Managed Care Contracting - Healthcare Resume Search
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Managed Care Contracting Resume


Desired Industry: Healthcare SpiderID: 69259
Desired Job Location: Woodland Hills, California Date Posted: 7/4/2013
Type of Position: Full-Time Permanent Availability Date: 8/2013
Desired Wage: 100,000
U.S. Work Authorization: Yes
Job Level: Management (Manager, Director) Willing to Travel: Yes, 25-50%
Highest Degree Attained: High School/Equivalent Willing to Relocate: No Preference


Experience:
CHILDREN’S HOSPITAL LOS ANGELES (CHLA) May
2011- Current
Manager of Contracting
(August 2011– Current)
Responsible for negotiation and administration of
Commercial, Medi-Cal and Vision Managed Care
contracts, including Delegated Medical Group and
Capitated Hospital contracts. Coordination and
contract negotiation with out of area hospitals and
health plans in transferring patients to and from
CHLA. Additional responsibilities include staff
management, day-to-day department operations.
Collaborating with Patient Financial Services,
Admitting and other internal hospital departments
to streamline operational processes. Support
hospital staff during governmental agency audits.

Highlighted accomplishments include:
• Negotiate carve outs (implants/prosthetics and
high cost pharmaceuticals) for Commercial and
Medi-Cal payors.
• Negotiate double digit increases for multi-year
contracts.
• Manage staff, which includes negotiation
oversight, priority setting and special projects
• Negotiate one time Letter of Agreements for
out-of-state, non-contracted payors with rates that
are within Managed Care rate parameters.
• Serve as a “Payor Relations Specialist” with
Commercial and Medi-Cal Payors. Scheduling in-
services and meetings to better improve
relationships and operations between both entities.
• Work closely with Associate Vice President and
internal departments to solve high priority, complex
issues including collecting >$3M open accounts
receivables (“AR”), reducing AR days and
streamlining registration coordination with health
plans and other payors.

Senior Contract Specialist, Managed Care
(May 2011 – August 2011)
Responsible for negotiation and administration of
Medi-Cal Managed Care contracts. Additional
responsibilities include day-to-day department
operations collaborating with Patient Financial
Services, Admitting and other internal hospital
departments to streamline operational processes.

Highlighted accomplishments include:
• Negotiate one time Letter of Agreements for
out of state of non-contracted payors with rates
that are within Managed Care rate parameters.
• Serve as a “Payor Relations Specialist” with
Managed Care and Medi-Cal Managed Care Payors.
Scheduling in-services and meetings to better
improve relationship and operations between both
entities.

ANTHEM BLUE CROSS/ANTHEM WORKERS’
COMPENSATION January 2005 – November
2010
Senior Contract Manager
Responsible for negotiation and administration of
workers’ compensation contracts for entire
California network. Oversaw provider contract
negotiation and implementation of workers’
compensation for Colorado and Nevada. Additional
responsibilities include day-to-day operational
problem solving with internal departments
including network management, bill review,
customer service, account management, MPN
Services, product development,
complaints/grievances, and provider database
operations for workers’ compensation network. SME
for provider operations manual updates, quarterly
provider newsletters, client RFP response and client
audits.

Highlighted accomplishments include:

• Contracting point-person for Nevada and
Colorado workers’ compensation product
implementation
• Renegotiated ~700 frontline medical groups
and ~2,000 provider contracts for an aggregate
savings of ~12% below the California Official
Medical Fee Schedule (OMFS) over a five (5) year
time period
• Led the creation of an exclusive workers’
compensation network for non-commercial network
providers
• Led the clean up of workers’ compensation
network with the removal of 12,000 providers that
do not treat workers’ compensation.
CATHOLIC HEALTHCARE WEST October 2002 –
January 2005
Manager, Managed Care
Responsible for the negotiation and administration
of 30 managed care contracts for CHW’s Ventura
Region (St. John’s Regional Medical Center and St.
John’s Pleasant Valley Hospital). Additional
responsibilities included maintenance and
development of positive internal and external
relationships, troubleshoot complex contractual
issues, and manage staff.

• Designated point-person for multiple regional
initiatives and business development negotiations.
Highlights include:
o Converted large payer contract from per diem
to percent of billed changes reimbursement,
increasing expected revenue by over 25%.
o Negotiated bariatric rates 50% greater than
goal for 4 So. Cal. CHW hospitals. Selected as state-
wide bariatric contracting specialist.
o Lead negotiator for out-patient surgery center
joint venture with anticipated revenues in excess of
$2.5 million dollars annually.
o Facilitated the completion of RFIs resulting in
center of excellence designation for CABG services
and Bariatric services (pending).
• Negotiated contractual payment recoveries in
excess of $1 million over two years. Highlights
include:
o Facilitation of St. John’s and Health Net
discussion for CHAMPUS underpayments, resulting
in recoveries of over $225,000.
o Identified and recovered over $325,000 from
various health plans due to billing errors slated for
write-off.

PACIFICARE OF CALIFORNIA October 2000 –
October 2002
Program Manager, Provider Focus
Act as a liaison between Pacificare of California and
seventy-seven (77) Los Angeles area provider
groups for the evaluation, implementation and
development of disease management and
healthcare quality programs.

• Improved enrollment in the Congestive Heart
Failure Program by over 40% by encouraging
members who had declined the benefit to enroll.
• Met all enrollment targets for the Congestive
Heart Failure, Coronary Artery Disease, End Stage
Renal Disease and Chronic Obstructive Pulmonary
Disease programs for assigned groups.

BLUE SHIELD OF CALIFORNIA/CAREAMERICA
HEALTHPLAN October 1996 – October 2000
Senior Provider Relations Coordinator/Contract
Manager (November 1998 – October 2000)
Responsible for the day-to-day contracting and
operational issues for ancillary/tertiary providers,
medical groups and hospitals for over 80,000
commercial and Medicare assigned members.

• Negotiated ancillary provider contracts
including vision, home health, ambulance, dialysis,
and SNF, including:
o A 3 year, fixed-rate capitated contract with
Blue Shield’s Vision services provider.
o Identified, contracted and credentialed 5 home
health agencies providing complete coverage for
the California network, within 3 months.
o A 68% reduction in capitation for the Medicare
transportation vendor between 1999 and 2000.
o Negotiated 30% to 40% billed charges rate
contracts with providers.
• Assisted in coordinating the Year 2000 HCFA
audit as Provider Relation’s liaison to the Regulatory
Affairs department and coordinated the completion
of information requests in compliance with HCFA
guidelines.

Provider Relations Coordinator (December 1997 –
November 1998)
Responsible for the day-to-day operational issues
for medical groups and hospitals with over 40,000
commercial and Medicare members. Additional
duties included network analysis, ad hoc projects,
and provider contracting.

• Successfully negotiated 30% to 40% discount
of billed charges contracts with non-participating
providers.

Credentialing Assistant (October 1996 –
December 1997)
Managed provider network information databases
and monitored network compliance.




Education:
Health Administration: California State University –
Northridge (Los Angeles), 1994-1997


Reference:
Available upon request.


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