Managed Care Contracting & Network Adequacy Expert
Resume:
Laurie Siegel
+1-407-***-**** • *************@*******.*** • Orlando, FL
Summary
Accomplished Managed Care Professional with 20+ years of experience in Provider Contracting and Medicare Advantage network development. Expert in high-stakes Contract Negotiation with large health systems and IPAs, ensuring strict CMS Compliance and meeting Network Adequacy requirements. Proven ability to execute Value-Based Contracting strategies and perform sophisticated Financial Modeling to optimize Managed Care Operations.
Professional Experience
Reimbursement Support Specialist August 2023 – November 2023 ELECTROMED, INC., ORLANDO, FL
Executed critical support for the Reimbursement team, ensuring all processes adhered to CMS Compliance and internal Medicare Advantage reimbursement guidelines.
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Facilitated documentation review and data collection to support financial modeling for high-volume reimbursement activities.
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• Collaborated with managed care operations to streamline claim submissions and improve workflow efficiency. Managed sensitive provider and payer data through Salesforce to maintain accurate reimbursement tracking and network support.
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Managed Care Consultant February 2014 – September 2020 SWB CONSULTING, ORLANDO, FL
Developed strategic goals and network development plans to expand Medicare Advantage provider footprints while meeting strict CMS Network Adequacy standards.
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Conducted complex Financial Modeling and analysis in coordination with Finance departments to evaluate the feasibility of new IPA/CIN Contracting initiatives.
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Drafted and executed contracting plans that supported organizational expansion goals and satisfied HEDIS and NCQA credentialing standards.
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Analyzed contract documentation to ensure all managed care agreements remained compliant with state and federal regulatory frameworks.
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Reimbursement Strategy Manager / Managed Care Contract Analyst March 2011 – July 2013 GREENVILLE HEALTH SYSTEM, GREENVILLE, SC
Lead negotiator for system-wide hospital and physician services, managing Large Health System Negotiation for complex Medicare Advantage and commercial contracts.
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Architected and launched the organization's PHO/ACO, successfully implementing Value-Based Contracting models and population health management strategies.
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Evaluated quality metrics and risk adjustment data to drive managed care education across 1,400 employed physicians, improving network performance.
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Managed strategic relationships and contract renewals for major national payers including UnitedHealthcare, Cigna, Blue Cross, and Aetna.
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Managed Care Consultant August 2009 – July 2010
UNITED HEALTHCARE, ORLANDO, FL
Served as the business lead for the implementation of a $58 billion Tricare business line, overseeing high-stakes Provider Contracting and network build-out.
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Negotiated and drafted comprehensive hospital system contracts across Florida and at the national level, focusing on rate optimization and CMS Compliance.
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Performed rigorous internal audits of contracts to ensure departmental performance objectives and network adequacy met strict local and federal regulatory standards.
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Recruited and onboarded new providers through standardized education programs, ensuring alignment with corporate compliance and managed care operation goals.
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Cigna Advocate August 2008 – August 2009
CIGNA HEALTHCARE, ORLANDO, FL
Acted as the primary managed care liaison at the Disney Center for Living Well, facilitating provider-patient communications and health benefit advocacy.
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Educated Disney employees on value-based wellness benefits, improving plan utilization and patient satisfaction within the Cigna network.
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Developed and executed community outreach and health fair presentations to promote benefit awareness and network engagement.
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Collaborated with on-site medical facility leadership to ensure medical management and care plans aligned with Cigna’s service delivery standards.
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Managed Care Consultant 2006 – August 2008
THE FINNEL GROUP, ORLANDO, FL
Negotiated complex Medicare Advantage physician and hospital contracts, optimizing both language and rate structures for profitability and compliance.
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Recruited and built a robust provider network for a competitive Medicare RFP filing in Florida, achieving 100% of required geographic network adequacy.
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Conducted compliance audits for vendors and contracts, utilizing advanced Financial Modeling to forecast and track contract performance against budget.
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Drafted new audit policies and procedures that improved the monitoring of financial performance for high-risk managed care agreements.
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MIS Account Coordinator February 2002 – July 2005
SCAN HEALTH PLAN, LONG BEACH, CA
Served as the technical MIS liaison for business units within the MCO, aligning information system requirements with Managed Care Operations.
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Project managed the implementation of the McKesson disease management system, gathering complex requirements from medical management and utilization management units.
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Directed system implementations and process improvement initiatives to enhance technical communication across the Medicare Advantage plan.
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Selected for the organization-wide communication committee to streamline technical reporting and business intelligence data sharing.
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Senior Contract Administrator - Managed Care October 1999 – February 2002 CORVEL CORPORATION, ORANGE, CA
Spearheaded Network Development across 10 states, managing all phases of Provider Contracting from initial recruitment to final rate and language negotiation.
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Orchestrated the renegotiation of a system-wide hospital contract involving 40 facilities, successfully resolving termination disputes through Large Health System Negotiation.
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Negotiated and executed high-stakes contracts for IPA, PHO, and physician groups, focusing on value-based reimbursement and network stability.
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Collaborated with sales and product management teams to analyze market trends and improve provider retention through proactive communication and CRM tools like Salesforce.
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Managed Care Consultant September 1998 – September 1999 PACIFICARE HEALTH PLAN, MIAMI, FL
Managed the start-up of a new health plan network in Miami, overseeing all aspects of initial recruitment and Provider Contracting across all lines of business.
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Ensured absolute adherence to Medicare regulations and CMS Network Adequacy standards through rigorous financial analysis and utilization data monitoring.
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Led the department through the NCQA accreditation filing process, establishing credentialing standards and documentation protocols from the ground up.
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Negotiated competitive rates and language for hospital systems and ancillary providers to secure a high- performing Medicare Advantage network.
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Education
Bachelor of Arts Bachelor of Science
UNIVERSITY OF FLORIDA, GAINESVILLE, FL
Additional Skills
Contracting & Negotiation: Contract Management Systems, Contract Negotiation, IPA/CIN Contracting, Large Health System Negotiation, Network Development, PHO/ACO Strategy, Provider Contracting, Value- Based Contracting
Regulatory & Compliance: Audit Policies, CMS Compliance, Credentialing Standards, HEDIS, ICD-10, Medicare Advantage, NCQA Standards, Network Adequacy Analytics & Finance: Business Intelligence, Data Analysis, Financial Analysis, Financial Modeling, Managed Care Operations, Market Research, Risk Adjustment, Utilization Management Technology & Tools: CRM, Data Warehouse, EPIC, McKesson, Microsoft Excel, Microsoft PowerPoint, Salesforce, SharePoint
Certifications
• Health and Wellness Coaching (Certificate) - Wellcoaches School of Coaching, Disney University Institute (2009)
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