Anh K. Tran

Phone: 206-***-**** Email: adkcj3@r.postjobfree.com Fremont, CA

Proven leader in the health plan and managed care industries with twenty plus years’ experience in Health Care Information, including eight years with Blue Cross Blue Shield. Extensive knowledge of provider contract unit cost management, provider contract modeling, claims cost analytics, State and Health Plan compliance audit requirements, medical-loss driver identification, contract risk mitigation, utilization data reporting and provider shared-risk structuring in population health management.

STRENGTHS & QUALIFICATIONS

Experience in financial operations and strategies at large national health plans

Worked through Health Plan consolidation, provider consolidation, industry power shifts among players, and insurance purchasing pools

Direct contract strategies with Hospitals and Physicians for Commercial, Medicare, Medicaid business, including value-based reimbursement, ACO, and patient-centered medical home

Experience in claims system administration for multiple lines of business, Commercial, Medicare, Medicare Supplement and Medicaid

Experienced in HEDIS reporting, utilization and quality data management, and Disease Management data operations

Participate in health care strategy creation and collaborated in important details so strategies and initiatives can take hold

Continual driving acceptance of analytics among professional staff to compare cost across providers

Possess business acumen to accurately evaluate financial contracts, statistics and trends, analytics, reporting, ROI and new cost trend identification

Implement Medicare Prospective Payment System, Inpatient MS-DRG, Outpatient HOPPS, APC, OCE

Well-versed in setup and use of Trizetto Facets to process claims, NetworX Pricer, NetworX Modeler, Optum Groupers, to implement provider contract for claim auto-adjudication

Well-informed in current analytics methods, quality of care, P4P and managed care initiatives

EDUCATION & CERTIFICATION

MBA, University of Southern California, Los Angeles, CA

BS, Mathematics, Actuarial Plan, Minor, Computing, University of California, Los Angeles, CA

Project Management Program, University of California, Berkeley, CA

Trained in Professional Coding

PROFESSIONAL EXPERIENCE

Stanford Health Care, Stanford Advantage Medicare Plan and Accountable Care Division

Finance Decision Support Manager 12/2018 – 5/2020

Provide analytics to Stanford Medicare Advantage plan in annual CMS bids, monthly IBNP, Risk Adjustment Factor RAF scores, and HCC grouping

Support financial statement reporting and auditing in health care revenues, and claims expenses for Stanford Medicare Advantage plan and ACO University Healthcare Alliance

Troubleshoot to help resolve challenges in provider contract valuation, EPIC/Tapestry claims and eligibility, health plan and PCP capitation and other provider relations operations

Medicaid Consulting Projects

Consultant 12/2017–11/2018, 5/2020-1/2021

San Francisco Health Plan

Provide business solutions for various health plan operations

Configure claim system, industry coding and fee schedules

Audit and enhance claim processing compliance with regulations

Bring clarity to operations through metrics reporting

Identify cost savings and continuous improvement

Alameda Alliance for Health

Improve HEDIS and Pay-for-performance metrics for Medi-Cal population in Alameda County

Identify reasons for low performance and provide data, method and material to providers and members via established channels

Compute and explain incentive payment programs to internal and external customers

Participate in NCQA accreditation initiatives

Conduct Medi-Cal Provider Appointment Availability Survey project for compliance

BMC Healthnet Plan

Synthesize proprietary data layout of eligibility, provider and claims data from Massachusetts Medicaid, MassHealth to four ACOs connecting to Boston Medical Center as the state auto-assigned all Medicaid members to ACOs in 2018

Report health status on auto-assigned member panel, age, gender, AID, DxCG Risk Scores, Social Determinants on Health, risk-adjusted capitation, and statistics at the beginning of the program.

Provide predicted high-risk patients so front-line staff can focus in on members with the most urgent medical needs

Accountable IPA/MSO, Long Beach, CA

VP, Business Intelligence Reporting 4/2016 to 11/2017

Contract with Health Plans, Hospitals, Physicians, Lab vendors, Radiology vendors on fee-for-service and capitation arrangement

Ensure a productive, respectful and collaborative relationship with all Health Plan delegation auditors while fulfilling the IPA's obligations, new and current CMS/State regulatory guidelines, and HP/Vendor contractual agreements

Respond to chart requests, supplemental data requests, and Physician Opportunity Reports also known as Gaps-In-Care lists from all Health Plans

Meet with primary care offices to inform and to improve HEDIS rates and to reflect appropriate HCC scores

Analyze provider contracts using claim experience; Lead audit team to identify fraud, waste and abuse in medical claims; Respond to large claims disputes cases

Review UM and claims data to identify root cause and capture potential under-payment/under-use and over-payment/over-use for further review during the UM/claim processing cycle

BLUE CROSS BLUE SHIELD OF LOUISIANA

Director, Provider Reimbursement and Payment Policy 9/2012 to 4/2016

Manage $3B in annual hospital contracts; audit for recovery over $5B in claims annual spend

Contributed to #1 discount Hewitt ranking in the Louisiana and the winning bid to administer Louisiana state employee jumbo group for five years

Consistently met contract unit cost goal and observed medical trends. Reduce contract exposure to charge and increase cost predictability

Contract new rates and implement terms in claim payment system for auto-adjudication at high accuracy rate

Well-versed in Facets applications, peripherals and databases. Implement current reimbursement methodologies, test and configure inpatient and outpatient groupers, IPPS and HOPPS with APC and OCE

Determine reimbursement adequacy of services for in-network and out-of-network providers

Reprice claims and provide discount projection for new and renewed large employer groups

Led team of RNs who reviewed claims and medical records for payment integrity

UNITED HEALTH GROUP - OPTUMINSIGHT

Health Care Transformation Consulting - AARP Medicare Supplement Insurance Plan

Senior Director, Health Care Research and Reporting 1/2011 to 9/2012

Created metric dashboard with client to measure success of on-going pilot operations

Added transparency and qualitative value to Case Management and Disease Management transactions by Nurses; Reflected important work value performed at meaningful impact of Nurse’s interaction with high-risk patients; Improved accuracy of contract implementation related to quality incentives, resulted in $800K favorable shift

Leveraged managed care know-how and incorporate findings from research projects and pilot programs to study medical utilization, cost, disease/case management, and member/patient satisfaction in the insured population of Medicare fee-for-service with Medi-gap

Led a team of multidiscipline staff to comprehensively report on health management operations for AARP Medicare Supplement Insurance Health Plan of 3M+ members nationwide

Corrected a major claims data input issue made by external vendor for 3 years – outsource contract worth $3M annually; Correction drastically enhanced the validity of claims data used in client reporting and pilot program ROI evaluation

BLUE CROSS/BLUE SHIELD HEALTH PLANS (CA, WA, OR, UT and ID)

Senior Manager, Actuarial, Provider Contracting Analysis 2007 – 2011

Directed team of Actuaries to forecast unit cost trends resulted from contract negotiations

Assessed risks during contract negotiations with Hospitals and Physicians

Strategized the formation of networks of high value, high impact providers, proposed rates & reimbursement structure at each step of the negotiation process

Valued unit cost price increases accurately to stay within budgets

Evaluated and strategized provider contracts in CA, OR and ID; Support contract language in high profile negotiations and recovery of thousands of dollars in contract violations

Provided CalPERS narrow network analytics included ranking, setting thresholds and profiling providers by cost and efficiency measures to form selective and cost-effective networks

AMERIGROUP CORPORATION, Virginia Beach, VA

Vice President, Management Analysis & Reporting + Technical Operations 2006 – 2007

Managed a team of programmers and analysts to run analytics for the centralized operations of enrollment & claim processing, call centers, provider information & contract processing

Support Actuarial reserving functions in just-in-time claims estimates

Provided explanation of trends in claim inventory, timeliness, rework, and provider payment disputes volumes

Identified process improvement opportunities. Optimized business rules across nine health plans with five product lines each

Automated reporting, shared SQL scripts and programming techniques, promoted customer-centric thinking and action among staff

UNIVERSAL CARE HEALTH PLAN, Long Beach, CA

Associate Vice President, Data and Information Management 1994 – 2006

Monitored P&L and proposed bid on large employer groups, purchasing pools, Medicare, Medicaid and CA State programs

Engaged providers in the discussion of their financial performance and resolved disputes over reimbursement

Improved auditability, credibility, and availability of financial data. Analyzed major drivers of recoverable medical cost containment. Performed claims studies pertinent to settling litigation favorably

Served as data backbone during NCQA® and HEDIS reporting and audits during company NCQA accreditation, an important and necessary milestone in company’s history, 1999-2004

Passed financial and medical data audits from Calif. Dept. of Managed Health Care, CMS, NCQA, and other governing agencies. Created databases for Asthma and Diabetic clinical studies under MD’s direction.

COMPUTER & SOFTWARE EXPERTISE

Systems: Trizetto FACETS, EZCAP, NetworX Modeler, EPIC/Tapestry, DST/CSC Healthcare, OPTUM DRG grouper, Medicaid 3M Grouper, APC Grouper, Catalyst

Programming: SQL, SAS, MS Reporting Services, Business Objects, Tableau

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