Responsible for driving performance for value-based care initiatives in 25 assigned adult ACO practices. Worked closely with the ACO and Practice Quality Leadership Teams, assist with the integration of ACO population health programs and resources into practice workflows with the intent to optimize the patient experience, positively impact clinician and staff engagement as well as quality of care and the patient experience. Actively supported programs and work closely with clinicians to implement processes. Additionally, provided ongoing progress reports for the practices to assess the impact of the transformation initiatives, build relationships to enhance clinician and staff engagement and ensure performance improvement. Collaborated with Leadership team with on ongoing opportunities for improvement in Clinical Operations, Quality, Risk Reduction, and Patient Outcomes.Supported Managers of Practice Transformation/ACO to implement change required to achieve the clinical quality goals through development of routine feedback mechanisms, guidelines, etc. Participated in practice improvement meetings, providing expertise, coaching and guidance as necessary. Engaged in problem-solving with practices to improve access and patient-centered care. In addition, the liaison with Payer Quality Incentive Programs to confirm alignment between the ACO practices and payers. Participated in ACO and Payer collaboration efforts to improve quality of care and drive success for the entire ACO population.

•Administered all Payor financial incentives for Primary Care Physicians of the Einstein Healthcare Network and produce financial/quality dashboards for Senior Level Management. Collaborated closely with Einstein’s Adult and Pediatric Quality Medical Directors to educate the primary care physicians on Quality HEDIS measures and potential financial incentive revenue. Coordinated Capitation and Quality Incentive efforts with the Hospital Managed Care department to align with Network goals. Collaborated with Billing, Finance, Contracting and Credentialing departments. • Oversaw and supported the decisions regarding Capitation, payor quality measure incentives, other managed care projects and present outcomes to the Managed Care Subgroups and Senior Level Management. •Collaborated with the Practice Managers and Administrators of 42 Primary Care practices to implement all Payor Quality HEDIS and STAR Measures, Incentive plans/processes, results and incentive reimbursements. Developed Professional and trusting working relationships with the Primary Care Physicians and support the Regional Practice Administrators relative to any managed care processes or concerns.•Conducted standing meetings and communicate regularly with all Insurance Payors regarding physician quality measures incentive programs, capitation concerns/discrepancies, credentialing and all other managed care issues.

• Serviced a defined segment of high-profile professional, hospital, ancillary providers and integrated delivery systems in Pennsylvania. In addition, established and maintained professional and effective relationships between Independence Blue Cross and the Physician/Hospital Accounts to continue to improve provider satisfaction.• Independently organize and conducted regular monthly meetings with both the Professional and Facility accounts. Researched and analyze issues that impact these providers, including but not limited to issues regarding claim payments, provider data file discrepancies, Quality Incentive Payments (QIPS), Capitation, medical policy, utilization management, and other compliance initiatives. Educated providers’ on new initiatives, changes in medical, claims payment policy, and related operational procedures.• Compiled information gained during servicing activities to make recommendations to management regarding the identification of significant opportunities to improve operational efficiency, reduce costs and improve provider satisfaction. Conducted root- cause analysis and work collaboratively with staff in other business areas to assist with the resolution of complex provider issues and achieve expected goals/outcomes within established timeframes.• Worked collaboratively with Contracting and Reimbursement to support decisions and negotiations during the re-contracting process.

• Reviewed and analyzed HMO monthly reports, capitation/rates and system implementations. • Maintained the HMO/PPO fee schedule implementation as well as capitation rate tables for PCP’s and Specialists. • Coordinated fee and rate changes for Keystone Health Plan East and the Personal Choice Network, produce and manipulate financial business reports for the department.

Maintained a public atmosphere of trust and confidence in the administration of policies and Procedures of Independence Blue Cross by providing professional, expeditious, accurate and courteous responses to all Independence Blue Cross Associate's inquiries concerning their own health care benefits, as well as inquiries referred by Associates as a result of contacts received from subscribers, providers, family members, friends and the general public. As a Grievance Specialist, I analysis, interpret, research and responded to grievance referrals via the most appropriate method within departmental quality guideline standards to all members and those presented by providers.

Provided quality and efficient customer service to Members, explain Health Benefits, translate medical claims, handled membership and billing inquiries.