Ithaca College

Seeking Independent Consulting, business analytics, process improvement, change management, or operational implementation (Remote preferred)

Tucson, Arizona, United States

Collaboration with Claims Director in development of the vision and goals at a new claims operation for a an emerging TPA. Writing and developing Policies & Procedures and Process flow documentation for claims payment and other support services. Coordinating and Planning testing for new system configuration. Implementing a SharePoint site as a central repository for current operational materials.

Mirra Health Care – Tampa, FL (Remote)

Independent Consultant - Processes Improvement

Consulting role with Wisconsin Physician Services (WPS) TriCare Claims - Remote•	WPS is contracted with TriWest for TriCare Claims Processing. TriCare serves the Military, families         and military retirees.  It is a super hybrid of Medicare, VA & Commercial claims payment.  •	Provided Director level input on resolution of various client related claims processing issues.•	Issues ranged from researching correct pricing criteria to root cause analysis of system or         processor errors.•	Provided overview an analysis of new CMS initiatives and issues impacting pricing.•	Four-month engagement was halted after WPS lost TriWest contract.

The Jacobson Group

Consultant – Process Improvement & Client Issue Resolution - Remote

Management of Banner University Health Plan Claims Department. Department included three lines of business for Arizona Medicaid and Medicare. 220,000 covered lives.Managed daily claims payment operations for over one hundred staff three Managers and five Supervisors. Oversight of two major subcontractors for Remote Claims Payment and Mailroom Operations. Collaborated across multiple departments to onboard remaining providers for the Medicaid contract implementation. Addressed extensive provider payment issues and expedited payment of providers who were waiting for onboarding. Maintained overall claims compliance metrics.

Banner Health

Sr. Director Claims Operations

Daily responsibility for Claims & Customer Service Operations. Supervised sixteen management staff and one hundred twenty-eight regular staff.  Responsibilities also included budget and manpower management.Resolved claims operational backlog exceeding 45 days and an adjustment backlog exceeding 120 days in six months. Maintained compliance standards for the last 2.5 years.Led process improvement projects reducing interest payments from millions to negligible amounts. Improved Examiner and Customer Service Quality metrics to above compliance standards.Served on a management team conducting due diligence and evaluating the impact on assumption ofresponsibility of Autistic children from Medi-Cal. Review and evaluate impact to Department on internalization of Behavioral Health Claims and removal of Vendor.Key stakeholder in review and selection of Claims Payment System replacement, and for Customer Service evaluation of new phone and call handling applications.Developed and implemented a SharePoint Claims Landing Page and Dashboard for accurate research and rapid look-up of key information by production staff.Reorganized mailroom operations adding document folding and postage automation. Upgraded scanners and scanning technology to improve document throughput and catch up a 2-million-page backlog of scannable materials.

Partnership HealthPlan of California

Director of Claims and Customer Service

Collaboration with Account Manager in proposing new technologies for cost containment and operational improvement of Medi-Cal Services. Full P&L responsibility for department.  Required client presentations, identification of internal and external stakeholders, development of technical proposal, pricing and implementation planning across multiple departments and systems. Projects included smart-card for Medicaid Beneficiary ID cards, iPhone/iPad applications for medical records and several wellness applications.Partnered with the Xerox Palo Alto Research Center (PARC) to develop a fraud detection tool which is now being deployed in several Xerox operations and has identified over $20 million in fraud savings for Medi-Cal.Directed cost saving processes including: 45% reduction in department overhead by eliminating a substandard subcontractor; elimination of an ineffective software tool saving $3 million; recaptured $1.5 million by implementing a hospital credit balance recovery project.Led Fraud Team identifying and recovering $2 million within the CA Medicaid program.

Xerox State Healthcare, LLC

Director, Program Integrity, Fraud & Abuse

11/2011-3/2012Established and organized transition team for CAMMIS DDI claims program. Developed change management vision and transition approach to meet contract requirements, revised personnel plan, and hired team to function concurrently with the DDI effort.

Operations Transition Team Manager Health Enterprise

Project Management of Operational Readiness Testing (ORT) for assumption of Medi-Cal Fiscal Intermediary operations: created procedural documentation for conducting ORT; successfully tested over 125 business area functions.Completion of the Operational Readiness Testing was one of the key factors in determining readiness for Assumption of Operations.

Affiliated Computer Services

Operations Manager - Xerox / ACS Medi-Cal Business Partnership

Project Manager for five implementation areas, Claims, Mail-room, integrated Letter Management, workflow Process manager, and Report Manager.  Unisys, now Molina implemented a new MMIS fiscal agent operation for Idaho Medicaid. This was a ground-up implementation and integration of multiple systems.Successfully project managed implementation of the Letter Manager technical team. Within 12 months team developed over 200 fully automated letters interacting with multiple systems and based on client specificationsProcess Manager workflow, distribution of all incoming correspondence, and follow-up activities to the appropriate state and operations departments for handling and management  This included developing specifications for the workflow tool itself and implementation of a secure Right Fax link for routing incoming documents.  Key element of success was assisting the stakeholders with their transition from a manual paper based system to an image based automated system.  Identifying additional client needs, and writing modification change orders to the workflow process was key strategy for success.Report Manager, this platform was responsible for directing all reports and letters to their appropriate locations within the Medicaid system.  User subscribed reports of all types directed to clients and staff, Remittance Advice and correspondence all sent to web portal or print vendor.Hired Claims and Mail-room Supervisors to implement end to end claims operations including mail receipt scanning data entry and claims adjudication.  Daily management of supervisory staff and claims configuration staff assigned to the implementation effort.  Coordinated hiring and training of 29 claims processors and mail-room staffI maintained the project plans for all five teams and routine reporting of progress.  This position required active involvement with all key personnel on the project both client and internal stakeholders.

Unisys Health Information Management  (Acquired by Molina)

Manager Claims & Electronic Data Management Systems

CMS Demonstration Project-Recovery Audit ContractorManaged all operational aspects of Medicare recovery audits conducted under the Medicare Recovery Audit Contractor (RAC) demonstration project. Direct management of 25 nurse auditors, daily assignments and production goals. Improved audit production by 18% through process improvements.Department budget and manpower responsibility.  Management of support services including Customer Service Call Center, QA, Appeals Document Preparation, Mail-room and Imaging.Senior participant in proposal development for national RAC implementation.

PRG Schultz International

Director of Operations Medicare Recovery Audit Contract (RAC)

Took over final phases of the MMIS (State Medicaid) system implementation was audited by CMS and achieved certification with no deficiencies.Base responsibilities included Claims, Provider Enrollment, Customer Service, QA, Adjustments, Appeals, all Mail-room and Data Entry functions.  Full P&L responsibility for account performance.Additional responsibilities included management oversight of Pharmacy Benefit Management & Health Care Management operations tied to Nevada Contract.In August 2004 the program had received $250,000 penalties for contract non-compliance when I took over as director. Within three months we eliminated all operational penalties.The MMIS program was streamlined in 2005 by cutting manpower expenditures by 30% and expenses by 15%.Achieved a 2006 program expansion of $1 million to include Behavioral Health Utilization Review. Implemented cost reductions of an additional $1 million in 2006 budget.

First Health Services (Acquired by Coventry)

Director Operations & Account Management - Nevada Medicaid

Provided process improvement consulting for WellCare's Florida MCO's and was part of the transition team as Claims Manager for WellCare's acquisition of Harmony Health Care; Illinois and Indiana MCO's

WellCare Health Plans

Process Improvement Consultant/Claims Manager

Developed contract language and service levels for primary subcontractors. Served on Enterprise Alliance Committee representing Claims Operations in build/buy and sub-contractor assessments. Established account management operational and relationship parameters for Sierra's primary subcontractors.Coordinated with Information Systems resources providing operational support for claims system conversion.

Sierra Military Health Services

Project Director – Interim Consultant

UniCare a Division of WellPoint a national health insurance providerManage daily operation of UniCare's claims processing, customer, and client services center.Responsible for State of Illinois ASO accounts. The account serviced 250,000 covered lives in five Illinois funded plans.  Responsible for budget and manpower performance of account.Improved client relations by developing and implementing an operational improvement programs that resulted in the client forgiving over $1 million in performance penalties.Improved the customer service, training/hiring program that elevated the performance and quality of the customer service associates, reducing the response time by 50%, and saving over $100,000 in quarterly performance penalties.Created and facilitated the implementation of an Intranet work-site that captured the plan and policy documents and all updates on a daily basis, ensuring that all claims were processed utilizing the most current guidelines.Developed an Intranet metrics reporting tool which gave each Associate a weekly performance Report Card

Warren Ingalls

Warren Ingalls