Recognized throughout my career for being a visionary production leader leveraging in-depth knowledge of the market place and the health care landscape to significantly increase medical savings, quality, and operational efficiency. Solid organizational communication and time management skills. Adept at bridging performance gaps to complete business objectives, developing process improvement initiatives, and conveying complex solutions in a simple compelling manner.
Key Strengths
Systems Transformation Relationship Building Business, process, and execution
Positive “Can Do” Attitude Strategic Thinking Embraces Challenge
Change Leadership Creative Solutions Strategic Operations Management
Customer Service Risk Management Quality Auditing and Assurance
Financial Management Strategic Planning Process Analysis and Improvement
Innovation Organizational Excellence Administrative Cost Reduction
Core Competencies
Results driven with exceptional professional judgment and memory for detail with skills in developing process improvement, risk management, and team management directives.
Strong operational process improvement background through effective cost reduction, tactical planning, and productivity gain.
Expertise in operations management with extensive scope of responsibility and proven track record of delivering optimal results in a high growth environment that exceeds operational goals and yields measurable outcomes.
Known strategist who transforms strategic plans into workable solutions and bench marks for performance against key operational objectives.
Professional Experience
BLUECROSS BLUESHIELD OF NORTH CAROLINA, CHAPEL HILL, NC 2008 – present
Director of Claims Review and Payment Integrity
Leads a professional team delivering a seamless process for the member and provider that results in cost effective clinical determinations supporting member health and contractual obligations. Managed a total of 120 employees.
• Created and implemented High Dollar Review team that resulted in $35 million savings since October 2009.
• Redesigned Quality Audit Team to promote payment integrity which resulted in increased accuracy from 95% to 99%.
• Organized and lead Healthcare Summit with the goal of bringing together all key leadership areas of the enterprise to identify and focus on determinations and impacts to member health. This resulted in consistency in the interpretation of medical policies.
• Consolidated 6 independent budgets into 3 to streamline cost allocation and expenditures resulting in an administrative cost reduction of $ 5 million.
BLUECROSS BLUESHIELD OF NORTH CAROLINA, CHAPEL HILL, NC 2002 – 2008
Director of Care Management
Led a team of clinical and nonclinical staff that performed utilization and case management assuring compliance with regulatory agencies and policies. Responsibilities included direction of Care Management Department which is comprised of the call center, compliance, prospective medical records review, claim medical records review, pharmacy for quantity limitations and prior authorization, episodic case managers, durable medical equipment, skilled nursing facilities, including contract arrangement, vendor oversight, including 150 full-time employees and six direct management reports.
• Three–year phased migration of national accounts onto a local platform: Successful implementation included development of migration framework, member driven problem identification and resolution, and data analysis of group retention rates.
• Prior Plan Approval to Preferred Provider Network: Development of process to shift prior plan approval from the post-service to the pre-service review phase, redesign of end to end process, and development of staff training and change management modules.
• Departmental redesign: Headcount productivity analysis completed to support staff redeployment, implementation of team building and change management curriculum, and process improvement collaboration across all team members.
BLUECROSS BLUESHIELD OF NORTH CAROLINA, CHAPEL HILL, NC 1998-2002
Utilization Manager
Led a team that included multiple levels of clinicians and non-clinicians with a goal of providing pre a...
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