Johns Hopkins Bloomberg School of Public Health

Pitzer College

✏️ Building blueprints for transformational health service delivery

Statewide lead for CalAIM Population Needs Assessment & Population Health Strategy for Kaiser Permanente's expansion to 32 counties across California. Collaborate with Local Health Departments, other managed care plans and local stakeholders in 32 counties on Community Health Assessment and Improvement Planning processes. Advise and execute on implementation of Population Health program for Medi-Cal CalAIM contract.

Kaiser Permanente

Population Health Management Consultant

I have spent my 30-year career in organizations dedicated to serving the most vulnerable populations, especially Medicare, Medicaid, and individual exchanges. My sweet spot is designing and executing products and programs that delight members and providers, deliver quality and compliance metrics, and meet strategic objectives. I have decades of experience building collaborative partnerships, high performing teams, operating structures and technologies backed by strong analytical, forecasting and actuarial models. I understand how all the components of a process fit together and use a positive leadership style and collaborative “people first” mindset to support patient and provider needs within a culture of community, empathy and integrity. 

Throughout my career, I have been involved in many “firsts” for the Medicare business: the first national PPO Medicare Advantage plans, the first rollout of virtual visits for the Medicare population, the first house calls visits programs, the first population health and member rewards initiatives, artificial intelligence customer service platform, and many more. There is still so much opportunity for improvement in how we deliver care, and I would love to partner with organizations that are laser-focused on driving the transformation needed to heal our healthcare system.

Shanofsky Consulting

Principal

Led team of 320 FTE and BPO staff across three continents with responsibility for $30m/year spend on core service operations. Accountable for multi-channel member engagement and outreach, member and provider call centers, enrollment, billing, claims, grievances & appeals, CAHPS and HOS, and ensuring that all operations are in compliance with CMS and SOX guidelines.

Clover Health

Vice President, Plan Operations

Accountable for end-to-end operations for the West Region, including administration of value-based contracts, regulatory and quality reporting, service level management, risk adjustment, strategic initiatives roadmap and capabilities development.

Oscar Health

West Region Operations Leader

Brought in to stand up a new product development function, including developing department structure, tools, and internal capabilities, assess national market opportunities, and develop integrated care delivery services along an expanded care continuum.

Satellite Healthcare / WellBound

Vice President, New Service Development

Oversaw and managed Group Medicare Product organization, including portfolio management, change implementation, readiness and quality, performance and communications, and digital capabilities for Employer Group Medicare Advantage, Part D, Supplement, Ancillary and Specialty products and programs. 

Manage team of four Product Directors and four Specialists, supporting customization of more than 100 product options to meet the needs of large and mid-size employers in both public and private sector markets, including federal and state plan filing, regulatory risk assessment, operations and systems capabilities and processes, and client and member facing communications.

Established Product Steering Committee and supporting infrastructure for Product Roadmap of more than 30 development, pilot and running-the-business initiatives.

Created and led division Diversity & Inclusion Council, with 23% of employees participating (65 employees). Launched training program, mentor program, leader and group activities, and communications.

Vital signs results: 97% employee engagement.

UnitedHealth Group

Vice President, Product, Retiree Solutions

Responsible for  day-to-day, year-over-year and long-term product development strategic initiatives. Manage team of three product managers and two analysts. Act as program owner in company-wide initiatives to ensure that division needs and wants are addressed.

Developed and launched Population Health Collaborative program, a strategic partnership between UnitedHealth Group and primary care physicians to meet the needs of socially vulnerable seniors by providing care coordination and community supports.

Initiated and led numerous strategic initiatives on personalized member communications, member rewards, EOB transformation, Part D benefits and capabilities, and others.

Director, Product, UnitedHealthcare Retiree Solutions

Promoted by new division leadership to focus on strategic development initiatives to support business growth, quality outcomes and revenue goals. Oversee product development stage gate process and governance, and long term strategy development.

Spearheaded strategy project for National PPO and Medicare Advantage products to ensure product longevity, stability and affordability.

Program stakeholder for Group Retiree division for unusual product designs and requirements.

Director, Strategic Initiatives, UnitedHealthcare Retiree Solutions

Promoted to interim role during segment reorganization. 
•	Established department roles and performance goals. Trained and provided guidance and support to new department director. Transitioned annual product planning cycle and Prescription Drug product management activities to director and product managers.
•	Initiated Prescription Drug wrap overhaul project in response to changing CMS Guidelines. Worked with Mercer as presenter and liaison on important considerations for this product.

Director, Product Development and Product Management

Product Development Consultant and Group Retiree PDP Product Manager 
Group Retiree Services, UnitedHealthcare, Santa Ana, CA 				4/2007 to present
•	Establish Group Retiree Medicare Advantage, Senior Supplement and PDP product objectives & priorities and develop product solutions to meet organizational goals.  300,000 lives under management.
•	Provide advanced business expertise on strategic issues that affect functional areas and major segments of the enterprise. Cultivate strong relationships and act as a “hub” of information between sales, client management, product, regulatory and underwriting in a very quickly growing business.
•	Developed new PDP EGWP Wrap product in response to PPACA legislation. Oversaw filing with DOIs in every state. Established product guidelines and operating rules. 200,000 lives in 2012.
•	Responsible for the product planning and development of National Medicare Advantage PPO product to replace group PFFS plans. New product now has over 220,000 lives.
•	Conceived and developed Market Overviews for all Group Retiree service areas nationwide, including network capabilities, local market trends, and competitor profiles.  Created a valuable database of group plan structure information to help drive fact-based decisions.
•	Provide oversight to Group Retiree plan filing with CMS including service area expansions and exits, plan bids and product migrations.
•	Authored and conducted dozens of internal and external training and educational presentations.

Product Development & Part D Product Manager

Built a non-profit parent support organization for parents of children with autism.  Developed mission statement and educational materials including 80-page parent handbook and web site (www.lafeat.org), filed Articles of Incorporation, acquired D&O Liability Insurance, built online email community, organized meetings, recruited nationally recognized speakers, conducted fundraising campaigns, managed Board of Directors of 8-10 parents, provided advocacy services to families seeking funding for services from school districts and regional centers.

Los Angeles Families for Effective Autism Treatment (LAFEAT)

President

•	Analyze business processes and needs.  Participate in cross-functional task forces to identify current or future workflows, data definitions, information sources and strategic improvement for data related business processes.
•	IT Project Lead for HEDIS Reporting for four capitated HMO health plans.  Responsible for data source management, process documentation and workflows, and process improvement. Ensure data completeness and reliability, QA of CAHPS Sample Frames, HEDIS chart pursuit samples, preliminary and final rates, BAT and DST completion according to project schedule deadlines.  Represent the plan in HEDIS Compliance Audit for all data management related areas.  
•	Project Lead for Data Management Initiative to improve corporate reporting capabilities.  Completed internal assessment of corporate reporting needs through web-based survey across health plans in four states.
•	Project Lead for corporate initiative to implement standardized QA Process for encounter EDI processes across all health plans.  Led team to develop log processes, translation and validation programs, IPA and Vendor profile reports.

Molina Health Care

IT Business Analyst

•	Manage department of 30 staff responsible for member issues, eligibility and member outreach.  Manage call center staffing levels and performance indicators.
•	Chair three committees: Member Participation Committee, Grievance Committee, and Service Quality Committee, with a focus on meeting member needs and achieving NCQA accreditation.
•	Write member materials such as Evidences of Coverage, letters, brochures, and welcome packets for Medi-Cal, Healthy Families and Commercial products, to provide a consistent message at a sixth grade reading level. 
•	Conduct oral and written surveys to assess health care needs and plan performance.  Develop and implement recommendations for improvement.
•	Maintain policies and procedures in compliance with all legal, regulatory and agency requirements.  Represent the plan in regulatory and accrediting agency audits.

Molina Healthcare

Director, Member Services

•	Manage claim and credentialing departments for capitated IPA (total staff of 15 in company of 35 employees).
•	Write all system reports for the organization including eligibility, claims, utilization, and quality studies.  Extensive data analysis.
•	Responsible for encounter and CHDP submissions to all health plans.
•	Ensure compliance with all regulatory requirements, represent the IPA in all health plan and regulatory audits.

La Vida Medical Group & IPA

Operations Manager

Perform and report on market research related to competitive health plans, benefit trends, service area expansion.  Strategic mapping of provider, member and census data using Atlas GIS.
•	Coordinate and prepare health plan surveys and RFPs.
•	Develop access databases to support marketing functions such as lead tracking, commission payments to sales reps and brokers. 
•		Collect and report on provider, market, and membership data for web site, member/provider surveys, provider directory, internal analysis and regulatory purposes.

UHP Healthcare

Operations Analyst, Marketing and Sales Division

•	Negotiate, implement and monitor fully-delegated capitated provider contracts.  Resolve contract, capitation, risk sharing, stop loss, claims, eligibility, encounter, and other provider issues.  
•	Conduct facility and claim audits.  Orient providers.

Provider Network Manager

Regulatory Compliance Specialist
•	Coordinate regulatory audits, including direct interface with agency auditors and implementation of company-wide Corrective Action Plans.
•	Prepare DOC, DHS and HCFA regulatory filings for licensure, contract compliance and expansion.
•		Analyze pending and recently enacted legislation and regulations to determine impact on health plan operations.  Develop action plans.

Provider Relations Specialist
•	Customer service for fully-delegated capitated provider network, ancillary contract negotiation, provider orientations, problem solving, provider manual, newsletters, oversight of provider database maintenance.

Contract Administration Assistant
•	Prepare capitated contract documents, access and capacity studies, collect provider information and process credentialing applications.

Gretchen Shanofsky, MAS-PHM