*

Raymond R. Bihis R.N., M.B.A.

**-**** ******** **.

Mililani, HI 96789

Phone:808-***-****

Mobile:808-***-****

email: acxoi5@r.postjobfree.com

Seasoned clinician with a passion for controlling medical costs while maintaining quality of care to ensure optimum patient & population outcomes. Extensive experience in Utilization Management with a focus on cost, quality, leadership, auditing, monitoring, and create standards and systems to improve the results in the Medicare and Medicaid programs. Deep knowledge of healthcare payer systems in the areas of Utilization, Quality, Auditing, Case, Disease, as well as Wellness & Prevention programs in the local as well as national programs. Interest in healthcare economics and technology and its impact now and the future of healthcare delivery systems. How can we make changes and improve the healthcare system in our state as well in the national level? 10/2014-Current United Healthcare

Manager, Clinical Operations (10/2014 – Current)

• Oversight of Community Case Management Agencies, Prior Authorization Unit, Disease Management, and Service Coordination (CCMA) administrative support teams

• Developed and implemented an audit and training program with agencies including documentation, electronic reporting monitoring system, and

• Responsible for participation and leadership in NCQA, EQRO, & other regulatory compliance of the Utilization Management and Disease Management initiatives

• Developed, maintained, and trained of unavailable administrative and clinical guidelines and planned and implemented the program (i.e. Incontinence Guidelines)

• Developed an Incontinence Management Program which resulted in a 30% reduction in cost which includes creation of a clinical standard and training of 120 service coordinators, 57 community case managers, & 145 foster home care givers resulting in $1.3 million savings.

• Hiring, retention, support, & coaching of 25 direct reports which includes RN’s, LPN’s, Supervisors/leads for allied health & administrative support

• Interfaces & collaborates as a participant or lead with state, federal, & community agencies to improve access to care, decrease healthcare costs, identify and eradicate fraud, waste, & abuse

EXPERIENCES:

1/2009 – 10/2014 Ohana Health Plan

Manager, Field Utilization Management

• Oversight of Transition Care Unit, Concurrent Review, Prior Authorization, Intake, and Service Coordination support

• Maintain acute hospitalization ALOS at below or at the same rate as national baseline metrics (i.e. Milliman ALOS benchmarks). Current utilization at ~5d of Med/Surg

• Reduction of Average Length of Stay (Acute & SNF) readmission rates and preventable ED overuse by coordination of services across all functions wherein someone is touching the member across the continuum of care, especially those identified as moderate and high risk. 2

• Certified as an InterQual instructor. Responsibilities include training, continuing education &

• interrater reliability to ensure consistency of criteria application 1/2001 – 1/2009 University Health

Alliance (UHA)

Honolulu, HI

DISEASE PREVENTION AND EARLY DETECTION MANAGER:

• Project manager for an outsourced disease management and healthcare analytics program. Deployed successfully in 3 months and is currently providing health coaching, disease management, care considerations, & health intelligence to the health plan. Integrated with internal programs attaining efficiencies and efficacy resulting in positive health outcomes.

• Project manager for a claims editing software project which involved multi departments. Project implemented ahead of schedule, on budget, and is expected to have a significant return on investment and improvement of the claims processing by automating procedures, medical policies, & accuracy of payment.

• Development & implementation of preventive health, wellness, & education programs as part of disease & care management initiatives designed to assist members and employers in lowering their health care premiums, increase productivity, lower health care cost, & improve their quality of life.

7/2000 - 1/2001 Raymond Bihis Consulting & Case Management Honolulu, HI Provided consulting and case management services to Long Term Care insurers, health plans, risk management companies, pharmaceutical companies, healthcare IT & medico-legal consulting services. Clients included Crawford & Co., a risk management company based in Atlanta, GA, Bristol Myers Squibb, Schering-Plough, Long Term Solutions Inc. of Natick, MA; John Hancock Life Insurance Co. Boston, MA; Philips Telemonitoring Services, Bothell, WA. 12/1998 - 7/2000 AlohaCare Honolulu, HI

Medical Management Manager

Responsible for operations of the care, utilization, & disease management department of a Medicaid Managed Care Organization (MCO) with 44K underinsured and underprivileged members. Responsibilities include oversight of pharmacy operations; assist in the overall strategic plans of the MCO. Projects implemented are: Pharmacy benefits restructuring which resulted in savings of

$88k/month in 7 months, streamlined the care management department operations & reorganized the utilization management department to maximize efficiency including the development of tools to manage and track outcomes.

8/1997 - 12/1998 Kapiolani Health Hawai'i Honolulu, HI Case Manager

Responsible for case management, concurrent review, & retrospective reviews for the Kapiolani Health Hawaii Plans. Responsibilities include Disease Management and Quality Assurance activities for Medicaid & commercial members. Coordinator & point of contact for providers, physicians, members, & internal customers re: utilization, case, & disease management.

8/1995 - 8/1997 Queen's Medical Center &

Health Plans

Honolulu, HI

Rehabilitation Clinical Nurse & Utilization Review Coordinator 3

Responsibilities rehabilitation clinician in the Progressive Care Unit. Reviewer for medical necessity and appropriateness of medical procedures in conjunction with the medical director for the managed care plan of the Department of Defense/TRICARE. Point of contact for the providers, physicians, and the military lead agent in providing managed care information. CLINICAL EXPERIENCE:

11/1995 – 12/1997

3/1992 - 11/1995

Clinical Rehabilitation

Specialist then transitioned to

the Queen’s Health Plans

Rehabilitation Hospital of the

Pacific

Staff Registered Nurse

Honolulu, HI

Honolulu, HI

8/1991 - 2/1992 Rehabilitation Institute of

Chicago

Staff Registered Nurse

Chicago, IL

8/1990 - 8/1991 Humana Hospital

Licensed Practical Nurse

Hoffman Estates, IL

EDUCATION University of Phoenix Honolulu, Hawaii

Masters in Business Administration

William Rainey Harper

College

Arlington Heights, Illinois

Associates Degree in Nursing

Natioanl College of

Busines and Arts

Manila, Philippines

Bachelor of Science in Business Administration majoring in Economics AFFILIATIONS &

CERTIFICATIONS

10/2007 – 1/2009

Coalition for a Tobacco

Free Hawaii – Business

Council

Board Member

09/2000 – 12/2001 Case Management

Society of America

Advisory Panel Member

Hawaii Chapter

01/1993 – 08/1997 Certified in Spinal Cord,

Stroke & Orthopedic

Rehabilitation Nursing

CRRN Certificate

1991 - present Registered Nurse

Licensed in Hawaii

HI RN license # 38313.

Unrestricted & good

standing

SKILLS Skill Name Skill Level

McKesson InterQual Clinical Standards InterQual Certified Instructor McKesson ClaimCheck Auditing Systems Project Manager ActiveHealth by Aetna Health Project Manager

MS Office Suite (Word, Excel, PPT,

Project, Access)

Intermediate/Expert

4

ADDITIONAL

INFORMATION

Articles:

Advisor: Acute Care Waitlisted Patients in Hawaii 2006 to 2011: Published October 11, 2013.

http://hah.org/uploads/5/0/1/9/5019048/waitlist_final_report_06_10_fin al_2.pdf

Finalist for Top Manager: HEALTHCARE HEROES: RECOGNIZING HAWAII’S HEALTHCARE LEADERS. Pacific Business News (PBN). September 29, 2006 edition or online at:

http://www.bizjournals.com/pacific/stories/2006/10/02/focus11.html Quoted on The Honolulu Advertiser article:

“HEALTH TROUBLES WEIGH HEAVY ON FOLKS AS THEY AGE” http://the.honoluluadvertiser.com/article/2004/Dec/05/il/il09a.html Volunteer: LANAKILA REHABILITATION CENTER

Meals on Wheels Program

Volunteer Facilitator: PILI OHANA PROJECT: Diabetes and Obesity Management for the underserved and underprivileged. A grant provided by the John A. Burns School of Medicine to the Kalihi Palama Health Center.

Volunteer: "DRUGS & KIDS PROJECT" with the Hawaii State Bar Association. In conjunction with a legal professional, talk to 4th graders about “Choices” and how substance abuse may affect their legal and physical health.

Contributor: HEALTHY AGING PROJECT:

A Chronic Disease Self Management Program for elder adults. Sponsored by the EXECUTIVE OFFICE ON AGING. Member: METRO ROTARY CLUB.

Mr. Fitness: CLARK HATCH FITNESS CENTER. Honolulu, HI. April 2003. Co-Founder: ACCESS MEDICAL CLINICS. First Convenience Care Clinics in the islands inside Longs Drugs Stores.

REFERENCES Richard “Rio” Banner, MD

State of Hawaii Correctional Medical Director

Tel. #: 808-***-****

Ed Fess, MD, MBA

Medical Director

Ohana Health Plan

Tel. #: 808-***-****

Contact this candidate