Principal Owner
CurrentConsulted with various businesses in the health care industry specializing in efficiencies, cost savings, re-contracting and process improvement. Acted in the COO role for a stand-alone Medicaid NY health plan with 280,000 Medicaid members• Contributed to a complete turn-around in financial position from a large loss to over $6 million in profit.• Re-tooled the entire UM program, resulting in stronger, more consistent concurrent review, reducing admits per thousand by 28% and average length of stay by over 5%.o Created an accurate daily census reporting process.o Standardized authorization request forms and instilled rigor in ensuring authorizations were closed and necessary information was gathered.o Ensured MCG Guidelines were uniformly followed resulting in an increase of cases sent to an MD for review of over 500%.o Began a short-stay initiative resulting in savings of over $2.6 Million.o Supported the creation of Web tools to check the status of an authorization and do automatic look ups for services requiring authorizations.• Selected and collaborated with a call center vendor to reduce hold times of over one hour to industry standard metrics of at least 80% of calls answered in 30 seconds or less.• Developed a claims resolution team focusing on a reduction in provider ‘settlements’ and increased responsiveness to provider claim issues; this process also added an additional dimension to IBNR reserving.• Implemented a medical expense review team resulting in the use of additional claim edits, correction of claim processing errors and other medical expense controls.• Developed a standard provider contracting template in order to reduce ‘one-offs’ and reduce ambiguity in wording and add additional protections for the health plan.• Re-tooled the stop loss reporting and collection process.
