Rob J. Email & Phone Number

Baltimore, Md, Us

• Lead development and execution of a portfolio of ELT technical solutions that cover value-based care, enrollment/disenrollment, financial performance, network adequacy, benefit-cost, sales and marketing, and customer service.• Collaborate with IT to develop and support enterprise-wide strategies, telehealth, processes, and standards for business intelligence, data discovery, and reporting.• Co-chair vendor management activity including contract and service level agreement performance. • Oversee tracking, development, submission, and monitoring of data for regulatory reporting, program audits, and RFP responses.• Create staffing model projections for Enterprise and M&A initiatives.

Chicago, Il, Us

• Lead the FEP Benefit Cost Program through working with local BCBS Plans, Plan Clinicians, Benefit Cost Analysts and divisional Subject Matter Experts in Plan consulting to identify potential opportunities for benefit cost savings.• Work with clinical leaders in HEDIS improvement, and clinical excellence through the development and implementation of benefit cost containment strategies through effective network strategies and by providing leadership with care coordination implementation and care management initiatives.

Oakland, California, Us

Lead multiple teams responsible for multiple areas of health plan operations including regulatory compliance and reporting, quality and auditing, KPI dashboards, executive presentations, and provider data management such as network adequacy and print/online directories..Key Responsibilities and Achievements:• Lead a team of analysts in designing & automating over 50 reports that support daily operations.• Implemented Tableau and created an internal quality program with audit tools • Recruit high performing contributors to rebuild human capital infrastructure. • Participate in key committees with medical groups and executive leadership• Provider support to individual contributors, managers and senior leadership in the form of regularly written and numerical reports and presentations.• Own multiple NCQA standards that includes presenting to quarterly regional quality committee, annual review reporting and analysis, and tracking the effectiveness of interventions. People Management• Lead, manage, support, and motivate a team of reporting analysis, developers, business analyst, and consultants including identifying training needs and skills development.• Manage with an up/out strategy to ensure team is highly performing• Manage the day-to day functions and briefing the VP of Operations on any significant issues.• Monitor the workload of the analytics team, ensuring targets and standards of performance are achieved.Audit and Quality Assurance• Manage all regulatory reporting submissions such as Medicare Data Validation, HSD provider file submission, and Medicaid quarterly reporting to DMAS and DHMH.• Participate in all internal/external audits from entities such as NCQA.Process Improvement• Developed an intake and versioning control of all reporting requests

Us

Management• Lead a team of reporting analysts and/or senior reporting analysts• Initiated new projects that benefit the goals of the company• Managed the case investigation tracking system and oversee timelines to completion for vendor activities • Oversaw that all requests for their area are completed timely, accurately, following department policies and procedures• Ownership of a large-scale, ongoing project and/or area that may contain multiple reports, analysis, and representationsAnalysis & Reporting• Assess reporting results through data investigation, analysis, and evaluation• Analyzed data and trends and create documentation supporting all of the reports• Prepared written analysis and summarize results using graphical representations and professional formatting• Exhibited advanced knowledge of one or more areas of health plan operations - utilization, claims processing, claims payment, fraud, waste and abuse, and/or enrollment• QA'd reports for not only coding errors and issues, but also make suggestions on data representation• Prepare detailed written methodologies and communications to various departments within the company • Identified and present vulnerabilities in current policy and making referrals to the Reimbursement Policy group to improve payment controlsTeamwork & Organization• Planned and organize necessary ongoing reports and proactive work in order to provide a comprehensive package for the end-users• Ensured that reports support the overall scope of company's business strategies• Maintained data integrity and ongoing quality control of delivered reports• Work closely with all levels of end users, including executive level staff, to quickly develop reports which will be used to make strategic business decisions• Created detailed documentation outlining report criteria and provide recommendations to the requester based on the results of the report

Bowie, Md, Us

Provide detailed analysis and summary to the Executive Leadership Team, including company CEO, on an ad-hoc basis regarding the financial and operational performance of company’s core products which account for over $300 million in annual revenue. Analyze company’s past performance against current actuals. Conduct a COGS analysis, Client Financial Impact, and ROI/Client Revenue analysis on various Medicare Advantage and Risk Adjustment products. Key Achievements: • Built ELT Report that is used as a key resource for contract negotiations at the highest level of the organization. • Mentors group of Sr. Business Analysts to recognize opportunities for process improvement, constant collaborative decision making, and purposeful documentation. • Prepares and present monthly reporting packages that includes analysis of key business trends and actual versus plan variances, including comprehensive explanations of differences.• Oversee modifications and updates to standard operating procedures and processes, and drive performance of Medicare, Medicaid and Commercial lines of business.

Indianapolis, Indiana, Us

Lead consultant and subject matter expert managing all professional, institutional, contractual, and legacy system issues impacting the overall performance and P&L accountability for two Medicaid State clients. Directed management of operational, pricing, reimbursement, and technology based issues for company’s Medicaid line of business. Designed routine reports and run daily ad hoc reports. Key Achievements: • Led team of Sr. Analysts on improving performance and drove multiple projects to reduce costs.• Participated in on-sight client visits to triage revenue cycle and system related issues with hospital executives and state government agencies. Led the resolution of all financial impacting challenges.• Drafted appropriate documentation (i.e., policies, standards, procedures, and guidelines) pertinent to areas of accountability and conduct training and presentations across various departments. • Effectively led Provider Field Reps on how to immediately triage institutional reimbursement and Medicaid compliancy inquiries from large hospital networks.

Us

Project leader and facilitator active in high visibility projects such as the New Provider Reimbursement Model, HIPAA 5010, HEDIS, Electronic Payment System Enhancement, and Prompt Pay. Focused frontrunner of company goal attainment by serving as a mentor, trainer and motivator of colleagues that resulted in better and faster service to clients and turnaround of underperforming operations. Bringing together customers and stakeholders to address system issues, set action plans and time frames that led to 30% greater problem resolution that culminated in saving time, soothed customer abrasion and lowered operational cost. Designed, developed and maintained an issue tracking and metrics system that resulted in a 90% reduction in volume of open issues. Key Achievements: •Led enterprise level projects with high visibility. •Directed bi-weekly B2B conference calls with the largest book of business clients.•Authored companywide policies and procedures and create business requirements. •Managed in handling EDI (HIPAA) transaction provider set up and issue resolution, 4010 vs. 5010 transition, National Prompt Pay (claim interest) system development, EPS Enhancement, high volume impacting claim initiatives, and HEDIS (NCQA) projects for the Provider Operations Dept.

Master Of Business Administration - Mba, Finance, General

Master Of Science - Ms, Management Information Systems And Services

Bachelor Of Science - Bs