Manuel Jimenez, Mba Email & Phone Number

• Tasked with assisting the company develop a Value Based Payment strategy, a new process for the company.
• Revised and expanded the base agreement template, to update and add needed provisions to the agreement.
• Engaged in contracting to identify and expand the network for Gender Reassignment providers.
• Assisting in managing relationships with PBM providers.

Virginia Beach, Virginia, US

• Responsible for management and contracting of the Hospital, Provider, and Behavioral Health networks for Medicaid and Medicare lines of business for New Jersey.
• Successfully negotiated and closed contracting agreements to increase network adequacy for Amerigroup membership with multiple systems such as Hackensack Meridian, Capital Health, Prime HealthCare and St. Luke’s.
• Implement strategies to reduce Cost of Care, increase participation in Value Based Payment programs, and promote EMR connectivity.
• Temporarily became PSO Lead for New Jersey after departure of RVP until new RVP was brought onboard.

New York, NY, US

• Managed and improved relationships with facilities such as Hospital for Special Surgery, One Brooklyn Health System and New York Health and Hospitals.
• Took over projects seven months behind schedule such as Pay for Performance and brought them to completion within three months.

• Managed projects to identify, recruit and build a virtual ACO network for Comprehensive Health Management
• Recruited Skilled Nursing Facilities for Centivo to build out their Northeast Network.

New York, NY, US

• Managed inventory of over 100 large, multi-million dollar claims projects for facilities such as NYU, Northwell Health, New York Health and Hospitals, Columbia/Cornell, Mt. Sinai and others to close settlement.
• Work with Network Management and Providers to analyze claims data to identify opportunities to reduce re-work and improve both claims payment accuracy and Provider billing.

• Build sustainable technical and operational foundation for delivery system transformation and healthcare innovation initiatives. Assume full management of New York State Delivery System Reform Incentive Payment (DSRIP).
• Assumed full management of New York State Delivery System Reform Incentive Payment (DSRIP) directive that was launched in 2015, and integrated to minimize inpatient and ED utilization in Medicaid population by 25%.
• Developed overall Managed Care Strategy to improve revenue and prepare NUMC to move to VBP based agreements for high member volume plans.
• Lead with COO on NUMC Managed Care Workgroup to achieve the goals of reducing utilization, increasing revenue, and VBP contracting. Estimated first year potential earnings of $6 Million.
• Collaborated with cross-departmental leaders in conducting crucial and complex hospital and physician agreement negotiations to ensure accurate and timely execution.
• Identified efficiencies and redundancies in provider members' procedures; and apply results to developing resources to optimize quality and RAPS improvements, and reductions in utilization.

Tampa, Florida, US

• Assessed capabilities of existing network and outlined improved processes governing provider contracting, negotiations, and services. Coached and mentored team of five provider relations professionals in understanding.
• Assessed capabilities of existing network and outlined improved processes governing provider contracting, negotiations, and services.
• Coached and mentored team of five provider relations professionals in understanding quality customer service, provider collaboration, and internal team coordination; efforts that resulted in increased revenue.
• Partnered with peers to assess potential financial risks, and set failsafe in place as precautionary measure to satisfy providers and drive service levels. Cultivated substantial provider community relationships.
• Defined network requirements to prepare and launch new Medicaid line of business in Iowa in conjunction with Vice President of Business Development.
• Developed new VBP agreement tiered compensation strategy at WellCare to improve provider incentives and increase compensation for improved quality ratings. Previous model capped compensation and discouraged continued.

Louisville, Kentucky, US

• Accelerated negotiations of Capitated and FFS risk deals with IPAs and PCMHs to solidify provider networks in New York, Virginia, Maryland, and New Hampshire, and developed and executed all details of inaugural.
• Led Northeast Region in New York State through successful new contracts negotiations and developed the Network Delivery System; closed hospital, ancillary, and provider contracts for Maryland and Virginia.
• Negotiated Medicare Advantage PPO, HMO, and PFFS agreements with C-level acute care managers, sole community, and critical access hospitals, FQHCs, and multi-specialty physician groups. Negotiated first VBP Agreements.
• Confirmed CMS requirements of time and distance were incorporated into schedules and agreements with contract providers to meet successful filing of PPO network across 27 of 65 counties covered by CMS.
• Developed contacts, and conducted initial negotiations with hospital systems in New Hampshire to evaluate HSD filing potential in that state.
• Collaborated with HSD SME on meeting CMS time and distance requirements in contracting efforts in Maine.

• Reviewed data analysis to model historical utilization and develop rate proposals as well as respond to provider rate proposals.
• Reviewed and negotiated contract language provisions with high level administrators.
• Negotiated effective and competitive contractual relationships in accordance with company strategies.
• Assisted in the development and implementation of appropriate reimbursement methodologies and contractual strategies with Senior Management.
• Coordinated contract implementation with systems, operations (including registry and rate loading), and health services areas.

Hartford, Connecticut, US

• I had begun working with Aetna as the Provider Relations Representative, a role I held from 1997 to 2001. Within these roles, I integrated compliant and quality checks governing processes used in 500-physician territory.
• Recruited and obtained credentials for 350 providers in Brooklyn Network encompassing skilled nursing facilities, home care agencies, DME providers, anesthesiology groups, and infertility providers to solidify terms.
• Established long-term partnerships with administrators throughout multi-hospital network to provide optimal risk mitigation solutions that reduced specialist leakage by 25%.

US

• Manage the daily operations of a department dedicated to providing dignified health care to the Medicaid population.
• Increase enrollment in Medicaid program from 4,654 members to 5,639 members in six months, a 17% increase in membership.Develop concept of Breakfast meetings to attract large numbers of prospects to a single location.
• Develop sales training program for department with DEI Management Group. Increased the effectiveness of the sales staff.
• Balance phone coverage and field coverage to assure call center quality standards while maximizing field sales.Create spreadsheet reports to track call center coverage and determine staff needed at peak hours while.

Mba, Management

Bba, Management