Experience

Western Health Advantage

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

• Director of Medicare Operations

  • Jul 2021 - Present



Centene Corporation

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

• Claims Director

  • Mar 2019 - Jul 2021

  Responsible for medical, behavioral health and EAP claims administration functions for 3.8M enrollees in states of California, Oregon and Washington. Benefit lines include Exchange, HMO, PPO, Medicare, Medicaid, and Self Funded. Teams process on three disparate platforms, utilizing numerous applications. Responsible for medical, behavioral health and EAP claims administration functions for 3.8M enrollees in states of California, Oregon and Washington. Benefit lines include Exchange, HMO, PPO, Medicare, Medicaid, and Self Funded. Teams process on three disparate platforms, utilizing numerous applications.



HealthCare Partners of Nevada

• United States
• Medical Practices

• Senior Director Of Operations

  • Jan 2017 - Mar 2019

  Provide oversight and direction for all aspects of the non-clinical Managed Services Organization for delegated plan enrollees in state of Nevada. Membership primarily Medicare Advantage with enrollment of 74,000. Provide oversight and direction for all aspects of the non-clinical Managed Services Organization for delegated plan enrollees in state of Nevada. Membership primarily Medicare Advantage with enrollment of 74,000.



Sutter Health

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Director, Health Plans

  • May 2007 - Jan 2017

  Accountable for all aspects of Sutter Health’s Self-Funded Employee Health Plans (SutterSelect). Lead and manage all budgeting, financial, clinical, networks, legal, communications and operational activities of 9 self-funded plans with 100,000+ enrollees. Responsible for relationship and oversight of vendors (actuary, enrollment, pharmacy, behavioral health, stop loss) and third party administrator, UMR. Manage annual employee health plan budget of $500 million, with an operational budget of $5 million. Responsible for ensuring all components of the plans are ERISA compliant and adhere to all provisions of Health Care Reform. Manage the annual actuary studies, reviewing and validating actuarial assumptions and estimates, developing additional models and recommendations.

• Director, Managed Care Administration

  • Sep 2000 - May 2007

  Directed the eligibility, claims, authorization, and recovery operations of 14 Northern California MSO clients. Managed annual capitation revenue of $200 million, with an operational budget of $5 million. Supervised 80 staff including 4 direct report managers. Developed programs and processes to identify and address unique and system-wide client needs by providing the operational linkage to health plans, providers and members. Implemented guidelines, productivity standards, and best practices for managed care services. Migrated clients with professional and hospital risk arrangements to single platform, GE Healthcare, using plug and play approach. Developed, achieved, and maintained goals for corporate two-year work plan.



Hill Physicians Medical Group

• United States
• Hospitals and Health Care
• 300 - 400 Employee

• Director, Practice Support

  • Feb 1999 - Sep 2000

  Managed the planning, staff, and continuous operations of the Practice Support Department. Formulated and implemented strategies to meet budget and corporate goals and objectives. Developed and made recommendations for improvements to business processes, policies, and infrastructure to improve overall operational efficiencies. Cultivated and managed physician, ancillary, and health plan relationships.Assisted in the RFP and vendor selection process of the electronic commerce project. Collaborated with the selected vendor, WebMD, and members of Hill’s senior management team on re-engineering claims. Studied current state workflows and directly assisted in the development of future state workflows and rules logic. Provided oversight on implementation and systematization of new workflows and rules logic into IDX and WebMD’s Administrative Services application. Managed and coordinated deployment of claims to physician offices. Trained internal and physician office staff on the WebMD application.

• Director, Claims

  • Sep 1994 - Feb 1999

  Accountable for overall direction of the largest department within the PriMed organization. Managed 100+ employees, including those in claims production, enrollment and benefits, inventory control, internal auditing, claims training, healthplan compliance, and the mailroom. Operationalized new regions, products, and contracts. Primary decision-maker during the implementation of HBOCs ClaimCheck product. Oversaw several reimbursement conversions, the primary being a change from 1974 CRVS to RBRVS.

• Regional Manager of Provider Relations

  • Jul 1993 - Sep 1994

  Onsite manager for onboarding of new regional office. Managed and supervised day-to-day operations of teams, projects, customer expectations, and business priorities to achieve business objectives. Primary liaison between regional and corporate office. Produced monthly bed days and utilization reports.



Mercy Health

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

• Supervisor Claims/Customer Service

  • Jun 1990 - Jul 1993

  Developed department policy and procedures. Interpreted health plan benefits. Medical group liaison to third party administrator, Foundation Health Preferred Administrators. Managed the Customer Service ACD call center. Reviewed and distributed monthly primary care physician capitation rosters. Reconciled capitation. Analyzed claims payment issues and provided resolution. Nominated and selected by peers and managers within the Mercy Healthcare system as a Mercy Leader. Developed department policy and procedures. Interpreted health plan benefits. Medical group liaison to third party administrator, Foundation Health Preferred Administrators. Managed the Customer Service ACD call center. Reviewed and distributed monthly primary care physician capitation rosters. Reconciled capitation. Analyzed claims payment issues and provided resolution. Nominated and selected by peers and managers within the Mercy Healthcare system as a Mercy Leader.



PCA Health Plans

• Medical Practices

• Authorizations/Referrals Coordinator

  • Jan 1990 - Jun 1990

  Provided ongoing education to physician offices on referral/authorization guidelines. Notified the Provider Relations Department of operational issues in the physician offices. Provided ongoing education to physician offices on referral/authorization guidelines. Notified the Provider Relations Department of operational issues in the physician offices.