 Business owner for all aspects of Out of Network claims pricing with vendor partners that increased claims savings to the company of over $80M per year.§ Continuously monitor, measure and improve programs and processes that improve payment integrity and reduce costs .§ Implement new programs or enhancements by managing cross functional teams including external vendors, IT, claims operations, finance, AP, sales and legal departments.§ Use experience and business acumen to determine optimal opportunities and strategies to decrease costs, improve program performance and support long term success.§ Provide expertise in implementation, design and management of population management programs. Developed all aspects of the data exchange, invoicing, reporting and analytics.

 Direct oversight of key partner relationships for care management programs that reimburse our vendor partners over $40M per year and have produced return on investments (ROI) of up to 3:1.  Developed and managed all operational performance reporting and clinical metrics for ten vendor care management programs covering over 25 diseases.  Collaborate with vendor partners to identify opportunities to improve quality and efficiency of the financial and operational performance of each program. Manage the partnership between BCBSMA actuarial staff and vendor finance team to ensure sound objective measurement of financial performance occurs across multiple dimensions. Developed business case using various performance metrics which influenced the decision to transform the vendor delivery model. The net result was a fee decrease of over $20M per year with minimal impact on financial savings. Oversee the cost/benefit analyses, ROI analyses and business case development for new programs or changes to existing programs.  Recommend reimbursement and measurement strategies, develop and negotiate contract terms and complete contracting processes. Prepare analyses and presentations to Senior Leadership related to initiatives or other business performance measurements that provide clear communication and assist in decision making. Manage direct reports and cross functional teams with Medical Directors, Legal, Clinical Coordination, IT, Provider Relations, Communications, Finance and others as needed to implement processes and policies related to BCBSMA’s relationship with our vendor partners.

 Oversee development and adherence to $100 million Sales and Marketing budget. Managed relationship between Finance and Sales and Marketing area to analyze performance verses projected results, identify key cost drivers and impact on spending growth. Partner with area business leaders to develop modeling tools that forecast resource needs based on projected membership growth and recommend appropriate action to achieve corporate goals.

Developed key cost and utilization metrics to support medical management staff in managing provider and hospital networks. Produced streamlined actionable reporting packages. Directed IT staff and consultants in the specifications, development and production of corporate financial and utilization reports.

Negotiated contractual terms and administered financial arrangements with hospitals and physicians.Analyzed financial and utilization data to identify opportunities for improved performance.

• A new position responsible for creating, coordinating, designing and producing uniform Medicare, Medicaid and Commercial product line profit and loss reports for the four HPHC operating divisions. • Presented information to senior management at quarterly meetings. Continuously improved content and quality of meetings by preparing a focused agenda and reducing meeting times by 50%.• Developed budgets, forecast potential risks and opportunities for improvement. • Developed a cost allocation model to equitably distribute administrative costs among the divisions

Responsible for all aspects of developing the capitation payment structure to fourteen HMOs.Modeled financial and utilization data to decrease managed care reimbursement rates an average of 10% resulting in savings to the Commonwealth of over $20 million.Negotiated risk contracts with the fourteen HMOs based off the developed rates.Produced charts, tables and graphs to explain complex subject matter in understandable formatsPrepared all documentation required by the Health Care Finance Administration (HCFA).Rate Setting Commission

Successfully implemented a total restructuring of the reimbursement model in the home health industry, resulting in budgeted savings of over $6 million.Engaged in negotiations with industry leaders and senior government officials. Conducted statistical analyses and recommended appropriate policy changes.