SUMMARY

Effective, articulate leader with extensive executive level experience in administration, negotiation, planning and managing large and mid-size health insurance organizations in the private and public sectors. Senior-level Change Agent with exceptional analytical, interpersonal, communications and crisis management skills. During my Federal career, detailed to Washington headquarters twice to manage major insurance program initiatives due to proven leadership skills. Possess rare experience of managing Medicare and Medicaid programs in Puerto Rico and U.S. Virgin Islands, gaining a unique understanding of their culture, customs and complex relationship with the United States.

EXPERIENCE

Confidential

• Re-tasked regional resources to support implementation of the Affordable Care Act, initially including outreach for the Pre Existing Condition Insurance Program PCIP which increased enrollment by over 30 in the first month of operation.
• Reorganized 10 regional offices into four product line consortia and collaborated with Central Office Leadership to improve program management by: establishing clear program priorities and consistency in administering Part C D contracts centralizing the decision-making process and accountability implementing an objective data driven monitoring and enforcement escalation process and creating standard operating procedures tied to strategic compliance objectives.
• Developed a Compliance Oversight Report that reviews high enrollment insurance contracts based on comparison of 14 key operational metrics versus national benchmarks.
• Established business process infrastructure to ensure all regions meet program objectives, comply with established internal controls and are continually updated to reflect strategic goals.
• Revised customer service strategies including clear timelines for casework resolution, establishing accountability for performance and defining staff and manager responsibilities.
• Reduced customer inquiry casework each year since 2006 by approximately 50 . Current inquiries are at about 22 of initial intake at the start of the Part D program.
• Implemented the first comprehensive, risk-based audit strategy targeting the most vulnerable areas of managed care operations.
• Spearheaded the State Health Insurance Counseling and Assistance Program SHIP pilot project, whereby states were able to record Part C/D related issues into CMS' tracking system to ensure prompt handling and bypassing the need to contact 1-800 MEDICARE.
• Successfully addressed concerns of the Medicare Rights Center MRC relating to beneficiary access to CMS programs by implementing an assessment of a beneficiary's need for a retroactive disenrollment.
• Ensured that lessons learned from experiences dealing with the Southern California wildfires, Midwestern flood, and Gulf Coast hurricanes were incorporated into the Regional Office Continuity of Operations Plans COOP .

Confidential

• Supervised over 300 staff with a primary focus on the implementation and continuing management of the health insurance marketplace.
• Oversaw the initial Federal Facilitated Marketplace/State Partnership Marketplace application process, resulting in 192 issuers with 2,715 Qualified Health Plans QHPs and 119 issuers with 496 Stand Alone Dental Plans SADPs 120 issuers with 1,427 QHPs and 151 issuers with 733 SADPs in the Small Business Health Options Program SHOP .
• Managed the Eligibility team in obtaining a legal opinion permitting SSA to establish a routine use under the Privacy Act for information needed to complete a Marketplace application.
• Developed and implemented a business process flow that does not disclose federal tax information to Marketplace applicants yet allows for income verification processes to occur, satisfying IRS requirements and meeting the Marketplace needs.
• Oversaw major CMS initiatives including the Pre-Existing Insurance Plans, Early Retiree Reinsurance Program, Consumer Operated and Oriented Plans, State Exchange Grants, Consumer Assistance Program Grants, Rate Review Grants and approximately 573 million in discretionary spending Federal Administration and Program Operations . Results include:
• o Executed over 75 contracts and over 17 interagency agreements for approximately 509 million.
• o Awarded 2.2 billion in new grants including: 39 State Exchange Grants, 22 Rate Review Grants, 31 State High Risk Pool Grants, and 103 Navigator Grants.
• Negotiated with Office of General Counsel, trade organizations and other partners on terms and conditions included in the following Health Insurance Marketplace contracts: QHP Agreement, Agent and Broker Agreement, Web Broker Agreement, and Certified Application Counselor Agreements.
• Led the development of the paper application solution to allow employers to apply for SHOP health insurance coverage prior to the on-line application launch.
• Negotiated the roles and workload responsibilities between CCIIO and the Office of Financial Management OFM in order to process Advance Premium Tax Credit APTC and Cost Sharing Reduction CSR payments to issuers.
• Guided the development of Financial Management operating and continuity plans for Advance Premium Tax Credits and Cost Sharing Reductions, advance payment and user fee calculations, banking/payee information, payment aggregation/transmission of amounts to Healthcare Integrated General Ledger Accounting System HIGLAS , and processing payment reports to issuers.
• Developed a streamlined process allowing agents and brokers to operate in the Marketplace, leveraging past experience to identify operational complexities that would have caused market disruptions and participation obstacles for agents and brokers.

Confidential

• Spearheaded an expedited premium withhold resolution process with the Social Security Administration SSA through sequential identification of reject errors.
• Developed a critical systems testing process in conjunction with OIS to gauge the capacity of the 13 systems to handle 17 critical business processes.
• Streamlined the Part C D Audit process increasing health insurance contract audits by 50 while reducing resource utilization by focusing on high risk plans and business functions.
• Developed 80 beneficiary scenarios to identify potential 2007 enrollment issues, facilitate their resolution, and define a communications strategy to help external partners address these concerns.
• Led CBC in joint efforts with OIS and SSA to resolve problems with the premium withhold system impacting over 350,000 beneficiaries.
• Led a CMS task force to coordinate efforts with the SSA to resolve systemic issues identified through beneficiary casework.

Confidential

• Redeployed regional resources to support stakeholder/partner relationship management required for implementation of the Medicare Modernization Act MMA .
• Launched nationwide MMA related employer subsidy outreach program.
• Directed field activities supporting the education campaign to enroll 43 million members in MMA Part D Prescription Drug Benefit.
• Managed Part D related casework for over 30 million members nationally.
• Encouraged State Pharmacy Assistance Programs' participation in outreach and education activities resulting in auto-enrollment of over 150,000 low-income beneficiaries in the drug discount program.
• Identified over 358,000,000 in questionable federal share by aggressively managing the Medicaid financial review program.
• Assisted NYS DOH with the voluntary enrollment of 500,000 dual eligible beneficiaries in Medicare Advantage and Medicaid managed care plans.
• Implemented relationship management initiative with the health care community in the territories by conducting high-level visits to Puerto Rico and the USVI to understand the concerns of government, public and private providers as well as professional associations.

Confidential

• Reorganized Allegiance Health Services, L.L.C. as Interim Chief Executive Officer.
• Analyzed pricing and negotiated fee reductions with network physicians.
• Established physician network credentialing verification procedures.
• Revised Quality Assurance and HCFA compliance program structure and process.
• Developed managed care training programs for pharmaceutical company reps, physicians and practice managers.
• Negotiated contracts between hospitals, physician networks and insurers.
• Lectured on Interactions with Managed Care Organizations at numerous physician and practice manager workshops across the country sponsored by Centocor.
• Coordinated hospital preparations for 911 Receiving Hospital and Specialty Care Referral Center audits.

Confidential

• Led implementation teams for application and installation of Medicare Risk product and Managed Medicaid product resulting in HCFA approval for Medicare Risk and approval from New York State Department of Health and Office of Medicaid Managed Care for Medicaid and Child Health Plus.
• Created start-up Medicare/Medicaid HMO with dedicated Medical Management, Member Services and Sales Departments. Achieved ranking as second fastest growing Medicare HMO in the market within the first six months of operations.
• Created product specific hospital and physician networks for Medicare and Medicaid.
• Initiated Medical Action Plans and Member Service Retention Programs designed to deliver a Medical Care Ratio 88 . Implemented fee schedule reductions, expanded contracting efforts and initiated vertical and horizontal capitation arrangements.

Confidential

• Developed and implemented a Medical Action Plan focused on decreasing hospital days/1,000, admits/1,000, average length of stay and cost per day, which reduced days/1,000 by 13 and medical loss ratio by 6 resulting in a 10 million dollar profit, as opposed to a forecasted 6 million loss.
• Re-engineered fee negotiation process on high dollar out-of-network services, avoiding costs of 1.1 million.
• Directed Medicaid implementation efforts for Suffolk, Richmond and Nassau Counties eliminating the 9 hospital surcharge, avoiding more than 2 million in charges.
• Transitioned physician fee schedule to RBRVS, shrinking the number of fee schedule areas by 60 and reducing costs by 15 .
• Managed the integration of the MetLife and Travelers physicians, hospital, allied and ancillary networks in New York, New Jersey and Fairfield County, Connecticut.
• Redesigned the integrated MetraHealth delivery system, creating hospital-based physician networks supporting various HMO, POS and PPO products.
• Identified opportunities and initiated capitation contracts designed to achieve unit cost reductions in chiropractic, podiatry, laboratory and mental health of more than 6 per member per month.

Confidential

• Reorganized group account services department, achieving a renewal retention rate of greater than 90 .
• Streamlined claims payment procedures, reducing payment lag from 21 to 7 days and slashing complaints by 25 .
• Revised administrative systems workflow resulting in reduction of the dollar value of claims suspended for more than 30 days by 1,000,000.
• Reorganized Customer Relations resulting in a reduction of the abandoned call rate from 40 to 5 .
• Initiated coordination of benefits protocol, which reduced claims payments by 1,000,000 annually.

Confidential

• Created senior level administrative positions to decentralize responsibility while maintaining accountability for operations and performance against budget.
• Developed and completely revised the City's Emergency Medical Action Plan, elements of which are still in use today by FDNY's EMS Bureau.
• Maximized productivity resulting in a 50 reduction in ambulance response time to life-threatening emergencies while demand increased by more than 40 .
• Established EMS Emergency Manager position to facilitate communication and coordination with other response agencies and the Mayor's Office of Emergency Management.
• Successfully negotiated a rule making process with the GNYHA ambulance committee to unify command and control of all ambulances dispatched by EMS.
• Implemented a 750,000 computer conversion of the 911 ambulance dispatch system, initiating a computer link between the EMS Dispatch Center and the Police Department's SPRINT computer system which improved call intake and dispatch effectiveness.
• Developed and implemented Standard Operating Procedures governing designation of Specialty Care Referral/Trauma Centers and transport of patients to such centers.
• Designed, purchased and installed a 500,000 advanced life support Telemetry Coordination Center, staffed by physicians, to enhance medical control and improve paramedic communications and coordination capabilities.
• Expanded 911ambulance call receiving intake capabilities by 50 percent, resulting in 95 percent of calls answered within 30 seconds.
• Installed a billing system for patients taken to voluntary hospitals which increased ambulance revenue by over 5 million per year.
• Introduced most stringent infectious disease protocols in the country, used on more than 2,000 EMS responses per day.
• Expanded training programs and facilities by 500 percent over a 3 year period.
• Constructed rigorous pre-hospital care contracts establishing increased accountability for participation in the 911 EMS Systems for 1 million voluntary hospital ambulance contract services and volunteer ambulance corps.