Donna Breen Email & Phone Number

Stoneham, MA, US

Mclean, Virginia, US

Boston, MA, US

• Oversaw the entire claims payment life cycle, payment integrity office, provider credentialing, and provider data management for Commonwealth Care Alliance’s dual-eligible Medicare and Medicaid membership across.
• Executed the establishment and management of a comprehensive payment integrity office, projected to generate annualized medical cost savings exceeding $60M. This initiative encompassed the implementation of prepayment.
• Acted as the business lead for a corporate initiative aimed at revolutionizing claims processing systems and enhancing provider relationships.
• Effectively managed the transition of claims processing operations from an outgoing third-party vendor to Cognizant’s FACETs BpaaS environment within an aggressive 11-month timeline, covering the Massachusetts and.
• Implemented streamlined processes for provider issue escalation with the existing third-party administrator, ensuring effective management of payment discrepancies during claims processing run-out periods.
• Collaborated closely with internal compliance teams on CMS program audits, leading the review and revision of all claims processing policies and desktop procedures to ensure alignment with state and federal regulations.

Cambridge, MA, US

• Positioned as a thought leader, provided integral support to the sales organization, product development, technology, and go-to-market teams.
• Developed comprehensive solution proposals and effectively demonstrated how the Pega Smart Claims Engine for Healthcare could address clients' technical challenges, particularly focusing on claims processing.
• Leveraged extensive healthcare domain expertise to collaborate with payer organizations worldwide, engaging with stakeholders at all levels to deliver tailored solutions.
• Worked closely with the sales team to assess the scope and complexity of client system challenges, devising automated solutions for claims processing, payment integrity programs, and operational enhancements.
• Partnered with clients to navigate change management processes effectively, ensuring the adoption of the center-out business change model inherent in all Pega solutions.
• Collaborated with the go-to-market team to develop and deliver compelling product demonstrations and business architecture presentations, aligning with client needs and objectives.

Canton, Massachusetts, US

• Directed the claims payment life cycle across all lines of business at Tufts Health Plan, overseeing Medicare Advantage, MassHealth Medicaid, and Commercial divisions, serving a membership of approximately 1.1 million.
• Established and managed a multifaceted payment integrity office, yielding annualized medical cost savings exceeding $200M through initiatives such as prepayment claims edits, post-payment audits, and third-party.
• Formulated and executed a strategic approach to out-of-network pricing, resulting in annualized medical cost savings of over $20M.
• Directed the consolidation of claims processing operations into an enterprise center of excellence, streamlining processes and reducing administrative costs by integrating claims processing for all business lines into.
• Led the migration of claims processing for the MassHealth Medicaid business line to the HealthRules Payer platform.
• Played a pivotal role as a key stakeholder and team member in the evaluation, implementation, and ongoing operational management of joint ventures such as CarePartners of Connecticut and Tufts Health Freedom Plan.

Canton, Massachusetts, US

• Oversaw the claims payment life cycle for Tufts Health Plan’s commercial lines of business, serving approximately 650,000 members with a team of 180 staff members across five operational departments.
• Managed initiatives such as medical cost savings and clinical claims edit programs, resulting in annual savings exceeding $60M.
• Implemented strategic process improvements within the department, leading to administrative savings of $1.3M through initiatives targeting reduced overtime and FTE reductions.
• Served as the business sponsor for multiple corporate-level projects aimed at optimizing provider-administrative interactions, facilitating the transition of claims transactions to lower-cost channels, thereby.

Canton, Massachusetts, US

Responsible for the enrollment, ID card fulfillment and premium billing operations for Tufts Health Plan’s commercial line of business servicing approximately 600,000 members with a staff of 70 employees.

New York, NY, US

• Contracted as a project manager overseeing financial integration projects within the Americas Division.
• Successfully planned and executed a project to migrate customer billing and cash application functions from parent organizations into the local office, ensuring seamless operations and adherence to financial standards.
• Implemented revisions to policies and procedures for the monthly customer billing process, resulting in a notable reduction in the time required to generate invoices from 15 to seven business days, thereby enhancing.
• Contributed to the development of the revenue budget, managing annual revenues exceeding $175M and providing critical insights to support financial planning and forecasting.
• Acted as a liaison between internal stakeholders and external auditors to facilitate the completion of the year-end general ledger close, ensuring compliance with regulatory requirements and financial reporting.

Toronto, ON, CA

• Led the financial management and business administration operations of the Eastern Region business unit, overseeing a team of 20 employees.
• Managed monthly general ledger closing and P&L reporting, ensuring accuracy and timeliness in financial reporting.
• Implemented a change management program for the Client Administration Department, significantly enhancing the efficiency of the sales order to installation process and contributing to revenue growth.
• Provided strategic guidance to the Regional Business Manager and implemented robust cost controls to ensure the region consistently surpassed established financial targets.
• Developed annual budgets for the business unit, which boasted revenues exceeding $100M, aligning financial planning with organizational objectives.
• Conducted trend analysis and delivered executive-level commentary on monthly business statistics, offering valuable insights to support decision-making processes.

Bachelor Of Business Administration (B.B.A.), Business Administration And Management, General

Associate Of Science (As), Accounting