Business lead for operational performance stabilization of large co-op health plan
- Led team that assessed current and developed/documented new requirements for end-to-end enrollment, billing & reconciliation functions which included review sessions with client and vendor business/IT teams
- Developed EDI tracking & reporting, at transaction level, for transactions received from state exchange through gateway, core membership and downstream claims systems
- Developed & documented eligibility reconciliation requirements & process syncing exchange eligibility to core membership system and vendor claims systems
- Developed and implemented monthly premium billing requirements and process for all business lines
Vendor selection for gateway services for 230K Medicare plan
- Developed and executed RFP process that evaluated both BPO and SaaS options
- Developed detailed process flows for critical Medicare transactions
- Developed detailed Staffing Model to inform in-house business case evaluation
- Developed Total Cost of Ownership Model to support business case development and final recommendation
Business Lead for Individual and SHOP enterprise wide exchange implementation that included ten jurisdictions. Acted in business lead role from concept to post go-live specific to eligibility, billing and premium reconciliation and collection. Responsible for program implementation team of 80+ including internal PMO, outside consultant resources, internal IT and vendor implementation team. Built new Vendor Management Operation from ground up to support and monitor newly contracted third party BPO vendor.
- Managed RFP, vendor selection and contract negotiation for $100M BPO vendor contract
- Led team that developed new exchange requirements and service model for both individual and SHOP exchanges
- Led team that developed new financial process and controls to support BPO arrangement, including new GL reporting process and SOX controls
- Developed internal vendor operation structure, role descriptions and resource requirements
- Responsible for full exchange system integration nationally
- Led testing prioritization process to ensure successful go-live readiness
- Led large portfolio of change initiatives, many critical to meeting current and future market needs. Responsible for maintaining and enhancing 2 membership systems serving seven of eight regions.
Led program team that implemented Medicare gateway EBR services for large national plan serving over 1 million Medicare beneficiaries. Managed deployment and integration with three regional membership systems. Developed all custom workflows and work queue business process flows
- Responsible for system selection process and implementation
- Responsible for full integration of three membership systems, including configuration of workflows
- Developed all custom workflows, work queues (work baskets) and reporting
- Managed data conversion for three membership systems
- Created Medicare Risk Mitigation Team to apply Active Monitoring and auditing approach to highly manual, complex, and regulated Medicare function. Dramatically improved performance in CMS monitored elements in 12 month period
National Membership Administration shared service leader in eight regions responsible for individual plans, commercial group business, Medicare and Medicaid plans. Responsible for providing access to care to 9.2 million individual and employer group members throughout eight regions.