Negotiates competitive and complex contracts with healthcare providers using pre-determined internal guidelines and financial standards. Negotiates contract language in accordance with Aetna standards, engaging other departments as needed for review and approval of contract terms outside the standards. Conducts competitive and financial analyses to achieve best in market discounts and financial results that are within pre-determined targets. Manages contract performance and works with various internal departments to address questions, issues, and activities related to execution, loading and ongoing maintenance of provider contracts. Negotiates and supports the implementation of value-based contract relationships in support of business strategies. Manages relationships with key providers and ensures resolution of escalated issues related to, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information. Negotiates settlements as needed. May recruit providers as needed to ensure network adequacy and achievement of network expansion goals. Maintains accountability for specific medical cost initiatives. Serves as a SME for less experienced team members and internal partners.

Responsible for managing high dollar medical costs referred to Cost Management as well as administering bill review services. Participated in developmental and strategic levels of support for Meritain business. Managed and updated direct provider contracts, develop and on-board new and strategic approaches to existing programs. Supported all business needs which evaluate and manage the medical costs of clients.

Identified key cost of care savings opportunities at the Network level, tracked and aligned suggestions with financial goals and reported expected to outcomes to leadership. Assisted in the development of reimbursement frameworks and financial models and obtain necessary internal sign-offs (financial, network, operational, etc.) to permit execution on those models. Lead and coordinated cross-functional project/program teams with Business Owners of spend, category, and vendor relationships, and trended development and implementation. Analyzed complex financial information and reports related to provider reimbursement methodologies, such as DRGs, APCs, bundled payments and RBRVS; provided accurate and timely financial recommendations to management for decision making purposes. Developed sophisticated financial models utilizing Microsoft Excel. Provided recommendations based upon evaluation of financial trends and forecasts. Evaluated and monitored the efficiency and performance of programs, ensuring program execution was on target. Managed dashboard reporting by tracking monthly, quarterly and annually revenue and expenses. Reviewed historical operating results and proactively identified and analyzed potential revenue enhancement and cost saving opportunities. Performed a variety of pro forma financial and operating analyses as requested to support proposals. Reviewed fluctuations across SBUs in delivering cost of care. Differentiated impact of rate versus utilization variations. Supported SBUs by providing information, responding to questions and resolving complex problems and issues. Utilized value based contracting strategies such as Advanced Payment Methodologies, Case Rates, Bundled payments, etc.

Managed patient scheduling, billing, inventory equipment/instrumentation statistical information and charging. Responsible for the capital and supply portion of the operational budget.Worked with various members of Perioperative Administration to manage the operation of the Operating Room while providing support to the pre-operative and post-operative areas.Served as a liason between surgeons, anesthesiologists, central service, purchasing, finance and other departments. Interviewed, hired, terminated, directed, counseled and evaluated staff.Worked in conjunction with IS to develop systems to accommodate the needs of the operating room for the following areas: scheduling, charging, patient case information, instrumentation program, and preference card system for case preparation. Served as a resource to ancillary areas that utilized comparable services, equipment and procedures, such as Cardiac Cath, Endoscopy, etc.Met with vendors, evaluated product lines, and offered suggestions to minimize cost. Participated in the negotiation and implementation of the compliance process. Worked with Materials Management to maintain contract compliance, implemented new products per ministry initiatives, and tracked savings related to supplies.

Extensively modeled Managed Care Rate Proposals via Microsoft Excel for various Mercy Facilities while collaborating with Contract Leadership, Billing, Patient Access and conducted health plan provider calls. I have a vast understanding of both the language and finance sectors of Managed Care contracts including the various reimbursement methodologies. I possess experience in working with various levels of administration, clinical and non-clinical departments involving (CDM) chargemaster, registration, data analytics and many systems (EPIC, EPSI, Meditech). I'm also proficient in Microsoft Products such as Word, Excel, Outlook and Powerpoint.

I lead a multitude of projects which involved various leadership levels including administration. Project Management included collaboration with Accounting, Clinical, Patient Accounts, Senior Leadership, and ancillary departments in addition to external Health Plans. I negotiated hospital, psych, home health, hospice and physician managed care contracts for the Commercial, Medicare and Medicaid lines of business. I maintained the hospital chargemaster, while performing as the financial analytic contact for the organization. I conducted patient account financial audits, provided pricing, cost, benefit analysis and many other functions.

I negotiated Managed Care Contract language for the BJC Health System. These contracts included acute care, pediatric and transplant agreements, while working closely with Finance, Provider Relations and Quality. I approved Single Case Agreements with Managed Care Companies and trained in Six Sigma Methodologies.

I created financial reports indicative of claim discrepancies, with the primary focus on the financial side of Managed Care contracts that included Commercial, Medicare and Medicaid lines of business. I compiled and analyzed various reimbursement methodologies, proposals, and monthly managed care reports on a routine basis.