QUALIFICATION SUMMARY
• Established track record spearheading large scale operational turnarounds, revenue enhancement, and cost containment initiatives directly impacting in excess of one hundred million dollars annually for health plans and providers. Demonstrated success innovating data mining applications and providing analytical support in concert with external and internal stakeholders to evaluate root causes, drive fact-based decisions, bring context and direction to business initiatives, and support a continuous process for improvement.
• Commended throughout career for rallying and optimizing the performance of multidisciplinary teams consisting of IT, finance, operations, clinicians, external vendors, and other professional and subject matter experts in establishing complete business and functional requirements and translating those requirements into actionable quality solutions for highly visible initiatives on-time and on-budget.
• Expertise managing the contract life cycle continuum: evaluating/analyzing, negotiating, and implementing contracts and monitoring pricing accuracy resulting in $16 million in over/underpayment recoveries.
PROFESSIONAL EXPERIENCE
S & D MEDICAL, Bedford Hills, NY
Vice President - Managed Care: 2009 - 2010
• Performed on-site operational assessments of revenue cycle processes and recommended alternative best practice action plans in consultation with administrative staff and external vendors.
• Developed reporting applications that performed a comprehensive review of claim payment variances resulting from processing and billing errors, system configuration set-up, contract interpretation, and other claim adjudication irregularities.
• Project lead for IT due diligence process to evaluate and implement a radiology practice management solution.
BRONX LEBANON HOSPITAL CENTER, Bronx, NY
Director - Managed Care Finance: 2007 - 2009
• Managed the financial performance of a $140 million a year global risk arrangement.
• Provided decision support, actionable recommendations, and led initiatives to reduce risk exposure, enhance revenue, and improve operational performance yielding significant quantifiable results (e.g. reduced leakage, developed marketing initiatives, contracting opportunities, lowered denial rates, improve operational performance).
• Identified and reported on issues concerning the financial implications of existing and proposed activities/processes, resource allocation, and setting and maintaining performance standards. Closely worked with administrators and payers to develop and continuously improve financial/operational benchmarks and performance goals.
• Analyzed, evaluated, and negotiated managed care and facilitated the implementation of contractual changes.
• Championed effort to improve the accurate reporting of members’ health status and enhance risk adjusted premium revenue.
o Improved encounter transmission resulting in a 4% decrease in the percentage of ‘non-users’.
o Managed large scale medical record retrieval efforts for clinical audit review resulting in an annual $6 million premium revenue recovery. Teams were comprised of up to 25 personnel.
QUEENS-LONG ISLAND MEDICAL GROUP, Garden City, NY
Finance Director – Managed Care: 2006 - 2007
• Managed and maintained a prospective audit utility that analyzed the pricing accuracy of $45 million in claim payments annually prior to claim adjudication.
• Analyzed and identified root causality factors impacting core revenue cycle operations and guided cross-functional teams, external vendors, and payers through the process of resolving systemic causes.
• Conducted recoupment payment analyses. Collaborated with other team members to identify $1.3 million in provider overpayments.
• Led contract negotiations, supported contract preparations, projected financial impact of proposed contracts, and developed financial and non-financial contractual terms.
• Provided analytical support to monitor and forecast the financial performance of risk business.
• Headed Finance Managed Care Department. Managed day-to-day activities of 5-9 FTEs and per diem staff.
HEALTHFIRST, New York, NY
Senior Reimbursement Analyst: 2003 - 2006
• Oversaw system configuration set-up implementations. Managed the audit and approval process for 350 provider fee schedules representing $206 million in annual claim payments.
• Directed the fee schedule analysis and provider load deployment process for the organization’s largest fee consolidation initiative to date as of 06/2006. Audited and approved 460 consolidated provider fee schedules representing $48 million in annual claim payments.
• Conducted recoupment payment analyses. Identified and assisted with the recovery of $7 million in provider overpayments.
• Developed automated utilities to identify system configuration set-up errors. Led cross-functional team efforts to deploy appropriate courses of action to improve pricing accuracy and automation (e.g. policy/procedural changes, best-valued technologies).
• Provided front-end contract analytical support. Developed reporting utilities to project the financial impact of proposed contractual arrangements.
MULTIPLAN, New York, NY
Facility Rate Manager: 2000 - 2003
• Championed one of the largest PPO facility rate system migrations to date as of 06/2003. Oversaw the roll out of 68 thousand provider contractual rate sheets representing $2.2 billion in cha...
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