• Used knowledge of data structure, analytics and technology to manage the request, development, and deployment of in-depth/actionable reports and dashboards for the division• Provided direction for and promoted the growth of the company analytics program; provided guidance to analysts to meet business requirements; drove adoption and use of new technologies including but not limited to Truven, and Treo • Provided the strategic direction and leadership for a team that supports corporate and divisional strategy and goals• Served as technical expert and consultant to collaborating departments on corporate and cross-functional projects, reporting and activities• Primary Business Data Steward for division and lead related efforts on the BCBSLA Data Governance Committee• Collaborated with leadership to develop, implement and maintain data requirements and analytical software requirements to support global analytics and strategies• Collaborated with Reimbursement, Informatics and Actuarial leadership to ensure compliance with BCA mandates for required corporate data submissions including ValueQuest, National Consumer Cost Tool, etc., and other required data submissions to external vendors for data mining and analytic engagements• Lead development of client reports related to predictive modeling, risk and case mix adjustment by preparing and providing decision support overviews, demonstrations, and presentations to internal and external audiences• Communicated strategy and initiatives to team members supporting achievement of overall company results; staff development through clear expectations, coaching, feedback, formal evaluations, educational programs and maintaining positive professional environment• Directed department planning and budgeting in compliance with Corporate Objectives and deadlines

• Directed Provider Audit activities to ensure correct provider coding and billing practices, enforce reimbursement and member agreement compliance, and recover incorrect payments and identify opportunities to prevent internal claim systems (local, FEP, ITS) processing errors• Identify cost and utilization trends, provider billing patterns and variations vs. peers, and emerging issues in order to identify opportunities for system changes for future payments and recoupment of prior payments where possible• Promoted and maintained cost containment efforts in the provider community through audit activities, including detection, education, and responding to reimbursement appeals and inquiries; ensured all parties adhered to institutional, ancillary and professional reimbursement rates, fee schedules and contracts

• Developed competitive facility reimbursement systems that promoted long-term mutually beneficial relationships with providers, and fostered quality patient care• Provided specifications to IT, Medical Management, Benefits Administration and Network Administration for implementation and maintenance of facility and ancillary reimbursement programs for all networks and claim processing systems• Provided financial analysis of provider proposals• Directed the evaluation and implementation of new facility and ancillary reimbursement programs; researched new methods for reimbursing providers using external sources to identify industry standards

• Responsible for daily operations of Health Information and Patient Financial Services; patient registration, billing, accounts receivable and business office operations• Prepared various financial forecasts; cost center salary and direct expenses, month-end financial reporting, receivables levels (days in AR and aging), cost center productivity, and any department long-range strategic plans• Integrity oversight of financial and clinical interfaces, facilitated development of strategic system planning• Continuously monitored contractual arrangements with third-party payers, including state hospitals, to ensure maximum reimbursement obtained and negotiated contractual agreements when necessary• Maintained knowledge of managed care contractual terms and requirements, health insurance practices, and industry regulatory requirements• Oversaw all ongoing activities related to development and implementation of organization’s policies and procedures covering privacy of patient’s protected health information

• Prepared, analyzed, reviewed and projected financial/system impacts of various negotiation strategies• Monitored ongoing provider performance for changes in cost and utilization trends• Ensured contracts were executed, loaded, and audited accurately and timely• Recruited providers and negotiated high-level contracts to assure consistency with corporate initiatives• Developed and maintained professional working relationships with physicians and providers• Negotiated individual contracts with IPA’s, PHO’s, hospitals and ancillary providers• Provided oversight to staff relating to administration of provider networks within service area

• Accountable for direction and oversight of 35 staff employees• Managed Customer Service staff; provided workflow direction to support service standards and implemented action plans• Generated and maintained daily, weekly, and monthly production statistics• Ensured continued delivery of excellent customer service by motivating, training, and coaching staff• Ensured compliance with HCFA regulations required to maintain HMO contract• Performed account research and analysis of financial and reimbursement data• Worked with Physicians and other Providers to resolve contracting and/or claims issues

• Managed all billing invoices, cash receipts and commission payments• Created monthly revenue reports, adjustment reports, aging reports and related journal entries• Assisted with preparation of year-end financial statements• Developed methods and incentives for collection of delinquent accounts