Expert Details

Expert in Value-Based Healthcare, Payment Integrity, Analytics and Informatics, and Payer-Provider Collaboration

Expert ID: 733442 Utah, USA

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Expert has implemented a wide variety of value-based care models at more than 600 hospitals and health plans. He is recognized as an expert in Population Health, Bundled Payments for Care Improvement (BPCI), Comprehensive Care for Joint Replacement (CJR), MACRA, Merit-Based Incentive Payment System (MIPS), Alternative Payment Models (APM), ACOs, ACO Medicare Shared Savings Program (MSSP), Next-Generation ACO, Hospital Value-Based Purchasing (VBP), Core Measures, Comprehensive Primary Care Plus (CPC+), Hospital-Acquired Condition Reduction Program, Oncology Care Model (OCM), Joint Commission, NHSN, CDC, Reportable Diseases, HAIs, CMS, Epidemiology, Nosocomial Infections, Antimicrobial Stewardship, Post Acute Care Transition, Risk Sharing, Capitation, Network Contracting, Payer Provider Collaboration, Home Health, STARs, HEDIS, Medicare Administrator (MAC), Fee for Service Medicaid, Medicare Advantage, Managed Medicaid, Medi-Cal, and other areas.

Expert has defined go-to market and sales strategies for start-up and Fortune 100 companies alike. He is an expert in developing comprehensive healthcare solutions that leverage market opportunities and generate rapid revenue growth. His specialties include joint ventures, strategic partnerships, channel sales strategies, mergers and acquisitions, private equity, venture capital. Challenger Sale, Conceptual Sale, SPIN Sale, Account-Based Sale, SNAP Sale, Solution Sale, Miller Heiman, sales strategy, sales enablement, market segmentation, value proposition, and sales closing.

He is a P&L turnaround expert whose specialties include pricing models, contracting, negotiation, and other areas.

Expert has supported more than 80 health plans in North America to implement comprehensive payment integrity initiatives. His specialties include claims adjudication, fraud waste abuse, claims editing, subrogation, coordination of benefits, fee for service claims, dental, vision, pharmacy, medical claims.

Expert is highly knowledgeable in pre-adjudication EDI editing, concurrent claims editing, and retrospective data mining claims recovery. His expertise also includes medical cost management, network affordability, clinical decision support, claims platform, medical loss, disease management, care coordination, post acute care, actuarial analysis, gaps in care, HEDIS, STARS, commercial risk adjustment, provider network, Medicare Advantage risk adjustment, private and commercial exchanges, utilization review, provider credentialing, member enrollment, denial management, provider payer collaboration initiatives, Medicare, Medicaid, and Commercial claims editing, claims workflow analysis.

As a consultant, Expert has:
1) Worked with hospital systems to create health plans
2) Developed payer provider collaboration strategies to lower medical loss and administrative expenses
3) Designed go to market and sales strategies for disruptive new healthcare technologies
4) Defined flexible pricing models to maximize sales growth
5) Assessed new technologies to determine value potential
6) Designed STARs and HEDIS operational turnaround programs
7) Created financial risk sharing models for providers and payers - capitation, partial capitation, etc.
8) Improved ROI model to improve analytics software value
9) Designed new marketing and sales strategies to revitalize stalled revenues
10) Lowered network medical losses for health plans through disease management, care coordination, post acute care, and case management
11) Defined claims editing and FWA plan for health plans (fee for service)
12) Identified additional value-add services for claims clearinghouses (dental, medical, workers compensation, etc.)
13) Partnered with TPAs to conduct financial turnaround of operations
14) Maximized CMS reimbursements through value-based care models and population health initiatives
15) Improved clinical quality at hospitals through workflow redesign, analytics, and evidence based practices
16) Improved revenue cycle management for providers and IPAs
17) Created clinically integrated networks to improve outcomes and maximize revenue

Expert may consult nationally and internationally, and is also local to the following cities: Salt Lake City, Utah - Provo, Utah - Sandy, Utah - Orem, Utah - Ogden, Utah - West Jordan, Utah - Layton, Utah

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Education

Year Degree Subject Institution
Year: 2000 Degree: MS Degree Subject: Lean Systems and Instructional Technology Institution: Utah State University
Year: 1999 Degree: BA Subject: Spanish and Business Institution: Utah State University
Year: 1997 Degree: AAS Subject: Psychology Institution: Brigham Young University Idaho

Work History

Years Employer Title Department Responsibilities
Years: 2015 to Present Employer: Undisclosed Title: VP Business Development Department: Business Development & Strategy Responsibilities: Led commercialization strategy for new analytics and consulting services focused on payer/provider collaboration, medical management, and value-based incentive models

P&L business development responsibility for $550M/year book of business
Implemented value-based programs for health plans, ACOs, and provider-sponsored health plans
Led business development strategy for 2,000 hospitals focused on medical necessity and medical benefit management
Managed population health, revenue cycle, and value-based care analytics strategies
Introduced a disruptive analytics and consulting model to health plans and provider organizations including BCPI, CJR, MACRA APM MIPS and more
Manage deal execution and negotiated business terms, contracts, and due diligence
Grew sales 2.5x YOY and exceeded quota goals by 125% in 2015
Captured 48% of the health plan market in 16 months through strategic alliances and OEM models
Developed an analytics optimization program that added 35% more TCV to sales deals
Managed marketing and sales strategies for Medicare, Medicaid, Commercial, Exchange, Federal and State markets.
Years: 2013 to 2015 Employer: Verisk Analytics Title: AVP Account Management Department: Sales and Operations Responsibilities: Led Payment Integrity business portfolio at Verisk Health.

P&L responsibility for more than $88 million in annual revenue and $44 million in IOI
Provided healthcare analytics solutions that helped more than 73 health plans manage fee-for-service and value-based incentive programs ( claims editing, FWA, population health, revenue cycle management, STARs, HEDIS, and risk adjustment)
Defined pricing strategy, licensing/contract structure, budgets, and product development roadmaps
Achieved 220+% of revenue quota and set new records for revenue growth (added $23 million TCV) and profit margin (increased margins by 15% YoY)
Saved clients more than $690 million in expenses through our suite of analytics and services
Completed a sales turnaround through a growth playbook that emphasized strategy instead of products.
Years: 2008 to 2013 Employer: TheraDoc Title: Director Consulting Department: Consulting and Sales Responsibilities: Led value-based purchasing, antimicrobial stewardship, pharmaceutical, and core measures consulting practice and account management at TheraDoc

Improved value-based purchasing, ACO, MSSP measures for 500 hospitals and 31 ACOs
Improved core measure compliance through partnerships with laboratory, pharmacy, and epidemiology
Started and led a value-based purchasing consulting practice from the ground-up (35 FTE)
Created a sales and consultative services model that quadrupled revenue over a 5 year period
Supported the sale of TheraDoc to Hospira/Pfizer in 2012
Increased client accounts (acute care hospitals) by 300% over a 5 year period
Achieved #1 KLAS ranking in core measures, epidemiology and antimicrobial stewardship
Led 150 healthcare consulting and analytics projects on a budget of $110 million
Maintained a 100% client retention rate for 5 years
Expertise in antimicrobial stewardship, nosocomial infections, core measures, and value-based incentives.
Years: 2006 to 2008 Employer: Sento Title: Account Executive Department: Sales and Operations Responsibilities: Managed provider and member services for EyeMed Vision Insurance (35 million members)

Managed web-enabled self-help applications that combined voice, chat, email and web forums for 35 million members and providers at EyeMed Vision Care
Managed a P&L turnaround effort of a $25 million account with 12 supervisors and 350 employees
Increased revenue by 35% and improved profitability from a $900K loss into a $1.2 million profit
Ranked the #1 account at Sento based on performance and goal attainment
Improved employee productivity by 29% via an auction-based employee incentive program
Saved $240K/yr in costs and set employee retention records through a work-from-home program.
Years: 2001 to 2006 Employer: AT&T Title: Senior Manager Department: Sales and Operations Responsibilities: Supported a $2 billion business sales unit to create sales solutions and training programs.

Managed process improvement projects to improve sales processing across unionized departments
Gained consensus and buy-in from union leadership to streamline operations
Generated an additional 16,800 billable days per year in previously lost product revenue
Designed 7 marketing and sales training programs for 300 business-sales employees.

Government Experience

Years Agency Role Description
Years: 2013 to 2016 Agency: United States / Medi-Cal California Role: Payment Integrity Description: Provider BPO claims editing and FWA services to Medi-Cal plans
Years: 2015 to 2016 Agency: United States/ Medicare Administrators Role: Payment Integrity Description: Provide operational efficiencies to Medicare Administrators

Additional Experience

Training / Seminars
Provided extensive training seminars on value-based care, fee for service, marketing and sales strategies, go to market plans, and clinical analytics platforms.
Vendor Selection
Supported numerous hospitals, providers, and health plans in selecting practice management, EMR, EHR, population health, adjudication, home health, infusion, claims editing, FWA, HEDIS, analytics, clinical decision support, disease management, care coordination, and convener vendors.
Marketing Experience
Led the go-to market strategy for TheraDoc, Verisk Health, and Optum.
Other Relevant Experience
Companies appreciate my in-depth understanding of payer, provider and medical device/pharmaceutical organizations. Since I have worked for all three constituencies, I am able to define unique commercialization solutions that rapidly grow revenue and create differentiation in the marketplace. I have worked with the largest health plans, hospital systems, and technology companies in the United States to transition operational and financial models to value-based care strategies.

Language Skills

Language Proficiency
English Fluent
Spanish Fluent

Fields of Expertise

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