• Establish and manage strategies to optimized TriWest ‘s provider network to meet the needs of stakeholders for both the VA Community Care Network and TRICARE program• Oversee innovative network models to improve access to care for Veterans and TRICARE beneficiaries• Serve as a subject matter expert for network sizing and optimization models• Lead initiatives to develop value based payment models to help drive improved quality of care and reduced cost• Manage reimbursement strategies

Senior-level responsibility for developing and maintaining a provider network that meets access, quality, financial and operational requirements for VAPC3 and Choice programs.• Developed new department construct to better align with VA program requirements.• Designed next generation network sizing model leveraging past designs and incorporating Quest analytics to help ensure veterans have adequate access in terms of capacity and drive time.• Oversaw network growth from 100,000 to nearly 150,000 providers in one year.• Maintained high access standards while demand quadrupled with significant portion of growth in rural areas. Decreased referrals returned for lack of available providers.• Managed procurement, design and development of a new provider system of record.

Responsibilities focus on the delivery of data and analytical solutions to serve the needs of actuarial, finance, healthcare management and business operations units. Apply data-governance structures to ensure integrity of data. Developed and continue to administer a data warehouse designed to meet the needs of business and government contract requirements. Identify, acquire and implement medical informatics tools that leverage high level analytics and “big data.” Activities also include the development and delivery of reports, cultivating a self-service approach assuring timely metrics delivery for business and government entities, developing a data governance office ensuring operational system data is in sync and managing the Program Integrity Department to assure the highest level of achievement.Notable Accomplishments:• Managed the procurement, design, development and deployment of a corporate data warehouse with over 200 tables and 5.5 billion records. • Negotiated the opportunity for TriWest to be the first “non-Blues” plan Blues Health Intelligence customer and oversaw implementation.• Led a project to procure and implement a medical informatics tool (MEDai) to identify opportunities to improve quality and cost outcomes.• Collaborated in the development of a patient centered medical home model for TRICARE. • Worked with Milliman to design customized TRICARE healthcare cost guideline benchmarks.• Developed a healthcare network resizing tool.• Designed and managed the Data Governance Office that helped to markedly improve data integrity.• Identified opportunity to improve claims processing resulting in a sizable increase in claims processed as “in-network.” Led project in collaboration with Provider Services, Claims and IT to modify claims system.• Served as a key subject matter expert and author of TRICARE T-3 Managed Care Support RFP.

Directed high-level Healthcare Services Division projects to include the procurement and implementation of a medical management system. Served as subject matter expert and technical writer for TRICARE T-NEX Managed care Support RFP. Managed the transition-in for the 21 state T-NEX contract. Assessed healthcare informatics tools. Managed the analytical staff and the provider profiling system. Coordinated responses to internal audits and government inquiries. Contributed to pricing government change orders.Notable Accomplishments: • Led the deployment of first provider profiling program at TriWest. This necessitated: • Identifying and resolving issues with initial system deployment and data feeds; • Working with the business and system vendor to ensure that metrics were well defined and aligned to business needs; and • Overseeing the output of the data/reports for the business.• Managed the procurement, design, and development of a medical management system.• Developed a system for the disease management function which enabled a more efficient business process.• Expanded the availability of key operating indicators.

Liaison to and auditor for several acute care health plans. Provided daily technical assistance. Reviewed member communications and significant staff changes. Oversaw health plans’ network and administrative functions. Conducted annual audits of health plans. Developed the audit instrument for the 2001 health plan audit. Designed scoring instrument to compare and analyze health plans’ performance in Operational and Financial Reviews. Member of an Executive Management Advisory Board which analyzed the impact of key policy and programmatic changes. Led the development and implementation of non-clinical HEDIS measurements. Monitored and analyzed various agency concerns, including HIPAA privacy requirements.Notable Accomplishments:• Led the development and implementation of the AHCCCS program’s first Consumer Assessment of Health Plans Survey (CAHPS) which covered all 10 AHCCCS health plans. Directed contractor through development of the survey sample, instrument, questions, fieldwork, analysis and reporting. • Drafted the AHCCCS Cultural Competency Policy used by CMS as a model in other states.

Identified physician groups and IPAs for provider network development opportunities. Negotiated contracts. Managed relationships with provider office and IPA management.

Served as a legal consultant to Managed Care Compliance Solutions (precursor to Gorman Health Group). Primary function was to review various certification/recognition standards for health plans (NCQA, URAC, JCAHO, etc.) and determine which standard was strictest in its respective dimension.