Director Manager Provider Contracts Resume

Desired Industry: Insurance	SpiderID: 2680
Desired Job Location: San Francisco, California	Date Posted: 5/25/2005
Type of Position: Full-Time Permanent	Availability Date: immediately
Desired Wage: 90,000.
	U.S. Work Authorization: Yes
Job Level: Management (Manager, Director)	Willing to Travel: Yes, More Than 75%
Highest Degree Attained: JD	Willing to Relocate: Yes

Objective:
Group Insurance specialist with 30 years experience in commercial and government programs with technical, business and operational knowledge of healthcare delivery systems and network services. Skilled in contracting, marketing and claims administration with heavy emphasis on systems analysis, development and implementation, and medical services cost management. Client-oriented and customer satisfaction driven. Able to conceive, develop and implement strategies responsive to internal/external customer needs.

Experience:
Responsible to assure operational implementation of contract functions as it relates to development and execution, pricing, systems support and operations. Responsibilities include: analysis and development of contract structure (physician, hospital, and ancillary contracts) including compliance with State and Federal regulations and the intricacies of differing payment methodologies; assisting in recruitment and retention of network providers; maintenance of Claims and Provider subsystems to support the integrity and accuracy of contractual reimbursements; monitoring provider/vendor compliance with contractual obligations; development of policy and procedures that document the operational implementation of contracts; development, implementation and maintenance of audit policies and procedures to ensure the integrity of reimbursement and all data systems; negotiate reimbursement and execute Letters of Agreement for non-contracted providers/vendors; assist Claims and Member Services in the resolution of Member Billing and Collection issues. Member of Health Plan Policy Group, HealthCare Quality Committee, Chair of Health Plan Collaborative Committee, the Data Review Committee, and Health Plan Claims Coding Committee.
Managed mailroom operations for claims and administration departments, experiencing an increase in receipts of 115% over a 2-year period. Managed Data Entry and Claims resolution process with a book of business derived from independent and disparate marketing and underwriting sources.
Successfully managed move from use of outside vendor for microfilming to in-house optical scanning with desktop retrieval. Project included use of FAX Server and OCR/ICR with queue capabilities.
Successfully managed 2 distinct books of business on 2 separate claims payment platforms. This included a complete migration from an in-house Clipper-based DOS system to a Y2K table-driven system with auto-adjudication capabilities.
Successfully managed business during a period of growth, which saw receipts more than double and staffing increase by 60%. This resulted in the relocation of one piece of business to the San Diego area with reporting lines to San Francisco.
Hired to transition claims payment operations from an in-house Orbis program to the RDD MPower Claims system, and to relocate the operation to the regional Service Center. Transitioned to Network Management with responsibility for independent physician and IPA contracting and service for full range contracts (HMO/EPO/POS/PPO) as well as providing in-service and training and orientation.Worked as part of a team, which was successful in obtaining the state�s first NCQA 3-Year Reaccredidation for the Northern California Health Plan. Worked as part of a team that implemented policy and procedures that ensured a successful HCFA Audit for the Northern and Southern California Medicare Risk plans.Worked as part of a team that successfully filed and obtained DOC approval for a Medicare Risk product for Sacramento County.Successfully managed contracting and renewals at expected levels for physicians and IPAs in Marin, Napa, Sonoma, Solano and Sacramento counties. Prepared Orientation and Training Manuals for new providers; sponsored training seminars presenting new information regarding facets of membership, billing/eligibility, and claims.
Serviced a book of business valued at an annualized premium in excess of $41,000,000. Designed, implemented and managed employer group health plans created to facilitate marketing, quality delivery of care and cost management of health care/claims administration. Range of product lines included fully HMO, POS, traditional indemnity medical/dental plans, fully managed dental plans, short/long term disability, pooling/stop loss reinsurance, managed drug plans and vision plans. Modified existing products to meet client needs while enhancing service and profitability.
Maintained first year renewals at 98%; persistency at second year and beyond at 94%. Non-renewals typically based on rating issues. Consistently sold at each renewal additional or replacement coverages at fully managed care levels.
Achieved high penetration into managed care products - where available - during enrollment, averaging 50% penetration in first year cases.
Devised and delivered client specific spreadsheet reports detailing utilization and projected savings against projected and actual premium/premium equivalencies.
Prior to 1991 worked as a Project Manager with responsibility for managing litigation/legal matters for the Western region; represented the company in Small Claims Court in California. Directed staff of 3 as Regional Operations Support Manager, a staff of 18 technical specialists as Regional Technical Support Manager. Prior experience includes Quality Analyst/Reviewer, Technical Assistant, Claims Supervisor. Each new position was the result of promotion.

Education:
1975 J.D. Kendrick Hall School of Law - University of San Francisco
1975 B.A. History, Cum Laude - University of San Francisco

Affiliations:
Member of Gerson Lehrman Group�s Councils of Advisors.

Skills:
� Line Management � Successfully managed Claims Department with locations in San Francisco and San Diego, with 159 employees and an annual budget in excess of $6,850,000.
� Project Management � Successfully conceived and implemented contracts to manage disease-specific diagnosis and treatment costs, including pharmaceutical costs. Authored and issued RFPs to contract Medical Transportation, High Risk OB, and Home Nursing vendors. Worked with Finance to analyze medical cost ratios, subsequently issuing Medical Services Agreements to IPAs with Division of Financial Responsibility adequately tied to services. Negotiated and contracted fully capitated agreements for both Primary and Specialty Care.
� Team Leadership � Experienced in building cohesive, self-directed teams; Implemented initiatives which reduced cost per claim by 11%, increased productivity to exceed Turnaround Time benchmarks by 2 days, implemented quality initiatives which increased accuracy of claims processing by an average of 3% Financial and 25% Statistical. Developed and led a team responsible for provider recruitment and contracting for a managed Medi-Cal Health Plan.

Reference:
References Available upon Request

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