Experience

Outcomes Matter Innovations, LLC

• Hospitals and Health Care
• 1 - 100 Employee

• Chief Business Officer

  • Jul 2022 - Present



One Call

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Senior Vice President, Provider Network

  • Feb 2019 - May 2021

  Responsible for One Call’s Provider Network disciplines for all of Workers Compensation and Managed Care products. Division oversight included Contracting, Credentialing, Provider Relations, Provider Experience & Account Management, Retention & Support, Network Governance, Data Management and Provider Program Management. • Integral in achieving Prospective, Retro, and PDR Revenue channel targets through strategic provider partnerships. • Delivering targeted Network Cost Savings goals. • Creating a first in class provider network focused on quality and outcomes.• Developing an advanced Network Adequacy methodology to ensure a robust nationwide network. • Formulating innovative provider reimbursement models to promote quality and appropriate utilization.• Ensuring network growth and retention benchmarks are met.

• Senior Vice President, Health Plans and Business Development

  • Jun 2018 - Feb 2019

  Orchestrating business development for the company’s anchor products beyond Workers Compensation into the government healthcare industries (e.g. Medicaid, Medicare, ACA expansion, etc.). Primary focus is to ensure growth and profitability. Oversee budgeting, labor efficiency, network costs, and customer service aptitude. Evaluate and architect new product competency, placement, and speed to market for managed care products.• Evaluate and architect new product competency, implementation, and speed to market for government healthcare products. • Negotiate contracts with managed care payors within targeted net and gross margins, appreciating initial ramp-up hurdles to future state stability.• Identify and satisfy staffing needs to support the demands of growth. • Oversee supporting business unit matrix management to address challenges, issues, and opportunities for solutions.



Aetna, a CVS Health Company

• United States
• Wellness and Fitness Services
• 700 & Above Employee

• Chief Operating Officer, Kentucky

  • Oct 2017 - Jun 2018

  Responsible for daily delivery of health plan services for ~ 250,000 Medicaid beneficiaries throughout all 120 counties in the Commonwealth of Kentucky. Direct oversight includes the following cross functional departments: Appeals & Grievances, Member Services, Program Management, Provider Relations, Provider Engagement, Network Operations, Contract Management, Informatics & Analytics, and Community Outreach. • Oversight of the Operation’s $1.2B in revenue and achieving forecasted P&L. • Executive Lead with the Kentucky Department for Medicaid Services.• Guiding principal in Health Plan’s 2018 strategic planning and setting.• Provide a much needed platform for the Operations’ division leaders as they set department, team, and individual scorecards.• As needed, revamp personnel to build a team capable of delivering sustained growth.



Molina Healthcare

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Corporate Vice President, Market Leader

  • Apr 2017 - Oct 2017

  Responsible for Molina Healthcare of Illinois' success in the FHP, ICP, MMP, and MLTSS programs. Served as lead executive responsible for working with the Health Plan, State of Illinois, CMS, and Molina Enterprise to ensure a competitive focus on membership retention, loyalty, and satisfaction. • Crafted and implemented each product's business plan centered on maximizing revenue, increasing profitability, and growing membership.• Executive Lead in securing only one of five Request for Proposal (RFP) awards from the State of Illinois to expand managed care into all 102 counties. • Molina Leader for the Illinois Association of Medicaid Health Plans' (IAMHP) Operations Committee.• Executive Lead for Molina with the State of Illinois' Encounters Committee.• Ensured appropriate cost per unit contracts with key providers incentivizing improved member outcomes and high quality scores.• Solidified appropriate access to health care services through targeted network development.• Identified cost saving initiatives in contracting, operations, and employee productivity.• Achieved growth targets for the market through local community engagement deployment.• Served as a local resource for legislators, regulators, advocates, providers and members. Engaged as an active participant in external leadership boards and committees. • Facilitated routine engagement between internal Healthcare Services, Network Contracting, and the Provider Services departments satisfying timely, appropriate access to care for members and provider satisfaction.• Provided personal leadership that encouraged employee productivity and responsiveness to the needs of members, providers and regulatory agencies/staff.

• Chief Operating Officer, Illinois

  • Aug 2014 - Apr 2017

  Accountable for the overall direction and administration of operational departments, programs and services provided by the Molina Healthcare of Illinois' Medicaid (FHP/TANF, ACA Expansion, SPD/ABD), Dual Eligible MMP and Long-Term Services and Supports (LTSS) products. Increased membership from ~ 8,000 to 205,000 covered beneficiaries in 19 counties. Responsibilities included: implementing programs in alignment with Molina's growth strategies; ensuring the efficient and compliant operations of the health plan; and providing day-to-day leadership and management that mirrored the company's mission, vision, and core values for greater than 500 employees.• Formulated business plans, tactics and strategies to meet short-term objectives/obligations and secure long term financial growth and sustainability.• Increased annual revenue from $145M to greater than $650M.• Presented executive reports and recommendations on program performance to the State of Illinois, CMS, and Molina Enterprise Leadership.• Presided over the acquisition/integration of three Accountable Care Entities resulting in considerable growth. Completing this exercise also afforded expansion into the Cook County Medicaid market.• Developed and implemented performance measures to meet the operational needs of the company to efficiently utilize resources and maintain a successful system of processes & outcomes.• Ensured that the overall level of quality for contractual obligations met or exceeded the highest industry standards and created new or amended existing policies to improve operations as needed.• Contact point and leader on priorities for Molina operations (Network Management, Provider Services, Member Engagement, Appeals & Grievances, Claim Disputes, Contract Configuration, Encounters, Call Center, Credentialing, Program Management, Community Outreach, and Marketing).



Humana

• United States
• Insurance
• 700 & Above Employee

• Corporate Market Leader, Illinois

  • Sep 2013 - Aug 2014

  Developed strategy, drove decisions, and implemented programs to support growth for the company's Senior Products businesses (Medicaid, Medicare, D-SNP, Dual Eligible MMP, and Long Term Care). Integral in providing strategic consultation on business entry design in pipeline markets. Understood the needs and perspectives of core businesses which enabled the anticipation of future consequences and trends that grew the Humana brand nationally. • Developed internal and external partnerships to meet requirements of the CMS Financial Alignment Initiative (FAI) which include Dual Eligible and Medicaid models.• Led management and ensured full compliance with required CMS and State Medicaid filings to support Senior Products development.• Profit and Loss responsibility for $300M in annual revenue, culpable for superior performance and drove breakthrough growth.• Worked collaboratively with Senior Products, MarketPoint, and Humana Brand Marketing to drive methodology and implementation for Medicaid, SNPs and Dual Eligible programs.• Lead in collaboration campaign for product development and organizational readiness for priority Humana markets.• Built productive relationships and led cross-functional teams including Market Leadership, Public Affairs, Network Development, and Compliance to support program launch and continued operations.



Meridian

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Corporate Vice President, New Market Development

  • Jan 2013 - Feb 2013

  Executed new market development for an organization which hosts the biggest Medicaid HMOs in Michigan and Illinois. Responsible for researching new business opportunities, products, and services with an emphasis on increased market share and new customer development. • Oversaw Network Development departments to capitalize on new business opportunities. • Partnered with executive leadership to create and execute strategic plans in new markets to satisfy targeted P&L. • Acted as the liaison to government agencies that administer Medicaid and Medicare programs advancing company interests. • Created reimbursement structures that met providers’ needs by implementing a wide array of contracting options which included the implementation of narrow networks, HEDIS® performance bonuses, Patient Centered Medical Home payments, Centers of Excellence programs, Value Based Purchasing bonuses, and Shared/Global Risk arrangements. • Subject matter expert in market and competitive analysis including advertising and promotional planning campaigns that advanced brand recognition. • Effectively managed lean budgets while guiding resources and ensuring profitability.

• Director, Provider Services and Network Development

  • Jul 2008 - Jan 2013

  Direct accountability and management for the oversight and tactical execution of market development for all lines of business in Illinois (Medicaid, Medicare D-SNP, Medicare-Medicaid Alignment Initiative for Dual Eligibles). Identified expansion opportunities for growth and increased profitability in government programs which resulted in the company becoming the largest Medicaid health plan in the state. Comprehensive development of provider networks in alignment with regulatory guidelines. • Assembled a Medicaid provider network in Illinois including 72 hospitals, over 1,300 PCPs and more than 3,500 Specialists which supports more than 385,000 Members. • In voluntary markets, able to build provider networks in 29 Illinois counties and three Iowa counties through an open application process. • Implemented a business development strategy that resulted in the RFP award of the Greater Chicago region for the CMS and HFS Medicare-Medicaid Alignment Initiative (MMAI) for Dual Eligibles and the Integrated Care Program (ICP) for non-Medicare eligible adults with disabilities.• Secured a contract between CMS, the State of Illinois, and Meridian to launch a Medicare D-SNP product in three (3) counties. • Cross-walked strategic Illinois provider relationships to meet the requirements of the Iowa Medicaid Enterprise program allowing the company to develop an additional product for the Iowa market. • Lobbied and presented company’s interests directly to the Iowa Medicaid Exchange and Governor Terry Branstad to gain approval to administer the State's mandatory managed care Medicaid program. • Coordinated initiatives to build a physician network that met regulatory guidelines and worked with the Illinois Department of Healthcare and Family Services to receive new county approval. • Supervised 11 direct reports that supported daily operations. Team members responsible for provider contracting, data analytics, credentialing, provider engagement and marketing.

• Network Development Specialist/Provider Services Representative

  • Jul 2004 - Jul 2008

  Network Development Specialist responsible for contracting new providers and servicing existing relationships, including; hospitals, primary care physicians, specialists and ancillaries. Ambassador for the organization responding to any situation that demanded resolve. Concentrated efforts on improving quality scores which assisted the company in attaining recognition on a state and national level.