Michael Prell Email & Phone Number

Orange County, California, United States

Capitation AnalyticsProvider RelationsContractingUtilization/Profitability Analysis Reporting

Irvine, Ca

Revenue Cycle/Billing & Collections Management & Improvement Implementing EMR/EHR applications to maximize financial performance, lower cost & increase productivity. Workflow design that utilizes personnel & systems to maximize profitability. A/R analysis/audit to identify opportunities to collect revenue. Develop Business Plans to collect additional revenue. Identify operational opportunities to reduce denied claims. Manage Billing & Collections staff. Coach staff. Improve performance.Contracting, Provider Network & Managed Care Development & Operations Develop Business Plans to grow managed care markets. Negotiate payer and provider contracts. Credentialing and Provider registration. Contract implementation. Contract analysis to assess profitability, forecast financial performance & expected profitability. Provider & staff training and orientation.

Newport Beach, Ca

 Lead IPA's Efficiency & Effectiveness Committee performing database analytics that reviews trends in medical costs & designs interventions to address escalating costs that maintain quality of care. Realize over $7,000,000 in medical cost savings. Track & report hospital risk pool activity to senior management to monitor solvency of hospital risk pools & bed day utilization. Settle risk pools annually. Collect over $3,500,000 in risk pool revenue for IPA. Assure accurate & timely payment of monthly capitation to over 300 primary care & specialist physicians & ancillary providers contracted with Greater Newport Physicians. Edinger Medical Group, Cedars-Sinai Medical Associates & Cedars-Sinai IPA. Process incoming revenue/capitation files from contracted Health Plans to record accurate revenue & adjustments. Address with Health Plan representatives any discrepancies in payments or differing contract interpretation. Assure full & proper payments are made by Health Plans. Address issues of underpayment with Health. Model & estimate IBNR for purposes of financial reporting.  Prepare P&L Statements by IPA overall & breakdown by contracted Health Plan. Analyze existing & proposed capitation rate & payment structures based on IPA utilization to assess financial impact of existing & proposed capitation arrangements with providers.  Analyze incoming capitation & enrollment data to assure IPA is receiving payment for all enrollees at proper & contracted capitation rates.  Measure impact on revenue of HEDIS scores, star ratings, RAF, budget sequestration & premium tax. Analyze utilization, claims & encounter data to produce regular reporting & recommendations for senior/medical management on: service utilization, cost trends, provider capitation rates & viability of institutional risk pools, Model physicians/provider compensation rates & incentives. Manage 4-5 analysts. Manage software applications.

Mission Viejo, Ca

Manage all aspects of operations for a medical practice of 5-7 Orthopaedic Surgeons and 1-2 PAs.Supervise staff of 17 including front office, back office, physical therapy, authorization coordinators, surgery schedulers, and medical records.Manage all vendor relationships including: accounts payable, bidding and vendor selection and due diligence of proposed vendors.Handle all managed care negotiations and contractual relationships.Manage all marketing including web sites, promotional materials and community activities.Responsible for appointment and surgery scheduling, payor authorizations, physical therapy clinic, IT and financial management.

Lake Forest, Ca

Provider Contracting and Provider Relations  Negotiate contract with hospitals, major health systems, PHOs, medical groups, IPAs, ancillary providers and subcontracted affiliate provider networks. Perform contract and provider analysis to develop contracting objectives, rate targets and negotiating strategy. Analyze rates and rate structures including; straight discounts, per diems, case rates, percent of Medicare and other government fee schedules such as Workers’ Compensation, stop loss and proprietary fee schedules. Assist Sales and Account Management in obtaining new clients and retaining current clients by addressing client needs for providers and in addressing issues client’s have with providers. Expand relationships with contracted providers by increasing participation in additional products. Address provider issues regarding claims payment and contract terms. Mediate and resolve disputes between payors and providers.

Lake Forest, Ca

 Negotiate contract with hospitals, major health systems, PHOs, medical groups, IPAs, ancillary providers and subcontracted affiliate provider networks. Perform contract and provider analysis to develop contracting objectives, rate targets and negotiating strategy. Analyze rates and rate structures including; straight discounts, per diems, case rates, percent of Medicare and other government fee schedules such as Workers’ Compensation, stop loss and proprietary fee schedules. Assist Sales and Account Management in obtaining new clients and retaining current clients by addressing client needs for providers and in addressing issues client’s have with providers. Expand relationships with contracted providers by increasing participation in additional products. Address provider issues regarding claims payment and contract terms. Mediate and resolve disputes between payors and providers.

Associate Director, Provider Operations  Manage all health services contracting for health plan with over 280,000 enrollees. Negotiate and manage capitated and fee-for-service contractual relationships with: HMOs, medical groups, IPAs, hospitals, vision services providers, pharmacy benefits management firms, long term care facilities, ancillary services providers including DME, medical supplies, medical transportation, and a wide-range of outpatient facilities, interpreting services and pharmacies. Develop contracting strategies, contract templates and contracting plans. Assist providers with claims, prior authorization, compliance and other issues. Maintain favorable relations with providers. Write and update contracts to include all programmatic, legal and regulatory requirements. Obtain necessary approval of contract documents from executive management staff and legal counsel. Interact extensively with contracted providers representing CalOptima.  Represent CalOptima by making presentations to the CalOptima Board of Directors, Member Advisory Committee, Provider Advisory Committee and at a wide-range of community meetings. Lead numerous work groups in designing contract requirement and network design. Facilitate Steering Committee of CalOptima senior and executive management. Assist contracted providers to assess and understand contractual requirements and successfully implement contractual requirements. Manage provider terminations. Monitor compliance with contract requirements.

Director of Credentialing  Manage PacifiCare Credentialing Verification Organization (CVO), credentialing and recredentialing over 30,000 practitioners. Manage staff of 40-50 specialists, supervisors, IS and QI staff and managers. Implement document imaging software application. Enhance proprietary credentialing work flow management software application.  Prepare PacifiCare MCOs and MBHOs for NCQA accreditation. Address credentialing issues with NCQA to assure compliance by PacifiCare. Develop and administer PacifiCare corporate credentialing policies and procedures. Design workflow incorporating work teams empowering staff to be responsible for productivity, quality, timeliness, and customer satisfaction.Contracts Manager Responsible for contract negotiation, provider relations and network management for Talbert Medical Group. Negotiate and manage capitated, discount fee-for-service, and case rate contracts. Preparing and distributing RFPs. Manage processes for bidding and awarding contracts. Conduct site visits and audits. Train and orient providers and office staff. Capitate major specialties saving Medical Group over $1,000,000 per year.Medical Center Administrator Manage large medical clinic staffed by 6 providers and 30 support staff including RNs, front office, lab, radiology, pharmacy, optometrist, member services and PBX, serving over 6,000 commercial and Medicare HMO patients. Assure compliance with regulatory requirements and accreditation standards. Address and resolve provider, customer, member and patient satisfaction issues, complaints and grievances. Perform marketing and practice development for providers. Reduce operating costs by 20%. Achieve high quality, compliance, member service, patient satisfaction and facility operations and appearance ratings. Improve appointment scheduling to increase appointments by 30%.

Administrator, Primary Care Medical Group  Administer group of 18 practitioners located at 3 practice sites. Manage front and back office staff of 50. Develop Bylaws structuring and establishing Group governance and management. Implement productivity based physician compensation plan. Negotiate contracts with major HMOs. Reduce expenses 22%. Member of the Executive Committee and Contracting Board.

Mba, Management, Marketing

Bba, Business Administration And Management, General

Diploma