Served as the CEO and President of Healthy Blue, a leading managed care plan within the Healthy Louisiana Medicaid program that serves more than 300K members. I am responsible for the strategic development, growth, and operations of the health plan in providing innovative care in addition to being responsible for building and managing state and local relationships to foster growth and new opportunities to continuously deliver value to the state’s Healthy Louisiana program.

Led the health plan’s operations department to meet new growth and expansion by developing robust provider servicing capabilities and an innovative operational support structure. These capabilities include provider credentialing, provider operations strategy, reporting and analytics, program management, and provider network data support.Designed the operations department to effectively meet the needs of our customers by continuously aligning our internal and share service resources to improve the provider experience across a network of 29,000 primary care providers, specialists, ancillaries, and hospitals. Responsible for coordinating and driving accountability across the health plan’s shared service partners to meet and exceed our state and provider contractual service level agreements: these shared service partners included claims, member and provider contact centers, encounters, enrollment, system pricing and benefits configuration, and regulatory reporting.Managed the health plan’s project management workforce to oversee that all state Medicaid program changes and enhancements are executed per the specifications of the state requirements and provider contracts.Implemented the local efforts tied to Medicaid policy changes as a result of the Patient Protection and Affordable Care Act and ICD-10. Additionally, led the efforts to implement the state’s centralized credentialing verification organization.Developed and implemented reimbursement policy strategies to manage unit cost through operational process enhancements.Prepared the operational analysis for our finance and actuarial departments to deliver on the health plan’s effort to secure and negotiate actuarial sound rates and risk adjustments.Responsible for providing the operational support needed for new product implementations and product expansions.

Responsible for ensuring all provider contracts and amendments were configured to reimburse to the requirements of the negotiated agreementPerformed on-going state Medicaid reimbursement requirements analyses to ensure alignment with Medicaid; oversaw the implementation and systems configuration of any changes made in professional, facility, and ancillary reimbursementExtensively evaluated the reimbursement configuration and provider setup strategies for federally qualified health centers, rural health centers, community based hospitals, and behavioral health providersMaintained oversight of the requirements gathering, development, and management of all health plan regulatory reportsMaintained budget oversight and financial planning for the health plan operations departmentResponsible for identifying opportunities to improve efficiency and effectiveness of the operations unit within the GA health plan including reductions in contract configuration turnaround time, fee schedule load accuracy, and hospital charge master change managementEnhanced the health plan's provider customer service program through improved training initiatives, implementation of new standards and protocols, and increased accountability for associates responsible for provider servicing and engagementManaged several key Georgia Medicaid contractual requirements including, but not limited, to regulatory reporting, hospital outlier requests, hospital statistical and reimbursement reportsActed as an liaison between the health plan’s contracting department and corporate services to ensure negotiated contracts were administrable in claim adjudicating systemDemonstrated proficiency in understanding all methods of physician, hospital, and ancillary reimbursement methodologies as well as the implementation of these reimbursement methodologies into the claims payment system

Managed a team to perform research and root cause on provider claim payment errors: facilitated the launch of the pricing and benefits quality framework, created error input channels, developed team charter and handbook, hired and trained new associates, and developed team performance metricsProvided analysis and feedback to business stakeholders for issues submitted through the department’s error input channels: Quality Assurance audits, Internal Resolution Unit (IRU) submissions, Provider Appeals and Disputes, and Health Plan InquiriesResponsible for monitoring key performance indicators for the department: developed and maintained quality performance dashboard and published quality reports for department’s senior management teamDesigned business requirements and implemented an error tracking database to trend department’s quality performance as well as sources and categories of error

Managed a team of 24 analysts to process claims for Amerigroup’s Georgia and Virginia markets: monitored analysts’ production and quality, managed daily claims inventory, interpreted reports and operational metrics to meet the department’s goals and objectivesProject team member for Six Sigma Black Belt projects: prospective payment systems and configuration accuracy, manual claims payment accuracy, and corrected claim and clean interest dateConducted the analysis and created the strategy for improving high dollar claims accuracy: designed and maintained monthly claims quality dashboard, coordinated high dollar partnership meetings, and created action plans and developed solutions to improve our manual high dollar processing protocols

Managed an international consulting team, along with an internal team, to re-engineer Quality Assurance’s audit and rebuttal database: analyzed business requirements, aligned external consultants with internal resources, coordinated user acceptance testing (UAT), and led the implementation effort throughout Support OperationsDesigned claims processing instructions for Medicare Advantage Products

Coordinated medical student rotations, physician residencies, and student volunteer programsAdministered division’s ICD- 9 and CPT billing and coding, quarterly state reports, recordkeeping, insurance and authorization verification, and maintained patient’s genetic database