Health Staff
Resume:
Gary Gonzales
Okemos, MI ****4
E-Mail: ***********@*****.***
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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