Provider Network Development & Innovation Director @ ConnectiCare
Sr. Director Network Management @ Aetna
Director, Managed Care Contracting - Consultant @ UnitedHealth Group
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I have an extensive background in healthcare and contract negotiations including a successful record of contract negotiations from the health plan side as well as the provider side. My experience includes a broad knowledge of Medicare, Medicaid, SCHIP and many of the Managed Medicare & Medicaid programs. I have successfully negotiated & managed shared & full risk
I have an extensive background in healthcare and contract negotiations including a successful record of contract negotiations from the health plan side as well as the provider side. My experience includes a broad knowledge of Medicare, Medicaid, SCHIP and many of the Managed Medicare & Medicaid programs. I have successfully negotiated & managed shared & full risk agreements and capitation. Responsible for developing the Value Based Reimbursement strategy, exploring alternative contracting & strategized over market expansions & contractions for clients.
Have led contract transitions to pay-for-performance agreements and assisted in the development of an Accountable Care Organization, Patient Centered Medical Homes and a PACE program. I have a thorough understanding of various reimbursement methodologies including DRG, OPPS, RVU’s, fee for service, capitation & risk contracting. My financial background & experience gives me a strong analytical background.
Director, Managed Care Contracting - Consultant @ Provide Managed Care consulting services to payers and providers. Providing contracting strategy for re-negotiations, product and territory expansions, ICD-10 conversion and payment method conversions. Lead consulting services for Value Based Reimbursement transitions for both payers & providers Consulting on risk based, capitation & bundled payment agreements for commercial, Medicare & Medicaid products. Provide data analysis, benchmarking and clinical/financial outcomes analysis to support contract negotiations and strategy. Assist in STARs efforts & Practice Based Support expansions. From November 2011 to Present (3 years 10 months) Director Managed Care & Reimbursement @ Set hospital, Physician and ancillary service contracting strategies for the Health System. Provide strategic analysis & advice to Senior Leadership. In cooperation with physicians group developed alternative contracting such as Accountable Care Organizations & Patient Centered Medical Homes. Successful Negotiation of all Managed Care contracts for the Health System providing significant increases to reimbursement for the Acute Hospital, Rehab Services, Inpatient and Outpatient Behavioral Health, Skilled Nursing Facilities, Home Care & Hospice. Increases ranging from 10% to 45%. Negotiation of pay-for-performance contracts based on medical quality standards. Enhanced Acute Hospital contracts to include reimbursement for high cost implantable devices, high cost drugs and case threshold reimbursement. Negotiation and oversight of Medicare Preferred risk agreements. Including maintenance of Physician partner relationships & analysis of financial performance of risk agreements. Successfully complete all state & federal reporting requirements including cost report, 403 & RFA’s. Responsible for all revenue analysis & net revenue calculations for Acute, Rehab & Behavioral Health hospitals. From 2005 to November 2011 (6 years) Springfield, Massachusetts AreaManager, Medicaid Program @ Manage Medicaid Contracting & Provider Relations for the state of CT. From 2004 to 2005 (1 year) Manager, Network Contracting & Performance Mgmt @ Oversee all network contracting for Western Mass, North & South Worcester Counties. Expansion of the Medicare provider network through Partnership with providers. Developed a strong regional provider network building strong payer, provider relationships. Effected cost containment with risk partners significantly reducing trends in Physician, Hospital and Pharmacy utilization by implementing cost trend analysis and reporting packages. Maintained a successful Network region, including contract negotiations, financial analysis & feasibility, and network relationships. From 1998 to 2004 (6 years) Waltham & Springfield, MACFO @ From 1996 to October 1998 (2 years) Springfield, Massachusetts Area
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