Mary Simon Email & Phone Number

Greater Atlanta Area

Specialties: Managed Care Consultant specializing in Payer and Provider Network Development and Contract Negotiation for Medicaid, Medicare Advantage, ABD, Special Needs Plans, Long Term Care, and Commercial Health Plans from both the Payer or Provider perspective. Extensive knowledge in Contract language and rate structures for Health Care systems, Gain Share models, Value Based Health Care, Primary Care, Specialty Care, IPAs, PHOs, Multi-Speciality physicians groups, Behavioral Health, and Dental. Highly experienced in Medicare and Medicaid expansion to include HSD tables, exception filing and CMS approval processes.

Western Region

Overall Program management for the T2017 West network build. Responsibilities included Liaison between TOG and HNFS Senior management team, management of 20 plus consultants, understanding of CFR regulations , Tricare policies and manuals in order to support consulting team, weekly contracting progress reports, negotiation of large IDN and National Health System agreements, and defining strategies in order to meet HNFS defined goals.

Greater Chicago Area

Responsible for negotiating major hospital systems, FQHC's, specialist providers and carve-out agreements for NLHP's Medicaid products in Cook County.

Houston, Texas Area

Development of an Accountable Care Organization Network focused on the Star Plus and Dual Eligible MMP population. Responsible for the development of a strategic network of PCP, Specialist, Ancillary and Hospital providers. Play an integral role in the design of operational processes of the network development department.

Southeast Michigan

Network build for 2016 Medicare Advantage filing and 2015 Medicaid rebid project. Contracted with all major healthcare systems in SE Michigan, IPA, PO's, and Individual providers.

Greater Chicago Area

Development of a non-traditional PPO network to support the HealthEngine healthcare open marketplace portal and concierge program. Responsibilities include targeting specific provider types to educate them on the HealthEngine program and engage them in the Partner Provider Program.

Responsible for building a statewide large and small group hospital and provider network. Developed contracts, target lists and reporting tools.

Responsible for network development for a Medicare Advantage Duel Eligible Special Needs Plan. Managed contract negotiations for current providers and expansion markets, researched providers to meet Time /distance requirements, and track and report progress for market expansion in order to meet CMS filing deadlines.

Responsible for network development for Medicaid state expansion project to include Hospital , Multi-specialty, large group and individual provider contracting. Statewide Focus. Additional responsibilities include extensive data research and data analysis.

Business DevelopmentDevelop and Manage revenue based strategic channels for Diabetes Direct to Consumer Provider. • Global Medical Direct: Design, implemented program resulting in a $12 million annual revenue increase. • Global Medical Direct: Responsible for all aspects of Managed Care Contracting and Credentialing.• Midwest Medical Services: Responsible for all aspects of Managed Care Contracting and Credentialing.Corporate Recruiter• Midwest Medical Services: Responsible for the Recruitment and Interview process of Diabetic Field Representative for a major provider of Diabetic Orthotics and Prosthetics. Play a role in the hiring of 3-5 employees per month during major expansion.

Responsible for network development for a Medicare Advantage Special Needs Plan. Managed contract negotiations, researched providers to meet Time /distance requirements, completed Medicare Base File for upload to CMS, wrote CMS exceptions for failed specialties and managed all aspects of network contracting.

Florida

Network Development for New Florida Medicaid Plan

Louisiana

Build Network for statewide Dental plan

Georgia

Network Development Consultant for the initial build of a network in order to respond to a state Medicaid RFP. Responsible for the management of a team of consultants, identification of IPA’s, RHC, FQHC, PCP and Specialty providers statewide willing to execute a Letter of Intent, daily progress reports, and tracking of network gaps.

Pennsylvania And Virginia

Network Development Consultant for a Medicare Advantage Special Needs plan seeking expansion approval from CMS for the PA and VA markets. Contracting efforts were focused on Hospitals, PCP, Specialist, large Medical Groups, Mental Health and IPA’s. Managed all aspects of provider identification, rate and language negotiations, exception documentation for network gaps and daily reporting.

Development Provider Network for plan expansion in TX

Atlanta And South Carolina

Responsible for provider recruitment to include e-mail , mail or fax contract packages, all contract negotiations, and collection of credentialing materials. Provider recruitment was performed both over the phone and in the market.

South Carolina

Network Development Consultant for a start up SC Medicaid HMO seeking approval of the state. Responsible for all aspects of contract and rate negotiation with PCP, Specialist, RHC’s, FQHC’s, PHO, and large Medical groups statewide. Identified providers to fill gaps based on Medicaid requirements and completed exception dialogue when necessary. Traveled to the market to attend provider meetings and corporate strategy sessions.

North Carolina

Developed a Medicare PPO Network for one of their clients.

North Mississippi

Network Development Consultant for a Mississippi Medicare Advantage Plan seeking Medicare approval for expansion. Responsible for provider recruitment of PCP’s and Specialist in North MS.

Responsible for business development within the health plan arena. Responsible for revenue growth of 12mm annually

Responsible for negotiating health plan contracts for the Pharmacy Lab and supply division. Managed the credentialing process department.