Troy M. Risher

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

Dallas, Texas **287

(Home) 972-***-****

(Cell) 972-***-****

(Email) k1boti@r.postjobfree.com

Objective:

To obtain a challenging position in managed care offering the opportunity to utilize my knowledge and people oriented skills in the area of healthcare management.

Background Summary:

More than 15 years of diversified and progressive experience within the healthcare industry. Demonstrated expertise in HMO, PPO, POS, Medicare and Medicaid products enhancing internal and external relationships and providing overall superior customer service.

Education:

Amberton University – MBA in Strategic Leadership, May 2010

New Mexico State University- Bachelors in Community Health, May 1995

Professional Organizations:

Board Member of DFW Healthcare Alliance for Excellence

PROFESSIONAL EXPERIENCE:

LifeCare Management Services, LLC- Plano, TX

Regional Director of Managed Care (August 2008-October 2009)

As part of the Corporate Managed Care Team, I am responsible for ensuring that my assigned hospitals have viable payor agreements in place to stimulate patient referrals to LifeCare.

• Responsible for all managed care initiatives in relation to the 13 LifeCare hospitals located in the Western Region

• Interaction with health care plans, ppo networks, and other commercial payors daily to assist my assigned hospitals with patient referrals & conversions

• Maintenance of facility and payor data , such as new agreements, contract implementation & documentation

• Interpretation and negotiation of definitive payor agreements and single case agreements

• Visits with key payors in assigned region on a quarterly basis

• Work with Revenue Cycle staff o assist with collection activities

• Assist hospital staff with clarification of contracts, historical trends, and patient referral stimulation

• Marketing & promotion of hospital services to payor community and referring hospitals

• Building rapport and relationship with managed care counterparts at referring hospital partners

PHCS (Private Healthcare Systems, Inc.)/MultiPlan- Dallas, TX

Network Development Executive (September 2005-August 2008)

As part of the Dallas Territory Network Development Team, I was responsible for the management of large provider group & facility contracting in assigned markets.

• Interaction with providers and/or facilities daily to resolve service issues including but not limited to: claims processing, contracting, and claims appeals

• Maintenance of provider data , such as new groups, terminations and fee changes

• Interpretation and negotiation of provider & facility contracts

• Network recruitment and procurement

• Visits with key provider groups and facilities on a quarterly basis

• Work with Provider Data Management department regarding network updates and other data issues

• Assist Provider Relations staff with clarification of contracts and historical trends

• Work with claims unit for assistance in claims repricing

• Expediting the resolution of network problems /complaints

• Prepare and conduct technical/product presentations and demonstrations

• Overall responsibility for development and maintenance of PPO network in assigned areas/markets

ppoNEXT- Dallas, Texas

Senior Account Services Manager (March 2004- June 2005)

Established and built client relationships for those clients with the highest generated revenue by being the one point of contact for issue resolution and timely service.

• Interaction with clients, providers and/or facilities daily to resolve client’s service issues, including claim/contracting issues, report generation, and claims appeals

• Supervised team of claim analysts

• Maintenance of client data, such as new groups, terminations and fee changes

• Interpretation & negotiation of provider contracts as necessary

• Visits with clients quarterly

• Work with the data management department regarding provider updates and other data issues

• Work with network development and provider relations for clarification of contracts and to obtain historical information on providers

• Work with claims department for assistance in claims repricing

• Expediting the resolution of customer problems/complaints

• Prepare and conduct technical/product presentations and demonstrations

• Responsible for up-selling additional business & products to current clients

Genesis Physicians Group – Dallas, Texas

Senior Physician Relations Representative (September 2001 – March 2004)

Oversaw network management of assigned area to include recruitment and contracting of physicians for participation. Responsible for managing provider contracts and performing related analysis and provider communication.

• Manage large and complex provider groups and hospitals

• Team lead for analyzing trends to claims payment errors

• Supervision of internal physician relations staff

• Partner closely with Payers to determine trends and solutions to ensure correct payment

• Identify network gaps for recruitment and contracting to enhance market presence

• Assist contracting staff with review of reimbursement methodologies

• Developed internal relationships with Finance and Marketing to coordinate analytical support and effective administration of contracting strategies

• Mentored and advised junior members of the physician services team

• Account Manager for Value Added Services contracts

North American Medical Management, Inc. – San Antonio, Texas

Senior Provider Relations Representative (January 2000 – October 2001)

Provider Relations Representative for over 250 IPA physicians. Responsible for handling IPA activity, managing provider contracts and performing related analysis and provider communication.

• Educated providers on proper medical billing utilizing CPT 4 and ICD 9 guidelines

• Negotiated PCP and Specialty physician provider contracts for participation in network

• Instructed IPA on Capitation, Shared risk pools and Managed care reporting

• Liaison between IPA physicians and Insurance payers

• Facilitated monthly operational meetings for IPA staff

• Consulted Office Managers on Capitation and third party payer responsibilities

• Analyzed network to develop recruitment goals and objectives

• Participated with Senior staff on network expansion

• Reviewed and resolved appealed claims daily for adjudication

• Reviewed and resolved Texas Department of Insurance inquiries

PacifiCare of Texas -- San Antonio, TX

Customer Service Associate II/Team Lead (January 1999 – December 2000)

• Responsible for providing customer service in Southwest Region

• Assisted with supervision of team members

• Assisted members with claims and benefit information

• Assisted providers with benefits, eligibility, and claim status

• Responsible for assisting representatives with attaining service goals

• Reviewed and resolved appealed claims daily for adjudication

• Reviewed and resolved Texas Department of Insurance inquiries

• Responsible for handling escalated issues to ensure problem resolution

Columbia LifeCare Center -- El Paso, TX

Health Education Coordinator (January 1995 – January 1998)

• Responsible for conducting various screenings (cholesterol, glucose, body composition, etc.)

• Supervised & coordinated teams for health promotion to several businesses, as well as public sector

• Responsible for health education to LifeCare clientele and staff

• Responsible for starting clientele on exercise and weight programs

• Responsible for case management of wellness clients, including: cardiac, diabetic & pulmonary rehabilitation

• Conducted nutrition counseling and testing

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