Lead health systems to develop payer partnerships, set up networks, and plan designs. Sell and maintain comprehensive consulting engagements including new offerings and ensuring quality implementation and customer service in all areas of each project.• Manage all Business Development and Sales for Strategic Collaboratives, as well as co-lead all Marketing and Thought Leadership for team. Led overall sales of $6.7 million.• Provide independent remote and on-site assistance in developing, implementing, and monitoring consulting strategies that achieve overall member goals for population health and bundled payment arrangements in the Value Based Care (VBC) space.• Accountable for project success: initiation (scope management), resource utilization, budgeting, and risk management execution (stakeholder, team, and milestone/tasks management), control (scope verification and change control, cost and quality, and risk monitoring) and closing (closeout, issue resolution, lessons learned, and final project documentation).• Dedicated Partner and Subject Matter Expert for multihospital health systems for their journey in VBC.• Oversight to project teams to ensure successful project results.Coordinate and deliver effective presentations to client audiences to communicate strategy and outcomes. Identification of subject matter experts to help hone strategies.• Incorporate appropriate client and Premier resources into client’s work plans; conduct analyses, develop case studies; identify and implement opportunities and solutions and provide customized, actionable recommendation to client’s executives.• Provides independent on-site assistance in developing, implementing and monitoring consulting strategies that achieve overall member goals.• Maintains strong professional relationships with engagement/ collaborative-specific client personnel through regular contact

Responsible for the design, development, delivery and business development of consulting services in support of episode-based payment models and similar payment innovations, with a special focus on providers and provider-sponsored organizations. Providers and provider-sponsored organizations face unique challenges in implementing episode-based payment arrangements. They usually do not have access to data that are needed to design appropriate episode constructs, data that describe the use of services across the continuum of care. They also often lack the analytic experience that health plans have developed in working with episode constructs and managing provider reimbursement systems. Provider and provider-sponsored organizations can also benefit from a better understanding of opportunities for success under new payment models, including approaches to transforming care delivery.Responsibilities:· Developing and managing the delivery of services to enable provider-sponsored organizations to pursue various payment innovations, especially those involving episode-based payment models· Industry thought leader in payment innovation, especially in terms of episode-based payment models· Achieving specific revenue and IOI targets while collaborating with other consulting activities within the NPH pillar relating to payment innovation· Lead development of new consulting products and services to meet emerging customer needs· Lead client teams to deliver a variety of services relating to payment innovation· Ensure quality and performance are established and measured with improvement goals developed· Work as a member of the Network Analytics leadership team to achieve revenue and IOI objectives

Provide content expertise to lead the design of innovative reimbursement models to develop and support Highmark’s transition from Fee For Service models to Pay For Value. Each model put into play as an alternative payment mechanism will be both industry-leading and highly relevant to the local market.Lead the development, implementation, and execution of new, innovative payment methods to support Highmark’s pay for value engagement models (ACO, PCMH, Bundled Payments, Global Payments, Capitation, etc.).Own bundled payment methodology, roll-out, and performance measurement for grouping logic, target bundles, target providers, and benchmarking methodology.Serve as the market-facing and internal expert on reimbursement aspects of all programs, ensuring the right decision support/interpreting the decision support related to provider engagement models, and bundled payment methodology.Partner with the Markets and Reimbursement Operations to understand and influence the provider glide path from Fee For Service to Pay For Value (P4V).Ensure that payment models evolve to support enterprise and provider strategy.Establish scalable operations to support the transition to P4V.

Analyze business processes to identify process gaps, areas for improvement, and financial impacts. Evaluate issues, develop recommendations and implementation and migration strategies. Interface with all client organizational levels, from end-users to senior executives. Serve as project leader for numerous engagements to determine workflow schedules; manage cross-functional project teams; and ensure high-quality deliverables, client satisfactions, and profitable results for both PNC and customers.Operational support for the development of requirements and specification documentation for a flexible and scalable platform to deliver data analysis and reporting capabilities to the client. The Healthcare Data Analytics platform provides clients with robust data analytics capabilities on various metrics including: financial, cost/budget, HR utilization, Kronos, and meaningful use reporting types of analytics.Collaborate with vendors, both onshore and offshore, in order to ensure upgrades, modifications, and new installations are thoroughly tested and are of high quality and delivered on time.Author requirements for Third Party Administrator (TPA) functionality (270/271, 837, 835)Jointly direct system integration and business user acceptance testing for all application-level implementation and integration for the healthcare solutions and deployment of code into test, QA, and production environments.Oversight for the predictive forecasting and contract modeling for healthcare clientele. This includes but not limited to the design and development of the application, but also the strategy for client customizations and implementation into production.Direct the Compliance Team ensuring operational processes, procedures and daily business practices are compliant with both healthcare industry and federal/state banking regulations for HIPAA, Health Information Technology for Economic and Clinical Health Act (HITECH), Sarbanes-Oxley (SOX) Act, and the Bank Secrecy Act.

Asked to step in as Subject Matter Expert (SME) to lead a team of business intelligence and data warehouse engineers in designing, building, and supporting the business intelligence component of PNC Healthcare Advantage, a new platform for processing healthcare transactions. Duties as the delivery manager for this fully custom BI application that is comprised of Informatica ETL, an Oracle data warehouse, and Oracle BI Enterprise Edition (OBIEE) dashboards and reports. Work closely with the PNC Healthcare Product and Operations teams to define requirements and then translate them into a state-of-the-art BI solution for large healthcare providers.

Network & Provider Relations Manager, 2001 – 2003Supervised the day-to-day operations for Provider Relations and Network Management for Medicare, Medicaid, Commercial, and County funded programs; as well as training and servicing of the network.• Oversight of providers within the network to ensure that they provided access to high quality, cost-effective care.• Negotiated and maintained provider and hospital contracts using case rates, per diems, DRG, percentage of charges, out of network agreements, as well as language interpretations and modifications.• Coordinated in the resolution of over and underpayments within network.• Administration of Provider Relations and Network Management staff.Associate Care Manager, 1999 – 2001Provided clinical reviews, service authorization, and care coordination for inpatient, partial, intensive outpatient, and outpatient services for mental health and drug/alcohol programs.• Escalated difficult clinical cases to the medical director and reviewed recommendations with the clinical review team and the provider entity.• Coordinated transition of care and maintained relations with members and provider network.• Maintained call center line for clinical case reviews for pre-certification.

Sr Mgr - Rev Cycle, Cred/Enroll & EDI BillingManaged day-to-day ops including credentialing and enrollment, electronic billing, and the overall revenue cycle for over 3,000 physicians in a multi-specialty discipline. Established quarterly and annual goals for staff and the entire department.Decreased acct receivables by over $7 MM in 1 year with a comprehensive redesign and overhaul of department.Spearheaded the acquisition and maintenance of federal & state regs related to 3rd party, credentialing, enrollment, billing, and reimbursement for Medicare, Medicaid, and Commercial.Forecasted monthly revenue for enrolled physicians and billable services.Led the technical aspects of electronic billing and the interface with other Physician Services Depts to assure efficient processes.Tracked accounts receivable on a daily, monthly, and annual basis to forecast budget.Practice MgrMaintained overall management of the practice for revenue, strategic planning, budgets, clinical services, billing, HR, and allocated space within each location of the staff and physicians.Recruited, hired, and contracted physicians based on the needs of the hospital and community-based programs to assure full physician staffing.Created an electronic billing interface for the practice for Medicaid, Medicare, and Commercial Payers. Managed billings of over $1.2 MM.In conjunction with the Exec Admin, forecasted the budgets for the practice and the physician compensation of all hired staff and managed the budgets for payments and controllable losses.Worked closely with physician leadership and appropriate hospital and site adminis to coordinate physician assignments to assure adequate coverage based on program census and defined access standards.Implemented, monitored, and refined quality of care measures across all UPMC Behavioral Health and University of Pittsburgh Physicians and the locations in which patient care was provided in both non-academic and academic settings.

Developed and maintained relationships with existing and prospective clients, in addition to potential strategic partners within state and regional markets, as well as directed the project management of service integration, initiation, and ramping for individual clients within targeted state and regional markets.• Managed the region service delivery team including field staff and project managers nationally.• Assisted with the identification, recruitment, selection, training, and ongoing day-to-day management of personnel necessary to deliver services in targeted areas.• Lead responsibility for an assigned region’s HEDIS performance including monitoring chart review progress and completion rates. • Maintained the financial reporting for all clients for the expenditures and enhancements requested.

BenovaAllegheny Department of Human ServicesParent & Child Guidance CenterCommunity Options of Pittsburgh, Inc.I.C.W. Employment Services, Inc.Held various positions within the Mental Health, Mental Retardation, and Drug & Alcohol communities and rapidly worked up through the ranks to achieve a solid career path in the healthcare industry.• Maintained program budgets and individual funding streams through the County.• Provided support to individuals enrolling into managed care from fee for service to choose a physical and behavioral health care plan for HealthChoices.• Responsible for conducting public and private consumer and provider presentations to educate and train on the changing effects of healthcare.• Developed outreach tactics to prepare consumers to make educated and informed choices.• Oversight and management of vocational, residential, and program requirements for staff and consumers.• Coordinated the community integration process for individuals residing at a State facility to move into residential and day program supports.• Directed case management for individuals with mental health and mental retardation.