Massillon, Ohio, United States
Strategic analytics leader with 28 years of managed healthcare leadership experience and deep expertise across Medicare Advantage and ACA program operations. Aligning analytics, coding, engineering and clinical teams to deliver scalable, high‑impact outcomes for insurance payers, plans and providers Recognized as the leader organizations rely on to stabilize complexity, untangle operational chaos and architect large‑scale, technology‑enabled transformations that improve accuracy, scalability and financial performance Proven track record of converting analytics, clinical coding and submission pipelines (EDGE/RAPS) into measurable RAF lift, recapture gains and sustained RADV/audit readiness Unique end-to-end experience with full spectrum of the healthcare enterprise: from provider patient gaps, to revenue cycle reconciliation, through payer plan processing and beyond into complex analytical solutions Experienced in building and leading high‑performing, cross‑functional organizations—spanning analytics, product, clinical coding, engineering and operations while establishing governance, KPIs and operating models that drive accountability and transparency Extensive end‑to‑end risk adjustment expertise across healthcare providers and health plan payers, aligning strategy, technology and clinical operations to improve reporting, gap closures, submissions, patient interventions and health equity outcomes Demonstrated success in standing up new teams and overhauling underperforming ones, implementing processes, workflows, technology roadmaps, compliance oversight and enterprise‑level project planning to support rapid growth and operational maturity Highly adept at developing executive dashboards, oversight frameworks and performance intelligence tools that translate complex operational activity into clear insights empowering senior leadership to identify bottlenecks, prioritize investments and accelerate improvement
Leader of Solutions Development focused on building and maturing cross‑functional engineering teams, stabilizing complex delivery environments and driving technology‑enabled transformation Known for stepping into ambiguity, untangling fragmented processes and establishing scalable structures that accelerate delivery and improve product quality Direct software engineers and serves as Scrum Master, guiding SAFe Agile ceremonies, PI Planning, backlog refinement and iterative delivery across multiple workstreams Builds clarity from chaos by defining requirements, aligning priorities and implementing governance models that ensure predictable, high‑quality outcomes Key Contributions: • Lead and develop engineering teams through coaching, structure and performance management • Establish SAFe Agile best practices and champion continuous improvement across delivery teams, expanding efficiencies through automation, AI ecosystems and knowledge hubs • Drive Program Increment Planning and manage cross‑team dependencies across product, engineering and enterprise technology • Translate strategic business and product objectives into clear, executable engineering plans • Serve as the central liaison between product, engineering and enterprise stakeholders • Implement governance, delivery accountability and risk‑mitigation frameworks to stabilize execution • Own systems documentation standards to support scalability, knowledge transfer and continuity • Promote strong cross‑team collaboration to deliver integrated, multi‑platform solutions • Oversee and manage multiteam large system migrations including SQL, Azure and Amazon Workspaces
Strategic leader for Medicare Advantage and ACA risk adjustment analytics and customer success, bridging clinical coding, product and engineering to improve RAF accuracy, submission quality and customer financial outcomes Key Contributions: • Manage team of direct reports in creating innovative new analytical concepts for Medicare and ACA risk adjustment within Veradigm's risk adjustment Analytics and risk Mitigation products, focusing on condition gap opportunities, MYRA/FYRA financial accuracy, ACA transfer payment strategies and innovative intervention planning • Triage, assign and perform customer deep-dive data analysis • Perform critical-to-quality analysis of customer data including trending large data sets, financial projections, integrated testing and population health anomalies • Serve as the subject matter expert for Medicare and ACA risk adjustment guidance and staying up-to-date on latest regulations, including ACA Edge ICD and BRDs, MA Advance and Final Notices, HPMS memos etc • Own customer financial improvement modeling and translated RAF trends into PMPM and annual revenue forecasts used in customer engagements and internal prioritization • Perform sales demonstrations for prospective customers on value and innovation • Project management of large scale initiatives ensuring coordination across the organization • Provide training and mentorship at various levels for staff and customers on RA concepts and strategy • Develop business cases and requirements for new and existing products • Serve in Scrum Master role in prioritization of development work following SAFe Agile practices • Own customer financial improvement modeling and engaging directly with current or new customers to update models • Collaborate with clinicians in outcomes, algorithm performance and new product development
• Collaboration with data scientists, researchers, risk adjustment experts and developers in business cases for algorithm development and improvement • Researching customer performance, designing requirements for new analytics and data products • Perform in-depth data analysis for customers, including claims, enrollment, pharmacy, lab data and government files (Medicare MMR, MOR, RAPS Returns, MAO, ACA Edge RARI, RARSD, RARCSD etc,) • Establish and own critical-to-quality data validation to ensure data integrity by seeking out anomalies in customer data files, trending norms and coordinating cross-teams for resolution • Regulate CMS/HHS guidelines for ACA and Medicare RA submissions, risk scoring and model updates on behalf of payer/provider customers to ensure compliance, accuracy and planning • Key contact as company subject matter expert, supporting training, guidance and strategy for customers and more junior staff • Key role as technology solutions liaison between business product designs and engineering solution life cycles • Design processes between the business and solutions development within an SAFe Agile structure • Design new analytical concepts for risk adjustment Data Validation (RADV) software for payer risk mitigation including identifying scenarios and conditions at higher risk for audit failure • Innovate solutions for health insurance plans to gain visibility into propensity scale for conditions with higher risk for improper clinical coding or documentation
• Own and create a primary data analytics and reporting team for Medicare Government Operations, including enrollment, appeals and grievances • Establish leadership and guidance for new team within membership, appeals and claims to provide coordinated reporting and metrics for government programs • Evaluate existing processes and develop roadmaps for centralization, increased efficiencies and technology automation • Own and establish department KPIs and oversight to executive tiers for financial solvency and compliance • Manage team of direct report analysts overseeing enrollment monthly reconciliation activities, including the discovery, reporting and resolution trending of discrepancies in various business processes such as enrollment, Low-Income Subsidy (LIS), Late-Enrollment Penalty (LEP), Medicare Secondary Payor (MSP), End-Stage Renal Disease (ESRD), MMR payment adjustments, member demographics and others • Own oversight and compliance for monthly premium billing activities for Medicare Advantage members, including validation of LIS, LEP and other discrepancies impacting direct member invoicing • Own regulatory reporting for government regulatory audits, including Medicare Part C/D annual reporting (enrollment/disenrollment, ODR and grievances), data validation audit, program audit, appeals timeliness, and pharmacy benefit management (PBM) • Develop quality control reports and programs to audit data integrity to ensure data elements are in compliance
• Defining required reporting and frequency for government programs both within health plan and clinical operations • Design, develop and implement new reporting policies, procedures and submissions as it relates to government regulated plans by the Centers for Medicaid and Medicare (CMS) and Health and Human Services (HHS) • Manage data transmission programs including Medicare risk adjustment (RAPS/EDS), CMS (HPMS) and (ACA) Edge Server • Design, data collection, analytics, quality review and submission of all regulatory reports to federal and state agencies such as Medicare Part C/D annual reporting, Medicare and Commercial risk adjustment and CMS plan connectivity secure FTP transfers • Production of health insurance plan analytics for both Medicare and Commercial risk adjustment including attribution of Hierarchical Condition Categories (HCCs) through various model scenarios, future risk score forecasting and trending • Complex programming and monitoring of ACA Edge Server submissions Creation and monitoring end-to-end from source system extraction, normalization across multiple systems, transformation to HHS compliant regulations through to error management and submissions to Edge Server • Management of varied direct and indirect reporting staff including full time employees, team leads and individual contractors • Overall project management responsibilities including work plan development, establishing timelines, budgetary compliance and tracking milestones to ensure regulatory and financial deadlines are met • Provide analytical assistance and information to clinical operation areas such as providers, clinical coders, physician billing and clinical leadership • Extensive experience in complex data sets crossing issuers, plans, payers and contracts
• Organize and maintain processes for the submission of data for Medicare risk adjustment • In depth knowledge of complex transition system planning, data governance and normalization • Responsible for the design, creation and extraction of data from multi-platform source systems for submissions to CMS risk adjustment Processing System (RAPS) such as Oracle, SQL SSMS and Teradata data stores • Project management and analytical oversight of submissions through CMS Encounter Data Processing (EDPS) • Responsible for organizing collaboration of government regulations with claims processing, membership administration and clinical operations for optimal diagnosis capture and claims submissions • Collaborate with multi-regional teams, trouble-shoot and perform analysis on complex data spanning several years • Project manage complex changes to CMS rules and implementing across programs to ensure compliance and functionality • Develop reporting tools to monitor volume, trending, reporting scores and reports etc Evaluate anomalies, issues and errors Develop resolutions, project guidelines and timelines • Subject matter expert for the organization on risk adjustment guidelines and risk scoring attribution
• Own leadership over conversion project to ICD-10 Diagnosis Code billing for the organization’s Ohio region for all EMR, billing, revenue cycle and clinical operations • Leadership over regional team (business project managers, IT project managers, testing leads, organizational readiness teams) • Executive communications through stakeholders across national and regional program management structures • Coordinate project issues between both business and IT to establish priorities, ensuring the timely implementation of deliverables • Evaluate and assign staffing resources as well as managing local project budgets and accruals to align project financial success • Creating forecasts, plans and pivoting allocations for multifaceted complex solutions • Resolve specific issues (policy changes, staff requests, project delays, etc) in partnership with nationwide regional programs
• In depth knowledge of revenue cycle operations and systems, with a focus on providing technology solutions in revenue cycle planning, system issue resolution, workflow development and associated staff training • Promote and support billing and collections system functionality and identify best practices including observing trends and inconsistencies in system use and provide feedback to management to identify opportunities for improvement in quality and productivity • Certified to perform changes in Epic Resolute Professional Billing as administrator Extensive awareness of all data sources and system triggers that are impacted by system changes and downstream impacts • Provide expertise in Epic Resolute PB end-to-end data flow and revenue cycle processes • Initiate and track progress for correction of reported systems problems, enhancements, or changes • Prioritization of outstanding work requests and act as intermediary between IT and business operations • Build tools and analytical reports utilizing Crystal Reports, SQL, Business Objects and Microsoft Office utilities to optimize operations and prioritize initiatives • Project management responsibilities including creating project plans, budgets, resource allocations, requirements and business cases • Extensive experience in managing multiple projects simultaneously with dynamically changing requirements such as government regulations and system transitions • Create moderate to complex databases and reports for revenue cycle departments, including technical writing in SQL and Visual Basic
• End-to-End revenue cycle operations including monitoring costs, workflows, denials, staffing • Build processes for end-to-end professional billing operations to maximize efficiencies and financial roadmaps • Build working relationships with Epic operations on innovations for emerging technologies
• EMR coding responsibilities including accessing patient records, entering appropriate billing codes (ICD, CPT) and updating pertinent electronic medical records in both Epic and legacy systems • Establish KPIs and metrics for leadership on front-line customer service experiences for patients across regional clinical practices