Executive health plan leader with operational oversight responsibility for UHC for Florida's Medicaid and Medicare programs (MMA, LTC, DSNP) serving a total of 480K members.

Virginia Community and State health plan leader responsible for P&L and specializing in product oversight of Virginia's CCC Plus/MLTSS program. Performed as regulator-facing Program Director for MLTSS implementation and ongoing oversight.

Virginia Community and State health plan leader responsible for operational oversight of Medicaid programs. Performed as regulator-facing Program Manager for MLTSS implementation and ongoing oversight.

Senior Products Division: • Administered Virginia market plan operations in support of the Medicare/Medicaid duals demonstration program (MMP) • Defined and monitored overall key performance measures and detailed analyses on financial, clinical, network and claims/utilization data sets. • Oversaw vendor management performance/SLAs and reporting for LTSS and behavioral health network providers and fiscal employer/agent activities. • Served as plan liaison with CMS and Dept. of Medical Assistance Services (DMAS) onMedicare/Medicaid issues in support of the 3-way contract.

U.S. Life Insurance/Long Term Care (LTC) Claims Division: • Administered data management, outreach, risk/eligibility determinations and controllership for 80K LTC providers.• Directed LTC claims Quality Assurance audit programs and processes.• Identified, created and prioritized provider process and technology enhancements.• Led a collective team of 32 provider adjudication experts, quality auditors, and compliance/practices specialists.

CSO Central Administration/Provider Systems Division: Responsible for various aspects of provider data administration and analysis; including physician and facility contract implementations, process analysis and design, contract implementation quality assurance, data mining/analysis and electronic provider file maintenance.• Directly maintained and analyzed contracts/fee schedules/demographics for 8,500 hospitals/ancillaries and 750K physicians on behalf of 18 health plans and the Coventry National Network.• Engineered numerous process and data quality improvement efforts including:- Application/process reducing fee schedule implementation timeframe by 98%.- Application/process for extract, analysis and presentation of providers/contracts from legacy systems for health plan audits and conversion.- Data automation/scripting technologies saving the company $1M annually.- Exception reporting catalog to prospectively identify data anomalies.• Developed comprehensive, enterprise-wide workflow management and quality assurance programs for provider and contract management activities. • Served as chief business process expert and technical/project management consultant for the Division and led team of 5 highly technical continuous improvement consultants. • Supported HMO, PPO, ASO, Medicare, Medicaid, TPA/Rental and Workers’ Comp products. • Developed Medicare reimbursement methodology support team and processes serving health plan network development and claim processing staff. Provided support for RBRVS, DME, Clinical Lab, ASC methodologies and support for HSS (Ingenix) product for Inpatient and Outpatient Prospective Payment Systems. • Led 5 managers and 130 FTEs across multiple sites.

As an inaugural team member of the start-up operation, managed implementations of Bloodhound's ClaimsGuard software service for payors totaling over $1B in annual paid claims. Key responsibilities: • Provided direct support for and participated in client sales presentations. • Led client efforts for initial and ongoing data extracts, data transformations and mapping. • Led product development and support meetings. • Clinical and business rule analysis and customization. • Oversight of client job processing/billing reconciliation. • Analysis and presentation of client results. • Client issue/relationship management.

CSO Central Administration/Provider Systems Division: • Managed audit, conversion, and integration of contract and provider files for acquired health plans with annual claim payments in excess of $500M. • Developed and managed implementation of best practice business process models and key cross-departmental audit and contract data summary repository applications. • Directly queried and conducted numerous claim and provider analyses on mispayments, network penetration and other business needs using combinations of output from data warehouse and transactional systems.Data Integrity Team: • Worked directly as part of core three-person analytics team to establish and maintain comprehensive metrics, key indicator reporting package and tracking systems for all claims customer service and support teams.