans tracking systems. Maintained the day to day functions of customer serviceManaged the implementation and development of a multi-million-dollar plan management system, this includedmember and enrollment tracking, claims payment, provider contracting/setup and authorization/medical managementsystemic integrations. Managed the activities of the Consumer Advisory Board and The Service Improvement Committee Member of the Department of Health and Mental Hygiene Enrollment Steering Committee Responsible for monthly and annual customer service reports to DHMH and internal teamsEducated practices and plan staff on STARS, HEDIS, and CAHPS initiatives.Assisted with ensuring plan encounter data was submitted timely/accurately to the state and interpreted by the plan correctlyCreated, established and maintained organizational provider directoryWellCare of New York, Kingston, New York 1/1996 12/1996FellowReason for change: Fellowship endedParticipated in 12month fellowship program that focused on all core aspects of HMO/PPO and Indemnity program management.Service, Sales, Marketing, Finance, Contracting, Utilization management, Case Management, Data Management, Workforce managementEDUCATIONM.S. - 2006 Health Systems Management University of BaltimoreB.S. - 1995 Health Science S.U.N.Y. CortlandInternship Developmental internship for UNICEF in Belize, Central America S.U.N.Y. Cortland |
