Assisted marketing with successful business growth as a new vendor in the marketplace.Consulted with Brokers, TPAs and Carriers to assist in all areas of cost containment, risk assessment claim management, select network development, quality initiatives.Implemented innovative MGU claims management program. Provided clinical financial risk assessment for underwriting on new business and renewals.Assisted brokers with new self-funded employers with benefits, employee education, pharmacy programs, etc.Performed clinical reviews, claim settlements, pricing/repricing services, dialysis cost management, DRG validations, ER/Facility claim reviews, management of high cost-cost professional fees, ongoing discount agreements, specialty drug cost management, etc.

Managed all issues related to Third Party Administrator claim payments prior sending to the Stop Loss Carrier to ensure appropriate claim payment including eligibility, payment accuracy, utilization, bill review and cost containment programs.Developed a claim inventory program to reduce aging claim volume and resolve carrier issues and concerns.Resource to sales team, underwriting and account management on current and new client prospects.Developed training materials for new hires, inexperienced staff and ongoing department growth and development for quality improvement.Clinical consultant to Stop Loss carriers for medical appropriateness, cost containment solutions, large claim auditing, vendor recommendations, risk assessment, treatment plan evaluation, alternative care recommendations and successful detection of fraud & abuse.Overseen TPA claims practices and payments, negotiations and/or settlements were accurately applied according to plan provisions and applicable state and federal regulations.Developed vendor portfolio to manage variety of high dollar diagnoses and specialty pharmacy.

Provided consultation on Stop Loss and reinsurance catastrophic/complex claims with quality cost containment solutions Clinical underwriting reviews for risk identification and cost projection with medical management recommendations Performed Workers Comp Telephonic/Field Case Management for Genex, MEMIC, USI & CIRMACompleted annual HEDIS projects, large claim auditing and vendor review, evaluated medical management programs Consulted on RAC, Medicare appeals and medical documentation to ensure accurate billing for several CT hospitals

Managed daily stop loss claim inventory, maintained weekly and monthly reporting to stop loss carriers and internal entities with clinical recommendations, cost containment strategies.Performed consulting analysis on HPHC medical and claim operations to identify area for improved quality and cost containment. Lead resource for underwriting support identifying potential large claims, concisely communicated risk with cost projection, providing solutions to improve quality treatment options to reduce ultimate claim costs.Reviewed comprehensive claim reports to identify potential high risk/cost members for medical management intervention

Accepted the position with the challenge of making the block profitable for purchase/acquisition within a 3year timeframeKey contributor to the revision of medical management, claims, underwriting, TPA management and marketing teamsProvided daily underwriting support with comprehensive reviews on new quotes for risk assessment and cost projectionDeveloped “best in class” vendor network, strategically negotiated contracts, managed vendor and TPA relationshipsConducted onsite clinical and claim audits, identified overpayments in excess of $14M on 8 reinsurance claim filesAchieved annual savings in excess of $19M with new cost containment programs effectively reducing the loss ratioExecutive management team member to integrate company during Sun Life acquisition

Created role and responsibilities with a “new to the industry” team approach to underwriting, marketing, product development, risk analysis, reviewed all reinsurance treaties for improved risk protection.Developed a vendor network to assist with high-risk, catastrophic medical conditions and claims.Pursued all opportunities to achieve annual claim savings in excess of $20M.Comprehensive review and tracking of trigger diagnoses and catastrophic notices, preformed MGU/TPA claim/performance audits.

Developed Catastrophic Case Management and Appeal Departments within a rapid growing new HMO in the marketplace.Managed Medical Management Department, created and developed new industry and community programs.Direct contact for Reinsurance team in regard to appeals or any questions as related to high dollar members.