SUMMARY

• me has 20+ years’ experience in pharmacy benefits project management, claims auditing and strategic client services. me has personally spearheaded billions in new client implementations, business process improvement and product development projects for major healthcare firms like CVS Health, Confidential, Catamaran/OptumRx, Anthem BCBS (nationwide), Harvard Pilgrim Healthcare, and various other Commercial Health Plans, Employer Groups, Medicare and State Medicaid Health Systems.
• me is an expert in point - of-sale pharmacy claim adjudications systems, including RxClaim and other PBM proprietary systems, including both Medi-Span and FDB-based systems. me know their strengths and weaknesses. me has led various corporate-wide, internal, client and third party matrix teams to unprecedented success by building trust through integrity and delivery. me understand how to conceive, adopt and successfully execute a healthcare-focused technology project from conception through Go Live.
• me is presently looking for an opportunity wif an organization seeking to recruit top talent to articulate itself to teh head of its competition. me look forward to discussing how me may halp you meet and exceed you're strategic goals and objectives.

PROFESSIONAL EXPERIENCE

Implementation Project Manager & Private Consultant

Confidential

Responsibilities:

• Helped CVS Health achieve most successful Welcome Season to date, implementing over $7B in new business, 6M members, processing over 9.3M claims on 1/1/2017.
• Claims auditing, contracting and infrastructure solutions for health plans, TPAs, hospital systems and self-funded employer groups.
• Partnering wif primary internal groups such as Sales, Clinical, Eligibility, Quality Assurance, Benefits and Account Management to gather, develop, implement and audit client pharmacy benefit requirements.
• Partnering wif TPAs, brokers and consultants to onboard new client business, including HRA, HSA/HDHP, traditional and government sponsored health plans.
• Developing and managing multiple, simultaneous implementation project plans, tracking progress using integrated task tracking apps and tools (MS Project, IPI-Pega, Salesforce.com).
• Leading weekly internal functional area and client/broker/consultant status calls.
• Tracking and driving client and internal action log items, ensuring timely and accurate delivery of client requirements, escalating plan-mitigating build, test and deployment issues wif senior leadership where necessary.
• Developing and instituting risk mitigation plans and strategies.
• Establishing financial protocols, billing and reporting systems, third-party claims extract feeds, medical data integrations, broker fee schedules, formulary, rebate and network pricing.
• Mentoring junior colleagues throughout teh implementation and project management process.
• Ensuring on-time, on-budget delivery of client requirements wif limited client and member disruption.

Regional Director of Account Management

Confidential, CA

Responsibilities:

• Managed $2B book of business, achieving record growth in 2007 (43% over plan).
• C-suite client management for health plans such as Harvard Pilgrim HealthCare (MA), MDNY Healthcare (NY), Network Health (MA), Citrus Healthcare (FL), Preferred Medical Plan (FL), First Carolina Care (NC), BCBS (SC).
• $500MM+ product upsells and contract renewals secured.
• Hiring/firing, mentoring, performance evaluations/merit increases for Account Executives.
• Matrix-team leadership for IS/IT/EDI Administrators, Business Analysts, Programmers, Clinicians, Medical Directors, Client Services, Provider Networks, Customer Care.
• Owner of teh product/service team, chief presenter in best & final presentations.
• Streamlined corporate communications, RFI/RFP responses and processes.
• State and federal regulatory compliance (me.e. ERISA, HIPAA, Medicare Part D, SOX), quality assurance (NCQA, HEDIS) oversight.

Account Executive

Confidential

Responsibilities:

• Led corporate-wide BPR, transforming teh sub-tier PBM into a top-tier player, winning teh Kaiser Permanente bid and resulting in record growth (196%, $92.7MM in revenue).
• Client executive-level management (Director-to-C-suite)
• Maintaining SLAs, negotiating service contracts and renewals, introducing new products and services.
• Client-base included John Deere (IL), Rocky Mountain Health (CO), Nebco (NJ), HydeRx (CO), Duane Reade Pharmacies (NY).
• Orchestrated new business implementations for more TEMPthan 80 pharmacy benefit programs through TPAs and self-funded employer groups, including CoreSource, Aon Hewitt, Toyota and Ford Motor Corp, utilizing both teh ReCAP and RxClaim systems.
• Developed and managed multiple, simultaneous implementation project plans, tracked progress relative to those plans, maintained action logs and related Salesforce.com cases.
• Led weekly internal functional area and client/broker/consultant status calls.
• Developed and instituted risk mitigation plans and strategies.
• Established financial protocols, billing and reporting systems, including third-party claims extract feeds, broker fee schedules, formulary, rebate and network pricing.
• Mentored junior colleagues throughout teh implementation process.

Manager of Account Management

Confidential

Responsibilities:

• Director-to-C-level client relationship and contract management for Blue Cross of CA, BCBS GA, BCBS WI, Blue Cross of ID, Cigna, Humana, Aetna.
• Hiring/firing, mentoring, performance evaluations/merit increases for Client Managers and Client Partners.
• Matrix-team leadership for IS/IT/EDI Administrators, Business Analysts, Programmers, Clinicians, Medical Directors, Client Services, Provider Networks, Customer Care.
• Project Director (2000 - 2002), PrecisionRx mail service pharmacy integration team, successfully reversed $MM losses to exponential $MM monthly revenue gains in just six months, while rescuing Blue Cross of California’s mail pharmacy fulfillment program.
• Account Manager (2000 - 2000), spearheaded teh “small business” product development program, an expansive BPR, transforming teh Blues-oriented PBM into an attractive choice for TPA’s and self-funded employer groups, paving teh way for record growth.
• Senior Client Partner (1998-1999), initiated “client cooperative business planning” as a collaborative client/PBM pro-growth initiative, yielding record business growth and revenue gains for both WellPoint and Blue Cross of Idaho.
• Client Partner (1997), successfully led teh Blue Cross of Idaho new business implementation project team to teh most successful Go Live experience in WellPoint’s history.
• Developed streamlined project plans and implementation/integrations systems utilizing Microsoft Project and Excel, tracking task completion, managing multi-departmental issue/problem resolution and risk mitigation, interfacing wif C-Suite/Executive “Team Lead” business owners.
• Participated in best & final presentations wif SVP of Sales.
• Oversight of State and federal regulatory compliance (me.e. ERISA, HIPAA, Medicare Part D, SOX) and quality assurance (NCQA, HEDIS).

TECHNICAL SKILLS

• $100MM+ Contract Negotiations, Fortune 500 C-level Management, Matrix Team Leader (>50 people)
• ROI, Predictive Modeling, Business Planning, Metrics, Analytics, Forecasting, Risk Mitigation
• Claims Auditing, Benefit Design Implementations, Pharmaceutical Rebates, Pharmacy Networks
• Enterprise Project Management/Implementations, M&A, BPR, Kaizen, Lean Six Sigma, Agile, Waterfall
• Commercial Health Systems, BCBS, Medicare/Medicaid, Pharmacy Benefits Management
• 340B, Fixed-Fee Drug Reimbursement, Government Regulatory Compliance (ERISA, HIPAA, SOX, PCI)
• Self-funded Employer Groups, TPAs, Brokerages
• Claims Adjudication Systems, (RxClaim, Recap, SXC, TechRx, etc.)
• Patient Health Management Systems (Facets, PeopleSafe, ReViewPoint, etc.)
• EDI, SaaS, PaaS, QAT, UI/UX
• Call Center Development/Management, KPIs, SLAs
• Retail/Mail POS Fulfillment Operations, Inventory Control, Quality Assurance
• Advanced MS Office (Project & Access), Adobe Creative Suite, WordPress, Website Building Tools
• Salesforce.com, IPI - Pega Integrated Project Management App, Pega TableauVirtual Office, Cisco, Citrix, Level 3, WebEx, GoToMeeting