Experience

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  Optum

  • Claims Process & Business Implementation and Capability/Change Mgmt., Associate Director

    • 2021 - Present

    Led team of Business Analysts/Consultants and PMs for Claims Operations in support of development of processing capabilities, operational changes, vendor interfaces/mgmt and healthplan/client implementations of Optum products and services.

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  Cognizant

  • Baltimore, Maryland Area

  • Sr Manager, Operations Service Delivery and Implementation

    • 2016 - 2020
    • Baltimore, Maryland Area

    Operations management of 20+ clients to assure timely and accurate delivery of contract services, > Oversaw day-to-day administration of matrixed delivery teams; met 97 to 99% of SLA's annually spanning claims, configuration, enrollment and billing, provider data, medical case management, and member service. > Handled project/change management implementations such as annual Medicare changes, new product/LOB launches, Automation initiatives, and IT upgrades on Facets and QNXT. > Oversaw/managed P&L revenue and cost targets; exceeded targets for multi-million dollar contracts.

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  TMG Health

  • Jessup/KIng of Prussia, PA

  • Director, Operations - Cross Functional Support (claims, enrollment, billing, configuration)

    • 2011 - 2015
    • Jessup/KIng of Prussia, PA

    Managed and implemented Operations and enterprise-wide projects initiatives and process improvements. Achieved 15% cost reductions and improved SLAs performance by 5 to 10+%. Led projects spanning: > New PDP processing and service platform for eligibility/enrollment, billing, letter generation/fulfillment > Account implementation and plan contract and provider configuration> Claims auto/electronic adjudication> Operational quality/control process> IT and PM life-cycle processes from scope/requirements to design, QA/UAT and cutover phases

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  CAREFIRST Blue Cross Blue Shield

  • Owings Mills, Maryland

  • Sr Director (08-10) and Director (03-08) of Operations Processing, Configuration and Project Support

    • 2003 - 2010
    • Owings Mills, Maryland

    Led National & Large Group Division (750k contracts; 20+M claims) Business/Systems processes, vendor and project management efforts across account setup, claims, benefit/plan, and service configuration/administration, and eServices/EDI to implement product, policy and government mandates and performance changes/improvements. Led 5 directors/managers, 80+ analyst and PM staff, an $8M budget and $40M in vendor contracts. Reported to the Sr VP.> Implemented operational capabilities and enhancements to increase auto-adjudication and EDI by over 20%, and achieved $2-4M savings per year, annual enrollment increases of 3-8%, and multiple SLA improvements of 10-20%. > Converted over 500k contracts (115 accounts) onto the NASCO system over 27 months. Led those division and vendor efforts across CareFirst for project management and implementation from planning, analysis, requirements and testing, to account management and operational deployment activities. > Organized and managed team efforts to automate business processes and implement initiatives for new capabilities incldg electronic/web self-service, front-end input, group/benefits setup, claim pricing and medical management processes. > Led cross-functional project team efforts to establish operational capabilities and products for TPAs and labor accounts, CDH, Medicare Advantage & PDP, and Med-Mgmt programs.

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  Cablevision

  • Bethpage, NY

  • Director of Operations Reporting & Metrics

    • 2000 - 2002
    • Bethpage, NY

    A Fortune 500 telecommunications service company with over 3M customers in metro NY. Led 5 Sr Analysts and PM responsible for developing, reporting and monitoring corporate metrics. Reported to the VP of Planning. Saved over $1M per year by migrating reporting onto new IT platform and vendor software (MicroStrategy), while also providing support to implement hundreds of new metrics and reports.

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  AETNA Inc (via merger with NYLCARE Health Plans)

  • NY, NY and Fort Washington, PA

  • AVP of Operations Business Process & Project Support

    • 1997 - 2000
    • NY, NY and Fort Washington, PA

    At NYLCARE, a NY Life subsidiary: Formed and managed a centralized unit (40 staff, $3.6M budget) supporting PM initiatives and key operational processes (EDI, provider and benefit files, desk levels, SDLC and user requests/support) for HQ & 8 regional offices (~30M claims and 20k groups). Automated/standardized processing to reduce cost $2+M per year and raised SLAs 15% (claim accuracy) to 28% (timeliness). Managed functions including a Claims and Group Processing system conversion, EDI and applications automation projects, and enhanced account installation and support services.

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  HORIZON BLUE CROSS BLUE SHIELD OF NJ

  • United States
  • Insurance
  • 700 & Above Employee

  • Director of Operations, the Federal Employees Program (FEP)

    • 1992 - 1997

    Oversaw all FEP Claims, Customer Service and Enrollment functions as well as Project, IT, Quality and Training support comprised of 6 Managers, up to 110 staff, an $11M budget, with ~ 2M claims and 300k inquiries. Reported to the VP of Gov’t Programs.Executed improvements and capabilities to turnaround prior mgmt's contract rating from poor to Excellent. Raised productivity and cut costs 5-10% per year with increased customer satisfaction. This reversed $1M losses per year to $3.5M profit in four years. > Restructured Claims and Service functions into "one-stop" business teams, and created new workflows and SOPs, QA and pre-pay programs, production standards, and metrics reporting. > Established a Program Mgmt area to focus on system and project development, claims efficiencies, benefit plan and provider configuration, analytics, quality and training. Worked with NASCO/EDS vendors to expedite 80+ improvements within 18 months. > Increased claims auto-adjudication to 85% and EDI claims by 15%, as well as implemented IVR/VRU technology improvements and inquiry outsourcing and fulfillment workflow processes.

  • Director of Operations, Corporate Large Group

    • 1990 - 1992

    Managed Claims and Customer Service: 3 Managers, 85 employees, a $7.5M budget, 1.5M claims and 180K inquiries. Managed key initiatives to turnaround market share and multi-million dollar losses (over $3M improvement) from contractual terms and SLA failures. Reported to Corporate Operations VP. > One of four division leads to guide and pilot implementation of a new claims and customer service system including development of migration plans, decisions, requirements, processes, UAT, model office, training and cutover. > Successfully launched Horizon's first Claims imaging platform technology with IBM, IT and Mail Services. > Worked with Sales & Group Operations to enhance product and group install workflows, and create a dedicated full-service staff.

  • Manager of Operations, Medicare Part A

    • 1986 - 1990

    Managed Claims, Customer Service, and Analyst staff of 45 employees and a $3M budget. Improved CMS contractor ranking from 55th to as high as 8th of 60 carriers. Reduced costs 35% while volumes grew 40%. Implemented a new Claims system, EDI applications, and established/trained COB/MSP unit of 12 staff with savings of over $20M/year. Progressed from Analyst to Sup to Manager.