David Croke Email & Phone Number

Hartford, Connecticut Area

Accountable for contracting and relationship management with all third party payers including nine commercial insurance plans and government programs for hospital and Pediatric Sub-specialty group (representing over 340 physicians and providers). Manage over $370M in net revenue for the organization. Since joining the organization, net revenue grew 43% or $60M for all commercial business. Oversight of all Revenue Integrity functions and organizational updates (Hospital and Professional), including Charge Description Master (CDM) maintenance, strategic pricing initiatives, and charge capture enhancements while ensuring system billing policies are consistent with industry and regulatory standards.In depth knowledge of professional fee schedule structures utilizing RBRVS (wRVU) methodology. Work collaboratively with all functions within the Revenue Cycle, as well as IT, Compliance and Clinical Departments, to confirm proper charge capture, uniform coding, consistent billing and reimbursement set up ensuring accurate payment from third party payers. Provide subject matter expertise throughout installation of Epic (EHR) software. Over 5 years of experience in support of Epic system for hospital and physician practice Revenue Cycle operations.Direct the team responsible for all external output to regulatory bodies and agencies including OHCA, CHGME, CHA, Medicare and Medicaid.Created monthly and annual reporting package that identified key financial net revenue and statistical results for the hospital and specialty group using accrual accounting approach in support of corporate financial statements. Work directly with finance team to develop annual budget projections based upon all third party and organizational growth forecasts.

Hartford, Connecticut Area

Accountable for contracting and relationship management with key hospitals in Connecticut representing 48% or $840M of total hospital budget along with two of the state’s largest physician groups and several hospital-based specialty groups. Consistently closed hospital and provider negotiations at or below budget targets, completing all necessary language provisions requirements, ensuring contracts were loaded accurately and on time. Performed financial impact analysis, provided comprehensive recommendations for fee schedule adjustments (representing over $800M in professional spend and over $10M in institutional spend) and developed all internal and external communications along with subsequent training for provider relations. Primary liaison on several key Enterprise projects such as Anthem Care Comparison, CareNex NICU vendor, AIM, Enterprise Facility Agreement/Plan Compensation Schedule, Enterprise Language Committee Sub Group, Contraxx Management System role out, New England Reimbursement Policy team, ICD 10 and 5010 readiness team, and Minute Clinic expansion. Responsibilities in these roles for local implementation included project management, complex data collection and analysis, results validation, system compatibility, and engagement of other key local departments such as Provider Operations, HealthCare Analytics, Sales/Account Management, and Medical Management. Possess extensive knowledge of institutional, professional and ancillary provider contracting and reimbursement structures including MS-DRG, RBRVS (CPT), and Ambulatory Surgery Center Grouper payment rates.

Hartford, Connecticut Area

Accountable for contracting with the majority of hospitals within the Connecticut and Western Massachusetts markets for the New England health plan representing a total of $125M of inpatient and outpatient spend. Achieved 100% of market-specific metrics, while working closely with Network Lead and Regional Vice President to ensure success and compliance with company requirements. * Achieved significant savings through several hospital negotiations equaling $5M annualized. * Converted 100% of all hospital renewals over to United’s standard contract template within required timeline.

Hartford, Connecticut Area

Developed, negotiated and managed a mix of full and partial risk arrangements, global integrated delivery system agreements, IPA, Hospital and direct physicians contracts equaling almost 20% of the company’s total healthcare cost.Accountable for management of Behavioral Health carve out, including overall cost analysis, ensuring provider network access standards were met, and contract obligations were fulfilled, serving the 270,000 statewide commercial members under a fully-delegated and capitated agreement.Managed relationships and led negotiations for 70% of all Ancillary providers statewide including Home Health, Home Infusion, Skilled Nursing Facilities, DME, Dialysis Centers, and Ambulance vendors which led to 5-10% savings over the previous Ancillary expense.