Contract Compliance/Senior Contractor

Barbara Eberle

**** ********* *****

Riverview, FL 33578

Contact: 813-***-****

********@********.**.***

Qualifications:

Seasoned Managed Care executive with experience in establishing community based partnerships

with matrix partners and other stakeholders in the healthcare industry. My Human Resources

knowledge (recruiting & retention) coupled with strong attention to detail, organizational skills, problem solving, planning and creative solutions have led to numerous process improvements in all positions held. In addition, the demonstrated ability to handle multiple projects within aggressive timelines utilizing my big-picture thinking has contributed to an excellent track record in achieving results in the following areas:

Experienced Healthcare Contractor; Physician, Capitation, Ancillary & Global Risk

Hospitalist/Practice Management

Vendor Delegated Oversight Management; Utilization Management, Quality Improvement, Appeals,

HIPPA, Credentialing, Customer Service and Network Development

Knowledgeable about Commercial, Medicare and Medicaid MCO’s

Managed Corporate Compliance Programs

Contract Management System Implementation (Emptoris)

Experienced Trainer

Provider Services Management

Experienced in Practice Management Infrastructure Development & Management; IPAs, PHOs,

and other provider types

Knowledgeable in:

HEDIS

URAC

NCQA

AAAHC

JACHO

AHCA

CMS

PROFESSIONAL EXPERIENCE

Health Integrated

Manager Care Management

November 2010-Current

Managed 2 UM units providing Concurrent Review service for a large managed care plan in Seattle WA

My current job requires me to coordinate duties with appropriate personnel to meet operational program needs, ensures compliance with state and federal health plan requirements, Medicare guidelines and NCQA standards; implements policies and procedures updates and integrates current clinical practice guidelines (Milliman); perform employee counseling, performance appraisals, and oversights employee training and development.

Collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS and Milliman Coverage Guidelines and clinical review criteria to determine appropriateness of level of post-discharge care and services, length of stay, and procedures.

Conduct IP admission review, post-discharge calls and discharge planning.

Manage 3supervisors and 25 nurses and 14 administrative staff

MedAssurant

Site Review Consultant

September 2010-Nov 2010

Reviewed Provider Medical Records:

High Level Visits

External Infusion Pumps

Enteral and Parenteral Nutrition

Transcutaneous Electrical Nerve Stimulator (TENS)

Power Mobility Devices

Oxygen

WELLCARE HEALTHPLANS

Director Health Service Delegation Oversight

March 2010-June 2010

The organization wasn’t a match for me so I resigned after 2 and one-half months.

CIGNA HEALTH CARE of FLORIDA

Contract Compliance/Senior Contractor

2006-2010

One of four people responsible for spearheading a Contract Management Solution Strategic Initiative (CMSi). In this role we successfully implemented a web based Contract Management System called Emptoris, in 52 markets, within CIGNA Health plans. Directly accountable for:

Contract Management Solution Implementation for all contractors and matrix partners

Worked closely with legal to maintain contract compliance within all markets

Configured all contract templates into Emptoris

Configured and maintained the security for end users of Emptoris

Assisted in the design of all training programs for Emptoris

Assisted in the training of all users of Emptoris

Wrote user manuals/materials

Configured the contract approval process in Emptoris

Perform all Emptoris new release testing and made go-no go decisions

Provided guidance and support to field contractors on national standards and use of Emptoris through

Consultative reviews to the contracting and matrix partners

CIGNA HEALTH CARE of FLORIDA

Director of Development

May 2003-2006

Responsible for Unit Cost and Access for the following markets: Florida, Georgia, Puerto Rico and the Carolinas. Worked very closely with contracting Market Leads and Sales personnel to provide Competitive Intelligence (market demographics regarding sizing and segmentation, membership, market share trends, and financial trends) for the above mentioned markets. Directly accountable for:

Planning, strategy and analysis to contractors and sales personnel on the above markets to

Ensure competitive parity.

Financial analysis and competitive positioning review. In-depth analysis of available data to develop unit

cost and access programs.

Assisted sales with finalist presentations and RFP Post mortem audits.

Remain diligent in identifying new trends, approaches and tactics used by competitors.

Assisted in Network build outs for all markets.

PARSONS MEDICAL CENTERS and URGENT CARE CENTER (3 facilities)

Vice President Operations

May 2002 to 2003

Performed all the duties of a Practice Administrator for three Clinics Directly accountable for:

Day to Day Operations of the clinics including the Human Resources management and training of the nursing, front office and provider staff.

Performed all MCO contracting and re-contracting.

Opened & managed an URGENT CARE CLINIC, the current clinic was opened in four months under my direction. Obtained contracts with CIGNA, Humana, AV-Med, United, Tri-Care, WellCare and Aetna, developed the Marketing Plan, hired the physicians and staff and manage the day-to-day operations, volume of 200 + visits a day.

Manage over 30 employees including 5 physicians & two ARNP’S.

American Family & Geriatric Care IPA (now know as UNIVERSAL Healthcare)

CEO

July 2001-May 2002

Successfully created an IPA organization capable of managing two large HMO “risk” contracts and a full service delivery system. Directly accountable for:

Day to Day Operations of the IPA including the Human Resources management and training of the nursing, and provider staff.

Managed the day to day operations/performance of the “MCO Risk” contracts.

Managed the systematic communication and information flow process of the day-to-day operations of the IPA, we held contracts with 52 physicians, in 38 locations across five counties.

Negotiated all Contracts; Primary Care (52), and Hospital (3) Ancillary (12) and (62) Specialist. Successfully wrote a Utilization Management (UR) program and put an infrastructure in place to obtain a UR license from the State of Florida.

Obtained Delegation Oversight Management for Utilization Management, Appeals and Credentialing from HUMANA and CIGNA.

Strategically developed and assisted in the filing of regulatory submission for network expansion for three counties plus an HMO license for the IPA. The IPA is now referred to as “UNIVERSAL Healthcare”.

Responsible for the Compliance Plan and all of the regulatory requirements as it relates to IPA administration.

Chaired the following Committees; Utilization Management, Quality Improvement and Practice

Managed over 20 people

West Coast Primary Care IPA

CEO

June 1999 May 2001

Successfully incorporated and created an IPA infrastructure with two strategic goals in mind; (1) Retain and improve contracts from a unit cost and access perspective and (2) manage the Humana “risk” contract Directly accountable for the same duties listed above for American Family & Geriatric Care. Successfully wrote a Utilization Management (UR) program and put an infrastructure in place to obtain a UR license from the State of Florida.

Managed over 10 people.

MORTON PLANT HOSPITAL

Director Operations

Physician Hospital Organization

Clearwater, FL

February 1995 – June 1999

Successfully created a Physician Hospital Organization (PHO) for Morton Plant Hospital. Directly accountable for;

Day to Day Operations of the PHO including the Human Resources management and training of the nursing, credentialing, financial and provider staff.

Network Development: Negotiated and contracted the provider network for the PHO; 159 Primary Care Physicians, 390 Specialists, 4 Hospitals, 6 Outpatient Surgery Centers, 6 Radiology Centers and 3 Skilled Nursing Facilities.

Negotiated and obtained full “risk” contracts for the PHO with CIGNA, HUMANA, PRUCARE, and UNITED.

Contracted with BAY CARE Health System to manage the employee’s healthcare.

Monitored the performance of the PHO contracts; held 30,000 “risk” lives, and 34,000 PPO lives, (180 million dollars in revenue).

Negotiated and implemented a Third Party Administrator (TPA) contract with Florida First to administer delegated claims for all of the HMO contracts.

Successfully wrote a Utilization Management (UR) program and put an infrastructure in place to obtain a UR license from the State of Florida.

Successfully obtained Delegation Oversight Management for all of the above the risk MCO contracts for: Quality Management, Utilization Management, Claims Administration, Credentialing, HEDIS reporting and Provider Profiling.

Developed reports, tools and processes to monitor the performance of the Delegation activities, Compliance and Customer Satisfaction.

Chaired the following committees; Utilization Management, Quality Improvement, Credentialing and Practice Management committees. Co-chaired the Board of Directors.

Managed over 25 people.

Humana Health Care Plans, Inc.

Director Provider Relations, Delegation Oversight, Compliance and Contracting

Tampa 1992 – 1995

Successfully managed the Humana Staff Model Clinics. Positioned the clinics to be sold.

After the sale, moved into the position of Director of Provider Relations. Directly accountable for;

All capitation contracting and delegated Oversight Management to include Primary Care Physicians,

Cardiology, Chiropractic, Podiatry, General Surgery, Mental Health, Radiology and Laboratory.

Responsible for all aspects of Provider Relations.

Implemented referral and claim software called (KENETRA) installation for 1,150 physician offices.

Network Development: Worked very closely with the Sales department in assessing underdeveloped

locations/networks and determining if opportunities existed.

Oversaw the Hospitalist/Practice Management Program.

Watson Clinic

Nurse Manager

Lakeland FL

1991 – 1992

CIGNA HEALTH CARE of FLORIDA

Practice Administrator

Tampa, FL

1987 – 1991

Performed all the duties of a Practice Administrator for three Staff Model Clinics

Directly accountable for;

Day to Day Operations of the clinics including the Human Resources management and training of the nursing, front office and provider staff.

Developed and implemented a physician orientation program that included a strong orientation to Utilization Management, Regulatory Compliance and Customer Satisfaction.

Responsible for all aspects of Practice Management for three staff model centers.

Network Development, worked closely with the sales department to sell the staff model concept to employers and to increase commercial member growth and improve customer satisfaction.

Managed more than 50 people.

Administrator

Kaiser Permanente

Dallas, TX

1984 – 1987

Performed all duties of a Practice Administrator for a large staff model practice that employed over 100 physicians, 35 Registered nurses, 75 MA’s and 45 Allied Healthcare employees. The clinic had 150,000 HMO member lives assigned to it. Directly accountable for:

PARKLAND MEMORIAL HOSPITAL

March 1981- 1984

Day to day responsibility for the Burn Center and the ICU’s.

Weekend on-call hospital nursing administrator.

Chaired several Hospital committees.

Managed over 75 people.

TAMPA GENERAL HOSPITAL

Director Burn Center and ICU

1973- 1981

Successfully opened the Tampa General Burn Center as Director of Nursing, with Dr. Roger Sherman, Director of USF Medical Program.

Appointed as an Affiliate professor for surgical residents at USF.

Weekend Director of Nursing for all of the ICU units.

Managed over 80 people

EDUCATION:

B.S., Health Care Administration, St. Leo University, Dade City, Florida

A.S., Nursing, Bluefield State College, Bluefield, West Virginia

Registered Nurse: LICENSE NUMBER: RN9309053

BLS certificate

Other competencies:

Microsoft Publisher

Word

Excel

Sharepoint

Power Point

Emptoris (Contract Management System)

Contact this candidate