Operational Transformation, Oversight and Management
- Currently supporting Federal Employee Program (FEP) Director’s Office with management of end-to-end sourcing and implementation of a new healthcare informatics solution. This program is a large endeavor that involves multiple vendors and resulted in the implementation of several new applications for end users. Activities include:
- Essential program management tasks to ensure high-quality project delivery within approved scopes, timelines and budgets
- Managing and integrating of inputs from various vendor partners
- Managing team that oversees technical architecture, security, and development of related solutions
- Providing ad hoc support to program executives to build support for the program and engage critical stakeholders and user groups
- Managed the assessment of business operations and processes for a multistate home health company across its four constituent subsidiaries and provided recommendations for operational improvement initiatives to current state as well as a future state model and a phased plan for implementation . The assessment included review of core operations (including new member enrollment and scheduling), clinical operations, compliance, internal audit, finance (including billing and collections for services provided) and human resources and business development functions.
- Conducted the review of provider contracts including the evaluation of contract structure and reimbursement terms, analysis of payment term configuration in relevant systems, identification of root cause for issues identified and mapping to internal processes. Provided oversight of claims accuracy analysis identifying numerous claims adjudication concerns.
- Served as the Project Manager of a 12-week engagement and 7 person team assembled to assist a health plan complete the review of 1,500 institutional, ancillary and physician provider contracts. The team populated contract templates in order to facilitate the timely implementation of a new TPA relationship. The project included the following:
- Creation of customized templates for each provider category
- Design of a three-tiered quality assurance process to provide opportunity for all parties to execute detailed quality reviews of data elements critical to each stage of template development
- Facilitated in-person meetings, as required, to review specific complex contracts and provider relationships
- Designed a template-indexing format that supports sorting by provider type, contract terms and parent/child relationships
- Completed an operational assessment of the Overseas Claims Process for a Federal program including analysis of the end-to-end claims process including the mailroom, data entry, translation, coding and claims adjudication, technology & EDI, testing, payments, fraud, waste & abuse, and customer service. Also performed an assessment of processes in these areas resulting in a detailed report outlining findings and related opportunities. Knowledge gained during the operational assessment was utilized to propose future state solutions to concerns previously identified and make near term implementation recommendations.
- Directed the Overseas Claims new vendor identification effort for a Federal program including the identification of potential vendors and development of a Request for Proposal (RFP) valued at over $45M. The vendor identification process included market research to identify vendors operating on the global stage and vetting potential vendors to determine those capable of meeting the program’s needs. Development of the RFP included creation of the proposal timeline, identification of internal stakeholders, gathering of client business requirements, RFP document development, RFP issuance and RFP response evaluation and scoring. Also directed site visits, post-site visit RPF re-evaluation and final scoring calculations. The process resulted in the provision of a final vendor recommendation that was accepted by the client.
- Supported the Federal Employee Program (FEP) Director’s Office with planning and project management during the pre-implementation phase a new healthcare analytics solution. The project included the identification and coordination of multiple vendors and internal and external stakeholders. Managed a team that oversaw technical architecture, security, and development of the proposed solution.
- Oversight of the Revenue Cycle component of the merger of three health systems with over $1.8B in annual revenues. Key responsibilities included:
- Assisting with the establishment of ‘Day 1’ and short-term stability plans
- Development of the ‘end-state’ operating model to ensure coordination across organizations of the future state revenue cycle design
- Integration planning to enable planned migration from the current state to the Day 1 operating model to the future state operating model, synergy analysis and validation to identify and quantify net revenue improvements, cost improvements and cash acceleration opportunities
- Participated in the development of a comprehensive corporate compliance program for a large health system operating a hospital, skilled nursing facility (SNF), physician practice groups, home health agency and various other entities.
- Worked with the Department of Corporations of the State of California to assist in the oversight, monitoring and liquidation of a large physician practice management company having annual revenues in excess of $1.3B and serving over 1.2 million members.
- Served the Superior Court of Orange County, California as Conservator of an HMO located in Irvine, CA. Responsibilities included oversight of all aspects of the organization’s operations including, among others, all financial operations liquidation of assets, negotiations regarding the settlement of debts and human resource issues.
- Performed various roles in numerous litigation matters assisting small (less than $500,000 annual revenues) and large (multibillion) public and private organizations.
- Managed a document review and warehousing process for a litigation matter that resulted in groundbreaking settlement, over $200 billion.
- Increased client sales from a $35,000 one-time event to an annual revenue stream of over $300,000.
- Responsible for the success of commercial client accounts to include business development, the effective management of multi-faceted projects, development of intellectual capital and the mentoring and professional development of staff.
- Responsible for evaluating financial, operational, reporting, technical accounting, compliance and disclosure issues. Including internal control weaknesses and review of organizational processes.
- Performed due diligence for a large (Fortune 500) commercial lender to assist them in evaluating the performance of various entities on a pre and post-lending basis.
- Served as CFO of a behavioral health company and was responsible for overall financial operations including monthly financial statement development, new program costing and development, review, revision and implementation of processes, procedures and internal controls, billing and collection activities, expense monitoring and annual operating and capital budget development.
- Reduction of Unapproved Services by 31% within first 30 days.
- Creation and implementation of a plan to identify and collect approximately $900,000 of unbilled claims.
- Reduced unbilled accounts by $2,000,000 over a two-month period.
- Directed activities for general accounting, patient accounting, payroll, accounts payable, admissions and medical records areas including supervision, training and evaluation of personnel and assessment of internal controls, policies and procedures.
- Prepared monthly organizational and departmental expenditure, variance, FTE and statistical reporting.
- Developed statistical reports and analysis to be distributed to management via an online executive reporting tool and a comprehensive financial model that was used to project the organization’s monthly and year end revenues, expenses and profitability.
- Review of physician compensation allocation, including draw timelines and revenue generation.
- Reduced consultant utilization by over $350,000 per month.
- Maintained financial responsibility for a three-facility system operating 550 inpatient beds, an Urgent Care Center and an ASC and participated in the planning and implementation of financial and operational initiatives focused on turning around the financial performance of these facilities.
- Prepared annual cost reports for Maryland, Virginia and the District of Columbia, performed financial statement trend analysis, prepared and reviewed Blue Cross/Blue Shield reasonable rate factor calculations, and calculated and analyzed interim and annual statistical performance indicators.
Planning and Cost Control
- Prepared the $260 million annual operating budget with appropriate procedures and controls surrounding the organization’s spending including conducting analyses and financial modeling for current and proposed new product lines with a focus on resource planning, feasibility and profitability.
- Served as the Finance lead in the successful negotiation of two multi-year union contracts with total membership of 1,400 employees.
- Participated on multi-disciplinary committee responsible for organization wide program and operations review. Committee submitted recommendations detailing over $15 million in cost savings and options for the restructuring of numerous programs and operations to executive management.
- Designed and implemented an online executive reporting tool.
- Established procedures to utilize budgeted FTEs to drive Human Resources’ hiring practices.
- Implemented an electronic purchase requisition approval process.
- Responsible for providing high-level financial, operational and administrative analysis and support to the Chief Executive Officer, Chief Financial Officer and Board of Directors.
- Provided operational oversight and maintenance of $93 million DC Healthcare Alliance contract with the District of Columbia Department of Health (DOH), including claims adjudication, annual reconciliations and statistical reporting.
- Served as the liaison between the hospital system and DOH.
- Initiated process for a multidisciplinary team to review the revenue cycle.
- Orchestrated outsourcing of all back-end business office operations.
Healthcare Economic Strategies
- Responsible for supporting and collaborating with over 170 Spinal, Kyphoplasty and Neurostimulation product and corporate sales representatives located from Eastern Pennsylvania/Central New Jersey through South Carolina to strategically determine services required in designated geographies and responsible for driving those strategies.
- Actively supported and developed regional physician and hospital relationships by identifying economic issues and reimbursement support needs, conducting assessments, presenting findings and recommendations and addressing pressing needs.
- Assisted in the development of strategic and tactical plans to help facilitate solutions that supported economic improvements and assured spine surgery was a viable treatment option for patients.
- Provided account management for designated customers and insured initiatives and updates were communicated to all key parties. Responsible for insuring that clear messages were disseminated to sales on payer trends, reimbursement changes, and billing and documentation requirements.
- Successfully developed a practical knowledge of spinal and biologics procedures, coding and reimbursement.
- Performed numerous hospital and physician practice assessments resulting in coding, documentation, and operational improvements totaling millions of dollars.
- Participated on a committee to develop care pathways for the Kyphoplasty procedure.
A Practical Guide to National Hospital Fraud Investigations, May 1999. Chapter 400: “The Three-Day Rule for Outpatient Services.”