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Health Staff

Location:
Troy, MI
Posted:
September 08, 2014

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Resume:

Gary Gonzales

**** ***** *** ***

Okemos, MI ****4

517-***-****

517-***-****

E-Mail: acftpg@r.postjobfree.com

Managed Care Administrator/Contractor/Director

** ***** ** ************ *********** positions in the Health Care Industry

- on both the payor and provider side. Progressive experience includes

provider "risk" and FFS contracting, provider network development (local

and national), physician recruitment, health plan/provider management,

Operations, Consulting, fee negotiation, policy and procedure development,

communications, interface with state and national regulatory agencies.

Skilled and effective change agent.

EXPERIENCE

BHM Consulting, St. Louis, Mo.

Health Care Consultant - December 2013 to present

Organizational Health Care Consultant to BHM with clients all over the U.S.

My first assignment was/is as the Chief Executive Officer for Gerontology

Network (GN), based in Grand Rapids, MI. I was appointed by the Board of

Directors of GN to assist in the dissolution of several non-productive

business lines, but to keep the operation functioning successfully in the

meantime. The project is expected to end on July 31, 2014.

Physicians Health Plan (PHP), Lansing Michigan

Director, Network Services - Sept 2010 to July 2013

The major function of the Director of Network Services is to provide

leadership over all aspects of the Network Services Department (13 staff),

including contracting of the provider network, facility/medical record

reviews, credentialing/re-credentialing, provider issues and complaints,

system implementation of payment arrangements, maintenance of fee

schedules, vendor management, provider incentive programs resulting in

optimal access to quality, compassionate, cost-effective health care

services for all health plan members. PHP is owned by the Sparrow Health

System of Lansing, MI.

. Responsible for the overall implementation of provider & vendor contracts

and accuracy of claims payment. Chief architect of the Plan's Pay for

Performance program. Roughly $6M paid out to PCPs during my tenure,

resulting in 30% improvement in HEDIS scores, GDR usage up 20%, ER usage

down 8%, 10% reduction in LOS - in the first year of the P4P.

. Participated with management in the development of the Plan's overall

strategic and operating objectives. Provided leadership to include

planning, directing, organizing and implementing strategic priorities

within the Network Services Department.

. Organized and led the efforts of the department manager, supervisor and

contracting officer to achieve effective and efficient coordination of

all units within the department. Developed the organizational structure,

operational standards, and policies and procedures to meet the objectives

of the overall operation. Promoted three professionals during my tenure;

continued to meet department goals with 50% less staff then my

predecessor.

. Recruited and hired qualified staff and provided for their training and

development. Set performance expectations and goals, evaluated results,

and provided feedback to direct reports.

. Developed and implement departmental goals that supported the strategic

objectives of PHP and the Sparrow Health System. Consistently met most

goals during my three-year tenure, in spite of fewer staff and enormous

competitive pressure. Michigan Association of Health Plan Pinnacle Award

winner.

Capital District Physician's Health Plan (CDPHP), Albany, NY

Director, Practitioner & Vendor Contracting - Nov 2007 to October 2009

Accountable for managing seven contracting professionals, practitioner and

3rd party vendor relationships for the 24 county (400,000 members) service

area - mostly covering the Capital District in upstate New York.

. Increased the service area to reach more Medicare-eligible

beneficiaries by helping to add six new counties to the CDPHP

"footprint"

. Contained health care costs by keeping physician and vendor increases

to acceptable levels in 2008/2009

. Saved the plan at least $5M by bringing behavioral services management

in house in 2009

. Developed a new compensation model with a large Hudson Valley-based

provider to bring new efficiencies and cost savings for both the plan

and the provider

. Helped to re-design the contracting department, improving health plan

general and administrative expense by 10%

. Hired and promoted 4 professional staff in 18 months

St. Joseph Health System/St. Jude Medical Center, Orange, CA.

Executive Director, Contract Operations, 2001 - 2007

Responsible for turn-key implementation of all provider and health plan

contracts throughout six physician networks, three hospitals, and support

departments (Finance, Claims, Eligibility, etc.) in a highly dynamic

organization. Primary SJHS contact with the HMO and PPO payor community

on most contractual or operational matters.

Maintained close communication with internal medical and administrative

leadership on changes in contracts, health plan regulations and disputed

matters. Responsible for the identification and tracking of cases sent

for legal intervention.

. Assisted in the process to bring SJHS to solid profitability by re-

contracting with targeted health plans

. Recovered over one million dollars in disputed claims from the Plans

in 2001

. Achieved greater efficiency by creation of a streamlined Division of

Responsibility tool

. Claimed eight million dollars as a result of the indemnified services

recovery project; two million new dollars claimed as a result of the

specialty pool recovery project

PacifiCare of California/PacifiCare Health Systems, Cypress and Santa

Ana, CA.

Director, Provider Services and Contracting (promoted from staff level)

1989 - 2001

Negotiated budget-favorable risk contracts with over 100 IPAs, medical

groups and hospital providers within 8 Southern California counties, all

within acceptable MCR targets, while maintaining a positive working

relationship with each

. Primary management level professional servicing the San Diego county

based provider community, including Sharp, Scripps and UCSD

. Developed and implemented a plan to improve health plan margins at

levels exceeding 3% for Secure Horizons and 7% for Commercial

product lines

. Secure Horizons USA contract negotiating professional/trainer in 5

states

. Accountable for successfully managing a staff of eight professionals;

three of which were promoted during tenure

1984-1988 Held various provider servicing and contracting positions with

Maxicare, Partners, CIGNA and Arizona Physicians IPA (1st Medicaid risk

plan in the nation)

EDUCATION

USC, Los Angeles, CA; Bachelor of Arts, American Studies

University of Redlands, Redlands, CA, Master of Arts, Management



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