Strategy & Operations Analysis and Assessment
- Led product development initiative for national health plan to meet changing market needs and streamline product portfolios with the ability to accelerate development of affordable, consumer-focused products within a six-month timeframe. Utilizing detailed market research, critical product characteristics were determined by market segment creating key product portfolios in markets across the country.
- Oversaw product consolidation strategy for regional Blues plan across multiple state markets to streamline product portfolio as approach for a $31 million migration of healthcare business onto single source-of-truth platforms.
- Advised national behavioral services health plan on $20 million savings opportunity through development of a future state operating model for provider and network operations areas through operational and IT recommendations.
- Engaged by national specialty health service plan to assess provider and network operations areas and determine cost and operations improvement opportunities; led development of transition plan to move network operations from a shared service function to a service line-specific model, including development of a new organizational model, staff and role transition plans, and financial model reflecting impacted costs and savings of transition.
- Advised on care management platform solution decision for national specialty healthcare management organization to support a new line of business for its integrated health population; work included identifying critical business support needs of the solution and assessing capabilities of numerous vendors to support this population.
- Assessed claims accuracy issues for national healthcare insurance provider to determine impact on regional medical economics unit. Results included helping the plan redefine per member per month (PMPM) impact of claims inaccuracies from an original forecast of $0.87 PMPM to $3.39 PMPM.
- Led and defined hospital contract analysis for Medicaid managed care insurer to identify gaps and discrepancies between contracts and claims payment, identifying 2.5% of claims payment “leakage” due to reimbursement inaccuracies. Recommendations on potential corrective actions included reimbursement methodology opportunities, operational streamlining, and vendor management changes. Payment accuracy errors of over $12 million in net overpayments to its participating hospitals were identified.
- Engaged by COO of a large regional Blues plan to assess its Pharmacy Benefits Managers (PBMs) and consumer directed health product operations; developed new organizational structure and operating model to effectively manage product through resolution of existing operational issues and implementation of increased process standardization for new business accounts and carve-out PBMs.
Health Insurance and Information Exchanges
- Stood up three new health insurance organizations in 18 months and began health insurance operations both on and off Exchanges October 2013; worked with organizations on assessing and developing critical capabilities from definition and development of plan designs to implementation of 11 vendors for back office capabilities.
- Engaged with major mid-Atlantic health plan to operationalize its health exchange product portfolio across multiple jurisdictions, including the implementation of plan designs and rates for individual and small group markets across the organization.
System Migration & Implementations
- Oversaw consolidation and migration planning of healthcare business across two state health plans, including consolidation of product portfolio, migration of enrollment and billing data onto a single platform (FACETS), build-out of provider networks, and the conversion of data and business processes onto a single claims platform.
- Planned and developed strategy for $250 million migration effort for national healthcare insurance carrier to migrate customer base of 40,000 groups (National Accounts, middle and small market groups, individual, premium and ASO business) into new operating and technology platforms.
- Developed implementation strategy for second largest deployment of back office technology across North American business units of a $3.2 billion professional services firm. Identified standard process and work for implementation across all units and determined customization requirements and capabilities to meet market-specific customer needs.