Westbury, New York, United States
A strategic health care leader with 20+ years of progressive hospital, managed care analytical and financial experience with a track record of delivering strong results under compressed time frames. Skillful at leveraging technology, people and process to increase efficiency and drive organizational change. Proven executive with broad scope including health plan finance, medical economics, fee schedule/provider reimbursement, value-based contracting, QARR/HEDIS reporting, IT, provider relations and network/claims analytics. Results-oriented, collaborative leader with substantial experience in recruiting, developing and mentoring high performance, analytical teams in an ever-changing healthcare environment.
• Established a Medical Economics unit at Fidelis in December 2006, to recruit and train analytical staff, develop performance reporting, monitor/review medical cost trends, oversee provider reimbursement operations, and partner with IT in the development of a data warehouse • Co-Chair of Business Intelligence Steering Committee driving the development, integration and adoption of enhanced BI tools/analytics for performance measurement and strategic planning • Developed medical cost trend reporting to support actuarial estimates used for monthly financial close process, as well as, year-end audits • Lead the annual development of Fidelis' multi-billion dollar medical expense budget • Own all facets of fee schedule implementation including: monitoring, preparation, quality control and financial impact of all changes to Federal/State reimbursement methodologies • Streamlined fee schedule implementation process workflow which resulted in a 50% reduction in implementation time • Serve on several process improvement committees which set company policies related to fee schedule implementation and workflow • Transformed provider P & L performance reporting production several-fold, which empower critical strategic contracting efforts • Developed and standardized scalable models for quantifying financial exposure using different reimbursement methodologies and risk modeling • Routinely partner with senior executives in the benefit design, and financial modeling of the annual Medicare Bid process, and PFP/quality incentive programs • Leading the development of financial sensitivity analytics for risk-adjusted, quality-measured, value-based contracting arrangements • Manage and mentor 18+ FTEs, comprised of managerial and analytical professionals
• Primary IT leadership resource for partnering with Senior/Executive management regarding enterprise-wide quality related initiatives and analytics at Fidelis Care New York. This includes supporting QARR/HEDIS reporting and analysis, provider Pay-For-Performance reporting, Medicare PCP enhancement Payments, Encounter Data Submissions (MEDs), and Informatics. • Drive alignment within IT to ensure technology, processes and staff are scalable to support future reporting and analytical requirements for HARP, FIDA and the Health Benefit Exchange • Lead discussions in weekly QARR Steering Committee with C-level executives regarding analytical enhancement strategies, as well as, performance measurement of various quality initiatives • Currently managing 12 FTEs, comprised of managerial and analytical professionals • Manage relationship with technology vendor supporting NCQA certified software
• Recruited to primarily partner with Senior/Executive Clinical/Finance Management in developing shared risk arrangements, financial sensitivity models and cost saving programs designed to reduce unnecessary admissions, while improving financial performance • Developed and partnered with Executive management to implement 2014 hospitalist program designed to reduce inappropriate admissions minimally by 10% and reduce medical expense by approximately $20MM • Served on several Utilization Management and Strategy Committees focused on driving reductions in PQI admissions as well as developing key lead and lag measures to assess medical expense performance on an ongoing basis • Partnered with Clinical Management, IT and other senior executives in the benefit design, and financial modeling of a Pay-For-Performance program for HCP providers • Serve as the primary analytical team for supporting performance reporting for QARR & CRG, in order to increase risk score and maximize revenue • Managed and mentored 5 FTEs, comprised of managerial and analytical professionals
• Managed and enhanced all aspects of medical cost analysis and reporting at the national level for AmeriChoice Plans • Developed robust reporting which allow local senior management to focus on areas of concern requiring further “drill-down” analysis • Identified and sized medical cost liabilities in order to enhance Senior Management’s understanding of drivers of unfavorable development • Served as liaison between local Plan senior management and corporate medical economics team • Drove innovation in data-aggregation and foster “best practices” approach to ensure efficient turnaround, while maintaining accuracy • Performed ad-hoc “impact” and “scenario” analysis for corporate Senior Management to identify utilization trends and cost drivers at the Plan level • Served as key resource in the identification of adjustments that supported the monthly close process, and the setting of reserves • Led a team of medical cost analysts who support monthly & quarterly reporting deliverables