Jerry Reyes Email & Phone Number

Greater Chicago Area

Greater Chicago Area

Led assigned hospital, physician, and ancillary negotiations ensuring that negotiations result in the unit cost targets expected and meet the objectives of the company. Well versed in payment methodologies within the agreement including Medicaid (containing DRG methodology), Medicare, and Marketplace. Several negotiations have also included risk models such as pay for performance, episodic care, shared risk and full risk.• Led expansion efforts for 97 County Health Departments to meet network adequacy as well as reduce out-of-network utilization. • Created Policy and Procedure for Single Case Agreements which met NCQA standards as well as becoming a benchmark for the organization. A key component of this initiative was creating a Non-Par Utilization Tracker which allowed for partnership with medical management, documentation for pursuance of single case agreements, as well as an instrumental tool to track savings through negotiations. This resulted in $340,000 of savings in 2017. • Spearheaded initiative through claims analysis which allowed Plan to confirm Pathology, Anesthesiology, Emergency Medicine, and Radiology utilization with each hospital. Led cold calling campaign to contract with providers in order to meet State and CMS requirements. Able to successfully recruit 85% of providers into network.

Maywood,Il

Lead negotiator for all payor types including managed care organizations, affordable care organizations, government programs, as well as commercial products. Audited payors to ensure correct rates were adjudicated by conducting claims analysis which included outlier, MSRG, as well as Medicare Based Reimbursement. Worked cross-departmentally as well as communicating directly with the Senior Leadership Team in order to prepare for joint operating committee meetings with payors. • Finalized settlement negotiations which led to an increase of 5% in expected reimbursement. • Conducted analysis of providers and negotiated increased rates for certain providers to reach rate parody among MCOs. This adjudicated an additional $346,000 of additional revenue.

Evergreen Park, Il

Negotiated complex, competitive agreements with insurance carriers according to prescribed hospital budgets. Researched and create Pro forma for new technologies and other hospital initiatives. Maintained and updated insurance carrier expected reimbursement data base. Presented to LCMH board any new health care initiatives such as the Health Care Exchange. Maintained dialogue with all assigned insurance carrier counter parts in order to keep abreast of any forthcoming changes in the health care environment. Provided sales and marketing support for community relations.• Executed 100% of assigned agreements above defined LCMH budgets.• Increased LCMH’s book of business by adding the new agreements which primarily focused on the Health Care Exchange as well as Medicare lines of business. • Researched and worked with a number of internal departments to add the following new services: Heart Failure Clinic, Wound Care Clinic, I stent Trabecular Micro Bypass, Spinal Cord Stimulation System and led the initiative to add working Hospitalist to cover the 11pm to 7am time span.

Chicago, Il

Effectively negotiated complex, competitive relationships with hospitals according to prescribed guidelines in support of national and regional network strategies. Managed hospital compensation, reimbursement, and pricing development activities. Understood and manage medical cost issues to initiate appropriate actions and strategies. Provided sales and marketing support, community relations, and guidance with comprehension of applicable federal and state regulations. Initiated legal contract reviews as needed and ensure all required reviews are completed by the appropriate functional areas. Serviced all issues for the following hospital clients: Provena Health System, Centegra Health System, and Adventist Health System. Wisconsin hospital responsibilities included United Hospital System and Prohealth Care. • Decreased Aetna's exposure to annual charge master increases by decreasing hospital service reimbursements at a variable cost structure in numerous agreements.• Implemented or improved charge master limits in 20% of my assigned agreements limiting inherent increases a hospital could provide.• Removed language barriers that would decrease the percentage of claims requiring manual adjudication in 15% of assigned hospitals resulting in fewer claims issues and a solid working relationship between the hospital and carrier.

Rosemont, Il

Effectively negotiated hospital contracts within corporate defined budgets. Managed hospital compensation and pricing development activities. Addressed all service issues related to all assigned hospital agreements. Maintained dialogue with all assigned hospital counter parts in order to keep abreast of any forthcoming changes in the health care environment. Provided sales and marketing support for community relations. • Executed 85% of assigned agreements at or under defined budgets.• Created a competitive landscape by restructuring 10% of existing agreements.• Assisted sales force with presentations to potential self- insured clients and the benefits of the CCN network.• Identified several non-participating hospitals reimbursed at a contract rate and adjusted to a non-participating rate.

Matteson, Il

Negotiated hospital and physician agreements. Addressed all contract and reimbursement issues for assigned related to assigned providers. Assisted with capitation payments to assigned physician groups. Ensured physician directory is accurate for assigned providers

Northbrook, Il

Contracted with radiology providers on behalf of managed care providers. Provided in service for all newly contracted providers regarding Utilimed. Resolved all reimbursement, contract and other issues with assigned radiology providers