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Spring, TX 77379 bgcowboys22@yahoo.com 713-392-6520

Strategic Planning / Cost Reduction / IT System Conversions Process Improvement / Regulatory Compliance / Diverse Products and Services / Claim Operations

Seasoned, ambitious executive with several years developing and directing management operations and initiatives in the healthcare industry. Intuitive leader with acute business skills and expertise in healthcare programs and market penetration. Extensive experience in managing all client and vendor/partner relations and skilled in developing, equipping, and empower- ing teams of up 215 staff in a multi-line health plan of over 300,000 members.

Areas of Expertise:

Strategic Planning and Implementation

Cost Reduction and Avoidance

Budgets and Forecasting

Regulatory Compliance

Contract Development / Negotiations

Budget Administration / Management

Internal Systems and Controls

Claim Operations/System Configuration

Staff Development Programs

Team Building and Leadership



Senior Vice President of Operations (2012-2015)

Successfully led multi-line health plan operations for over 350,000 members in Medicaid and private sector program to include examining every aspect of program operations for regulatory compliance, incorporating best practices in managed care, and remediating processes and systems. Over sight of Call Center supporting multiple lines of business with 150 customer service representatives.

Developed Claim Strategy for all lines of business: Through claim automation efficiencies was able to add 50,000+ new members across two product lines without adding additional claim staff and also deployed claim examiners to other operational areas such as Call Center and System Configuration.

Managed relationships and vendor contracts with Clearinghouse vendors.

Managed Delegated Entities such as Call Center backup support and Behavioral Health and Vision Claims. Over- sight of non-conformance, CAPS and possible liquidated damages.

Oversight of Delegated Entity audits for Behavioral Health and Vision claims, Call Center delegated entity customer service delivery.

Steered strategic direction of the Contact Center to achieve excellence by implementing First Call Resolution goals and partnering with vendors to conduct CAHPS surveys and improvement strategies.

Oversight of all new Program, Service and Organizational implementations.

Directed and managed activities in the Call Center operations including IVR and website tool improvement plans.

Reviewed and Approved all Call Center operation policies and procedures.

Directed Member Services, Materials, Eligibility files, ID cards ,Member Handbooks, and Summary Plan Descrip- tions.

Managed all member complaints and appeals processes.

Coordinated audit activities with URAC during accreditation reviews.

Served on Member Advisory Committee and Member Outreach Council.

Led ICD-10 implementation as Executive Sponsor was responsible for outcomes, training, financial analysis.

Vice President, Claims - (2008-2012)

Initially hired at Community Health Choice as Vice President of Claims to establish claim processing strategies, performance metrics, assess the claim platform capabilities and long term viability. During this time, I procured and implemented a new claim system that improved claim processing accuracy and automatic adjudication. Implemented a work from home claim processing program which resulted in claim processing efficiencies. Managed the Claim System Configuration after imple- mentation of the QNXT managed care system. As Executive Sponsor, I met weekly with all 40 members of the implementa- tion team, created the Governance and Charter for the implementation and monitored the activity of all implementation teams.

Claim Operations Service Level and Accuracy Performance: Monitored Claim processing performance and reported Quarterly to the State of Texas- Health, Human Services Commission. Requirements were met all quarters from 2008 through 2015. Reported Key Performance Indicators to Board of Directors, Management and Executive Team on weekly and monthly basis. Network Provider and Member Satisfaction survey results reported high satisfaction with accuracy and timeliness of claim payments.

Created Claim Advisor roles to provide support to Provider Relations staff with any provider inquiries. Created Cus- tomer Service position responsible for processing claim adjustments for first call resolution with network providers.

Oversight of Workforce Management tools, Call Center KPIs, Call Quality Monitoring and Calibration program and Virtual program.

Directed the successful implementation of bundled payment methodologies by supporting provider contract strate- gies and executing sound strategic decisions.

Played an integral role in the development and monitoring of critical metrics, such as service level agreements and key performance indicators.

Worked with Analytics team to create and improve Key Performance Indicators.

Monitored and reviewed all Key Performance Indicators at weekly Executive and monthly Management meetings. Presented Operational Key Performance Indicators to the Board of Directors at monthly BOD meetings.

Guaranteed effective operational governance through robust operations management business routines, including operating review.

TRISURANT (Health Administration Services) - Houston, Texas

Chief Operations Officer (1998 to 2008)

Directed a third party administrator in self-funded insurance strategies for over 110,000 members represenenting municipali- ties, school districts and other commercial clients. Oversight responsibility for all operational functions including Client Rela- tions, Member Services, Marketing and Provider Network Strategies, Workers Compensation, PBM relations, Human Re- sources, Claims and Call Center.

Guided client insurance committee meetings to review operational and financial plan performance.

Orchestrated strategies to improve operational performance for client satisfaction and retention.

Directed Market pricing strategies, market segments and market demographics.

Directed Financial reporting to self-funded clients through monthly face to face client meetings.

Oversight of stop-loss insurance claim management and procurement for Clients.

VP, Operations - 2000-2005: I was promoted to Vice President of Operations to manage all operational areas including an in-house Behavioral Health Benefit Program benefit and claims process. I worked closely with an in-house Behavioral Health professional who operated the program we offered our self-funded clients.

Commanded all regulatory compliance, vendor contracts, and legal matters for the company to ensure flawless busi- ness operations.

Successfully managed an IT claim system implementation. Led all Implementation team activities as Executive Sponsor.

Directed System Release schedule and upgrades.

Oversight responsibilities for Account Management , Client Services and Marketing Business Plans.

Managed relationships with Insurance Brokers, Consultants and Key Client contacts.

Director of Claims- 1998-2000: I was initially hired as Director of Claims to oversee all claim functions and improve claim processing accuracy and clean up an existing claim adjustment backlog. As Director, I worked with all processing teams, Quality Assurance and Compliance teams to assure regulatory and client service level compliance.

Managed Stop Loss claims for Self-funded clients and oversaw the Claims process with Carriers.

Implemented a new telephone system to improve customer service experience and functionality.

Improved performance in Claim Processing, Adjustment Processing, Subrogation and Refunds.

Prudential Healthcare- Austin Claim Operation, St. Louis Claim Operation, and Houston Claim Operation - 1980 - 1997- Held the following job titles: Claim Examiner, Team Leader, Supervisor, Associate Manager, Claims Manager.

At Prudential, I began as a Claim Examiner and processed claims for commercial clients in both indemnity and managed care health plans. I served in a Team Leader role directing the performance of a team of claim examin- ers. As my career progressed, I was promoted to Supervisor, Associate Manager and relocated to open the newly formed Austin Office. Later, I was promoted to Claims Manager and transferred to the St. Louis Managed Care office. In the St. Louis Office, as Claims Manager, I managed a staff of over 140 employees. 100 of these em- ployees were claim examiners which included a team of 20 claim examiners who worked an evening shift from 4 PM to 11 PM. I served in management roles in the following Claim Operations Austin from 1982 to 1985, Houston Dental Claims Operation from 1985 to 1990, St. Louis Claims Operation from 1990 to 1992, Houston Service Cen- ter from 1992 to 1997.


Baylor University Waco, Texas

Austin Community College, North Harris County College

General Lines Insurance License- License # 2051957 Expires 12/17