Expert in Value-Based Healthcare, Payment Integrity, Analytics and Informatics, and Payer-Provider Collaboration
Expert ID: 733442 Utah, USA
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
|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|
|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.
|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|
|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.|
|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.|
|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.|
Fields of Expertise
pharmacy operations, pharmacy benefit management, medical record, medical informatics, health care market research, health care finance, health care cost control, health care quality assurance, health care provider, health care system, HEDIS, home health care, health care management, health care, Medicaid, Medicare, population health management, business startup, joint venture, mergers and acquisitions, channel management, private equity, contract negotiation, pricing, value proposition, value analysis, new technology business value measurement, market segmentation, P&L, health care marketing, sales management, business development, strategy development, strategy, market entry strategy, business strategy, financial modeling, mergers and acquisitions financial analysis, antimicrobial medical device, electronic data interchange, case management, machine learning, data mining, health insurance, insurance claims adjusting, utilization review, therapy, insurance operations, adjudication, Medicare fraud, medicaid abuse, dental insurance fraud, actuarial health care