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Management Project

Location:
Miami, Florida, 33165, United States
Posted:
May 25, 2010

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******* ************, PAHM

**** *.*. ** *******. Miami, FL 33165. ?786.***.**** ? *-****-*******@*********.***

Chief Operations Officer ? Vice President ? Managing Director

Delivering Business Development, Broad Technical and Business Acumen, Performance

Improvement

Dynamic and accomplished healthcare executive with more than 20 years of management,

operations, marketing, strategic planning, and budget administration experience in the

insurance and managed care arena with organizations ranging from over $200 million to

$87 billion in revenue. Expertise in integrating and improving processes to enhance

the total quality of the customer experience, while maximizing human and financial

resources. Exceptional cross-functional management background and demonstrated

performance in business and financial management, leveraging communications talents

and business acumen without compromising healthcare quality through effective

leadership, development and implementation of processes and procedures to dramatically

improve performance and streamline operations.

SELECTED ACCOMPLISHMENTS

Led corporate interdisciplinary teams for the systems conversions and operational

integration initiatives for VISTA Healthplan throughout the merger process of four

health plans (HIP of South Florida, Foundation Health, Beacon Healthplan, and

Healthplan Southeast)

Improved the Provider Service Call Center abandonment rate from 25% to less than 10%

within 120 days of direct management

Implemented paperless workflow system that resulted in a savings of $150,000 in

administrative costs

Developed and implemented a consolidated provider information system used for

credentialing and contractual data

Eliminated backlog in the Network Management and Credentialing Departments through

auditing procedures, incentivized production programs and flexible work schedules that

resulted in over $500,000 savings in labor costs

Developed a Financial Recovery Unit and implemented auditing procedures that resulted

in the identification of $11M in potential recoveries and the collection of $4M within

the first 120 days of the Unit's implementation

Completed successful AAAHC Credentialing survey to achieve a three year accreditation

for VISTA Healthplan

Developed a Claims Reconciliation Unit to resolve claims reimbursement contestations

that facilitated in the successful settlement and contract negotiation resulting in

over $5M million dollars of savings

AREAS OF EXPERTISE

Start-up Leadership Staff Development

System Conversions

Process Engineering Research & Analysis

Operations Systems Development

Communications/Negotiations Global Sourcing

Claims/Financial Recovery

Business/Strategic Planning Turnaround Management Training

/Development

PROFESSIONAL SUMMARY

UNITED HEALTH CARE Minneapolis, MN (May 2009 -January 2010)

Vice President of Network Data Management

Direct muti-site national operations for United Health Network Data Management

Department consisting of provider demographic, contract loading, delegated provider

roster management, and electronic provider data interface within 14 legacy platforms

and over 200 FTEs

Improved average turnaround time from 80% to 95% within 5 days through development of

inventory control reports and reduction of internal handoffs

Reduced production downtime from 20% to 12% by establishing staff management protocols

and policies

Team leader in the development of consolidated workflow tool to improve inventory

management and reporting

EMBLEMHEALTH HEALTH INSURANCE PLAN ADMINISTRATORS, HOLLYWOOD, FL (AUGUST 2007-May

2009)

Director of Claims Operations

Directed regional operations for the Claims Department consisting of OCR Claims

Validation, Claims Processing Operations, Claims Adjustments, Claims System

Management, Quality and Training, and Financial Recovery, with 140 employees that

support the national enterprise of HIP of New York, GHI, and affiliated companies with

an output of over 30M claims

Management expertise with Collective Bargaining staffing

Reduced the claims inventory backlog from 150,000 claims to a sustained inventory of

less than 50,000 claims

Created staffing model to increase productivity standards resulting in projected $1.4M

savings in labor costs for 2009 budget

P&L responsibility for a $14M departmental budget, $40M total operating budget

Established a new Financial Recovery Unit; YTD recovery of over $18M

Reduced cycle time from 25 day turn around time to 5 days in the claims adjustment

unit

Implemented performance metrics and a reporting database/program to monitor

productivity and quality standards resulting in a 20% savings in administrative costs

due to increased productivity

Created operations support for new Connecticare Medicare product

INDEPENDENT HEALTHCARE CONSULTANT (APRIL 2007-AUGUST 2007)

Developed auditing protocol and directed accreditation process that resulted in the

successful three year accreditation from the Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) for a national medical supply organization, MEDirect

Latino, Inc.

Served as interim Compliance Officer for the company

Designed proprietary auditing tool for healthcare organization accreditation

Developed all corporate policies and procedures, including HIPAA compliance training

and Risk Management Programs

VISTA HEALTHPLAN, SUNRISE, FL (JUNE 2000-APRIL 2007)

Vice President of Network Management Services (2003-2007)

Responsible for day to day operations and development of systems and configuration

protocols for the Provider Contract Administration, Benefits Management, Provider Call

Center, and Credentialing Departments (Network Management Services)

Sponsored several plan wide initiatives in collaboration with Medical Operations and

Executive Management for the improvement of the financial performance of the Medicare

line of business through the development of the Extensivist Care Program and Specialty

Networks

Implemented system contract compliance improvements using various reimbursement

methodologies and financial impact analysis to enhance contract negotiation and

implementation

Maintained Medicare and Medicaid fee schedules in accordance with federal and

statutory policy and analyzed local payment trends

Resolved over 50,000 claims reimbursement contestations resulting in the successful

negotiation of contracts with several strategic healthcare partners in the major

hospital systems, i.e., HCA, Tenet, Baptist Health Systems as well as Sheridan

Healthcorp, Pediatrix, et al.

Created the Claims Reconciliation Unit to improve provider satisfaction with the

resolution of claims reimbursement issues, reduce pended claims, and enhance

operational processes and improve communications between Provider and Claims

Operations

Eliminated department pended claims backlog of 10,000 claims within first 90 days

after hire

Designed a proprietary claims resolution summary analysis to report claims review

findings and educate providers on billing trends

Director of Special Projects (2000-2003)

Responsible for managing the integration and systems conversion projects involving the

corporate operations teams. Worked closely with department leadership to ensure all

necessary resources from the enterprise and various external consultants worked

jointly to achieve effective and timely launch. Coordinated and enforced all the steps

of the project implementation process from inception until the implementation

occurred. Developed training documentation and workflow protocols in collaboration

with operational teams for operations management and maintenance

Analyzed and documented operational constraints and characteristics of each operations

area, including systems, pricing and data reporting structures in order to facilitate

new project launches

Maintained and developed close relationships with operations team members to ensure

consistent communication and smooth pre-implementation activities

Ensured that all Project Plan documents were kept up-to-date, and built other

operations resource documents pertaining to each new project

Organized project meetings and pre-launch activities in conjunction with the

conversion team and department Directors

Developed and maintained overall project pipeline documents

Supported department leadership efforts by coordinating project activities with rest

of the conversion team as needed

Communicated and worked effectively with conversion team to escalated risk factor

affecting project launch delivery when needed

Lead integration team meetings and participated in senior Joint Operations Committee

sessions

Demonstrated and documented 100% follow through in every commitment

AV-MED HEALTH PLAN, MIAMI, FL (1989-2000)

Director of Claims Service (1994-2000)

Directed operations for the Claims Service Department comprised of the Provider

Service Call Center, Claims Audit and Review, Financial Recovery, and Grievance and

Appeals, with a staff of over 100 FTEs

Designed and executed research methodologies to identify customer needs in order to

improve provider satisfaction, resulting in increased provider service satisfaction by

10% from prior year

Improved department productivity by 30% by streamlining workflow systems, enhancing

employee skill levels through comprehensive training programs, creative resource

management, Flextime scheduling, employee incentive programs, and implementing

production and quality standards

Decreased workflow backlog by 53% through aggressive auditing techniques to identify

root causes, while increasing staff production and decreasing the influx of duplicate

submissions

Provided leadership and direction for corporate reengineering projects, integrating

and planning objectives for multiple disciplines within the company for the Amisys and

MACESS systems conversions, and the development and implementation of EDI

Conducted external provider office staff educational programs to promote provider

education of managed care, improve billing practices, and expedite claims processing

in accordance with corporate claims guidelines

Assistant Director of Contracts, Product Development and Benefits (1993-1994)

Designed and implemented three new product lines within nine months of direct

management (CHPA, Small Group, and Individual)

Communicated with state and regulatory agencies to ensure that all product lines were

in compliance.

Managed daily operations of the Benefits Management Department that was responsible

for group benefits, and contract configuration and maintenance

Trained Marketing Department staff regarding new product designs and best practices

sales and service

Developed and conducted internal training seminars for new product implementation and

procedures

Manager of Enrollment (1989-1993)

Managed operations (enrollment, billing reconciliation, and system configuration and

maintenance) for multi-product membership

Eliminated the departmental workflow backlog in a six-month period through the

implementation of employee incentive programs and creative resource management

Recovered over $800,000 from CMS for ESRD members

Decreased administrative costs by $100,000 with the implementation of a flex schedule

and increased production by over 60% resulting in the elimination of enrollment

application backlog

Assisted in the development of and ongoing monitoring of Formal and Informal CAHPs

Facilitated action plan accomplishments for state and federal accreditation

COBRA administrator for the Plan's large employer groups

CREDENTIALS

Bachelor of Arts, Business Organizational Leadership, Magna Cum Laude, St. Thomas

University, Miami, FL

Certified designation of Professional with the Academy for Healthcare Management (PAHM)

Six Sigma Lean Leadership Certification

Healthcare accreditation expertise

Proficient knowledge of Power MHS, QCare, Amisys, and MACESS systems

COBRA Compliance Systems - COBRA administration training

Bilingual: English and Spanish



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