Developed and negotiated cost-effective contracts in compliance with company standards, reimbursement standards, and network adequacy.  Negotiated contractual relationships, including incentive and risk-sharing models to attain defined corporate objectives.  Provided subject matter expertise for development and implementation of network reimbursement, risk sharing, and incentive models.  Designed health plan-specific provider-contracting strategies, including identifying specialties and geographic locations on which to concentrate resources for establishing sufficient network of participating providers to serve healthcare needs of plan’s members. Worked on policies and procedures for government plans (Medicare and Medicaid). Prepared adverse pricing analysis, developed pricing recommendations, and performed additional analysis as needed. • Identified opportunities for network improvement and supports network efforts to achieve results with relevant support and metrics.• Saved company money by implementing contract management system, as well as enacting software extension to existing PEGA CRM tool to answer internal and external emails in timely manner. • Led multiple continuous improvement initiatives to stop waste. • Drove development of strategies to ensure network adequacy. • Directed departmental staff to include interviewing, new recruiting, training, developing, mentoring, coaching, disciplinary, evaluating, counseling and terminating in conformance with health plan policies.

Negotiated various contracts, including incentives and risk-sharing models with key ancillary providers, facility-based physician groups, hospitals, PHOs, POs, and other providers to maintain competitive provider network.  Developed ancillary strategies to ensure network adequacy for all product lines, compliance with regulatory requirements, and financially competitive reimbursement rates. Led activities to support business configuration team, including configuration of contractual terms for ancillary contract language revisions and rate changes in Facets system.  Established rapport and maintained relationships with key ancillary provider network executive leaders to ensure strategic positioning of health plan within larger community. • Resolved complex issues related to contract implementation and contract adherence under tight timelines.• Peer-reviewed contracts and financial analyses submitted by contract administrators.

Facilitated provider-development strategic initiatives impacting all areas of company and affecting contractual arrangements with providers.  Negotiated favorable contracts and built integrity in contractual relationships within scope of responsibility and subject matter expertise.  Managed multiple projects simultaneously, using superior negotiation, financial, and collaboration skills.  Composed effective contract templates, continuously ensuring accuracy and detail.  Analyzed data/information related to current provider contracts and any proposed changes to contracts.  Drafted modifications to provider contract terms and provisions, and analyzed respective financial and operational impact on both parties. • Assessed contract language for compliance with corporate standards and regulatory requirements, and reviewed language with assigned health plan attorney.• Transformed department with process improvements through implementation of Change Health Contract Management system.• Created efficiencies through automation, single contract depository, and tools to allow more efficient tracking.• Developed online process that utilized SharePoint to submit single case agreements.• Increased county network providers and expanded Medicare product to meet adequacy requirements.• Worked with team members to develop negotiation skills and techniques while partnering with providers.

Established policies and procedures.  Acted as contract and administrative coordinator between DMC and contracted managed care plans.  Evaluated and negotiated managed care agreements (specifically for PPO/POS plans).  Assisted in identification and development of contracting parameters.  Developed contractual summaries and reviewed proposed managed care agreements.  Maintained standard required documentation regarding contract negotiations, operational requirements, and financial analyses.  Presented relevant negotiation activities to appropriate internal committees.  Administered provider network development functions for organization.  Recruited and evaluated providers for managed care plans affiliated with DMC.  • Served as liaison/problem solver between provider and managed care plan.• Educated providers on various program requirements, policies, and procedures.

Directed managed care, Medicare, all Medicare Advantage Plans, Medicaid, Blue Cross, all private/commercial insurance, workers’ compensation, and auto-related care.  Facilitated revenue cycle management.  Led provider contracting negotiations.  Performed claim reviews.  Acted as medical insurance adjuster and auditor, overseeing status review and accounts receivable.  Processed medical billing while organizing and maintaining daily production schedule. Trained staff on policies and procedures. • Led evaluation of employees’ performance.• Saved company money by implementing new software to add customers, inputting orders and billing in one system.