•Provide direct oversight of Provider Network Administration, Provider Configuration reimbursement and benefits, Encounters and Credentialing departments along with dotted line oversight of Provider Configuration Management for provider demographic loaded into core claim processing system.•Previously held direct oversight of Provider Inquiry Research & Resolution, Medical Review Team, Member Inquiry Research and Resolution and Risk Adjustment departments and served as liaison to corporate Enrollment, Claims, Clinical Editing, and Member Service Teams to include Call Center.•Directed the research and creation of benefit and reimbursement requirements for the Medicare Duals (MyCare Ohio), Ohio Medicaid Extension, Behavioral Health Carve In, and all newly acquired populations which account for approximately $800 million annually.•Administered the incorporation of the new Provider Master File developed by the Ohio Department of Medicaid to ensure accurate claims processing and downstream reporting. •Direct the weekly submission of the Managed Care Provider Network (MCPN) and Health Service Delivery (HSD) files to ensure accurate network adequacy regarding Medicaid and Medicare lines of business.•Ensure that all departments meet compliance and regulatory requirements through PnPs, Work Flows, and other documentation to meet Medicaid, Medicare and Health Insurance Marketplace regulations.•Work with quality and finance teams to help drive HEDIS and Encounter Acceptance through claims submission process and provider setup.•Serve as Medicare reimbursement subject matter expert for Molina of Ohio.•Oversee the provider online directories and provider print directory to ensure that they meet state, CMS and Ohio Department of Insurance requirements.•Successfully conducted provider loads for both Health Insurance Marketplace and MMP Duals lines of business to include over 19,000 provider records.

•Responsible for reimbursement methodologies/strategies/configuration for 18 Medicaid/Marketplace health plans to include start ups.•Corporate project lead for Ambulatory Payment Classification (APC) payment solution implementation working with various corporate divisions•Corporate project lead for ACA Primary Care reimbursement increase to ensure that contract, configuration, provider data management, etc. are prepared for the increase in reimbursement January 1, 2013•Reviewed plan contracts and approve for sound reimbursement to comply with corporate initiatives and unit cost goals

•Served as network lead for development of Medicaid network in the state of West Virginia•Maintained position of corporate project lead for both the development of an Ambulatory Payment Classification payment solution and the ACA Primary Care reimbursement increase initiative

•Managed the contract negotiations for hospitals, ancillary providers, and professional providers for the Medicaid product in West Virginia and South Carolina•Identified providers and develop network strategy in order to respond to request for proposals to allow for business expansion•Performed data analytics that are utilized in contract negotiations and cost savings initiatives

•Oversaw the reimbursement, reimbursement, and configuration of hospitals, professional providers, and ancillary providers which account for over 1.5 billion in yearly payments for medical care for Indemnity, PPO, POS, and Medicare Advantage products•Developed and implemented a change in laboratory services reimbursement that forecasted a savings of $1.2 million annually•Ensured that all hospital contract negotiations were limited to a market basket index in terms of overall payout•Strategically analyzed and established cost savings approaches through changes in reimbursement strategies, pay for performance, and cost management programs•Directed all contract modeling to guarantee that proposed contracts meet the objectives and goals of the organization•Served on high level workgroups that strategically planed for Accountable Care Organizations, Patient Centered Medical Homes, Episodic Payment and Micro Market development