Experience

CareAllies

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Senior Manager - Provider Engagement

  • Oct 2016 - Present

  * Administrator for 2 PODS (LLCs) within Renaissance Physician Organization IPA: Merit IPA, LLC and BCM Physicians Organization, LLC* Responsible for start-up and implementation of new IPA/POD, BCM Physician Organization, which went live 1/1/18. BCM Physician Organization includes 60 Primary Care Physicians and over 500 specialists from Baylor College of Medicine and Baylor St Luke's Medical Group.* Responsible for maintaining positive relationships with contracted providers, as well as the health plans that partner with Renaissance Physician Organization* Responsible for provider education relative to CMS/Medicare Advantage rules and regulations, as well as any health plan specific initiatives* Develop, present, and monitor monthly action plans to assist LLCs with hitting financial and operational targets (identifying high cost utilization patterns and suggested changes to help reduce costs without impacting the quality of care).* Responsible for PCP & Specialist provider network for each LLC (contracting, credentialing, system loads, etc.)* Compile and present monthly Board packets and financials* Ad hoc projects and analyses as required



Cigna HealthSpring

• Director of Network Operations

  • Aug 2011 - Oct 2016

  • 2016: Implemented, from the ground up, the PDV Team (Provider Data Validation), workflows, and policies in order to hit CMS compliance requirement of all health plans conducting quarterly outreach to their entire provider network to verify provider directory data, thus ensuring directory accuracyo Front to end tracking to demonstrate all providers have been included in outreacho Front to end tracking of provider responses, as well as tracking to demonstrate compliance measurements were met and updates are reflected in online provider directories within 30 days• 2011: Created a new team from the ground up: 1 Business Project Senior Analyst; 2 Plan Implementation Senior Associates and 1 Network Operations Specialist to manage the provider directory and network adequacy process for the TX and AR markets• Manage provider directory process, as well as, monthly directory addendum process for Texas and Arkansas• Manage team responsible for network adequacy – keeping HSD tables up to date, responding to network deficiencies, pursuing and securing contracts with providers to remediate access issues for memberso In 2015, this team eliminated 113 network adequacy fails across Texas and Arkansas• Manage physician side of expansion efforts: contract, credentialing, loading, auditing, HSD table updates, prepping data for CMS filings, etc.)• Policies & procedures, production of provider manuals, ad hoc analyses, etc.• Ensured all Network Operations departments within the 5 sub-markets in TX operated the same and reported upwards as the Texas market (not 5 different sub-markets) relative to policies and procedures.

• Manager of Contract Administration

  • Jul 2009 - Aug 2011

  * Responsible for Provider Directory production cycle and monthly addendum process* Maintain and update fee schedules within claims system, including, but not limited to, yearly Medicare fee schedule changes/updates and quarterly drug updates* Yearly benefit configuration in claims system* Managed Member Eligibility team - responsible for updating and resolving member eligibility issues within claim system* Managed Configuration Specialist team - responsible for loading par providers into claims system, as well as contract/fee schedule configuration, obtaining manual rates for claims department and loading of non par providers into claims system for claims processing purposes



Evercare of Texas, LLC

• Manager, Network Operations

  • Jun 2007 - Jun 2009

  * Managed a staff of two Contract Support Specialists who oversaw the credentialing and loading of contracted Long Term Support Service (LTSS) providers* Managed a staff of five Provider Data Analysts who were responsible for ensuring provider configuration accuracy within multiple systems (demographics, contract set up, fee schedules, etc)* Managed integrity of provider data transmitted to Maximus (State Enrollment Broker for Medicaid) each month via electronic file submissions* Responsible for quarterly provider directory production, as well as, bi-monthly online directory updates* Created and maintained templates to provide monthly & quarterly reports for State deliverables (i.e. Provider Add/Term Report, Provider Inventory, etc)* Created and automated department dashboard template; conducted ad hoc analyses for Network Operations, special projects, rate analyses, audits, etc



Evercare

• Senior Network Account Manager

  • Aug 2006 - Jun 2007

  * Liaison between Health Plan and Provider Network in the Northwest section of Harris County* Responsible for contracting Long Term Support Service (LTSS) Providers* Responsible for creating and maintaining positive relationships with provider and vendor clients* Service clients by ensuring proper contract assignment, resolving claim issues and assisting in the resolution of any and all provider related issues* Developed scorecard for future contracting efforts and performed ad hoc contract and rate analyses



Capital Healthcare Planning

• Strategic Planning Consultant

  • 2003 - 2006

  * Developed various strategic models to assist hospital clientele in expansion efforts* Focused on demographic projections, market share analyses, physician splitting analyses, inpatient and outpatient demand projections, payer mix analyses, inpatient and outpatient volume trends by service line, competitor research and utilization rate trending* Assisted in the development of a physician demand model which calculated both current and future physician needs by specialty for specific markets



Apogee Consulting Group

• Senior Consultant

  • 1999 - 2003

  * Analyzed managed care contracts and audited managed care accounts for various hospitals to ensure proper reimbursement per the contract* Identification and collection of over $4,000,000 in underpayments for hospitals in Texas, California, Florida and Illinois* Experience with inpatient, outpatient and workers compensation claims* Assisted hospitals in creating & maintaining Underpayment Review Departments to ensure proper reimbursement collection moving forward* Provided contract negotiations to facilities upon request