Healthcare Strategy & Network Operations Consultant

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Summary

This Healthcare Strategy & Network Operations Consultant is an experienced healthcare professional with 22 years of Managed Care experience, including 16 years in provider network management and development for Commercial, Medicare & Medicaid members, practitioners, ancillary groups and hospitals. Passionate about healthcare, employee development, and thrives in fast-paced environments. Leads provider focused teams which include provider network strategy, data management, and unit cost management. Oversees coordination and negotiation for the contracting department and develops expansion initiatives. This Healthcare Strategy & Network Operations Consultants ability to influence various functional areas and motivate groups to action without direct line management responsibility. Proven project management experience and ability to manage multiple complex projects while applying industry methodologies and practices. Energized by creative and critical thinking, building high-performing teams, and fostering continuous learning. 

Highlights

• Contract Negotiations Including Value Based Agreements
• Open Enrollment
• Account Management
• Client Relations
• Marketing & Product Development
• Business Analysis & Strategic Planning
• Completed PMP Training
• Sales Force
• Public Speaking
• Managing Plan Designs/Benefits
• Training & Mentoring
• Communications
• Critical Thinking & Negotiation
• Marketing Insights
• Managed Markets
• National Account Management
• Sales
• Operations
• Network Management
• Regulatory Issues/Requirements & Compliance

Relevant Accomplishments

• Directed departments responsible for network contracting, provider data management, regulatory reporting, behavioral health & physical health networks, provider relations, vendor account strategy and value-based incentive programs. Partnered with Compliance, Quality, Government Relations, Operations, Marketing and Clinical departments to execute company strategy.  Responsible for Blue Cross Blue Shield out Tennessee’s DSNP product in five states. Oversaw the development, implementation, management, and maintenance of healthcare provider network. This includes all specialty types for professional services, ancillary, behavioral health, and hospital.
  • Played a key role in negotiating contracts, managing provider relationships, and ensuring quality and accessibility for members. 
  • Managed all provider service activities in regional market.  
  • Successfully managed P&L for all Provider Services teams. 
  • Successfully developed and implemented cost containment strategies which resulted in $1.5M in savings within a 15-month timeframe.  
  • Effectively engaged providers to manage the company’s VBC, HEDIS, and STARS strategies. 
  • Product was in one state and I successfully expanded network footprint in four states within 1.5 years. 

Successfully managed budgets to be in alignment with corporate financial objectives. Oversaw the development and implementation of contracting activities for multiple states. Developed strategies to meet network access and unit cost objectives while also monitoring provider performance and subsequently implementing business solutions to address quality gaps. Closely collaborated with medical management and sales to develop strategies to meet market growth and medical cost targets. 

• Managed provider network of a $700M division and provided regional oversight for market operations. Oversaw network development, contracting, and maintenance, ensuring smooth operations and maximizing network value. 

• Successfully reduced company out-of-network spend by $3M by negotiating contracts with providers and implementing cost containment strategies. Effectively managed the company’s network utilization, ensuring the most efficient and cost-effective delivery of care to members. 
• Expanded product offerings throughout the state by working closely with product development and sales teams. Collaborated on product development and strategic planning, identifying areas for growth and opportunities to enhance existing offerings. This effort led to a significant increase in membership, tripling the state membership base and demonstrating the effectiveness of the network development and contracting strategy.  
• As Network Development & Contracting Executive, conducted negotiations with hospital/physician groups, expanded network options for members, and achieved market growth of 25% in 2015 and 10% in 2017. Created trend analyses, served as a single point of contact for contractual issues, facilitated provider education, and negotiated value-based agreements. 
  • Successfully expanded the business from Tennessee to the Alabama market, growing the company’s market share and improving its competitive position. This involved conducting market research, assessing the viability of the new market, and developing a strategic plan for expansion. 

• • Managed the provider network of a $700 million division, providing regional oversight for market operations. This included overseeing network development, contracting, and maintenance, as well as managing network utilization and ensuring the most efficient and cost-effective delivery of care to members. 

• • Successfully reduced the company’s out-of-network spend by $3 million by negotiating contracts with providers, implementing cost containment strategies, and optimizing the company’s network utilization. This effort maximized network value and minimized unnecessary expenses, contributing to the company’s financial success. 

• • Expanded the product offerings throughout the state by collaborating with product development and sales teams, identifying areas for growth and opportunities to enhance existing offerings. This product expansion led to a significant increase in membership, tripling the state membership base and demonstrating the effectiveness of the network development and contracting strategy. 

Roles

• Hospital Relations Manager | AMERIGROUP, now an Elevance Company 2011 – 2012
• Provider Relations & Provider Network Contracting
• Medicare Marketing Compliance SME
• Marketing Subject Matter Expert | Humana – Louisville, KY 2004 – 2008
• Market Manager |United Health Group  2008-2011
• Product Development Analyst

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Click “request expert” for a free initial screening call with this expert or a similar expert regarding your expert consulting needs