DAVID L. ANDERSON
Lansdowne,PA
Summary
Highly experienced Healthcare Industry Professional with almost 20 years of collective experience in various roles of Healthcare Operations; a creatively motivated team player with an a passion for collaborative team issue resolution and proactive relationship management demonstrating excellent oral and written communication, team building, audit oversight, compliance leadership and claims payment yielding successful outcomes. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
18
18
years of professional experience
Work History
Contract Implementation Analyst
Centene - Delaware First Health
Newark Delaware (Remote)
10.2022 - Current
- Perform day to day duties and testing of contract implementation, including UAT to ensure that systems accurately reflect contract’s negotiated terms
- Perform audits of provider setup within provider information system to ensure accurate contract implementation and subsequent claims processing and review and price contract related pends to ensure claims payment accuracy
- Ensure accurate contract implementation and subsequent claims processing through provider setup, UAT testing and post production testing related to Fee schedule and pay class updates.
- Troubleshoot and problem solve contract implementation issues related to basic system configuration
- Review contracts and assign pay classes and applicable provider information based on contract language and submit configuration request to accommodate claims payment processing.
- Assist with internal communication of all new and revised material contract terms and provisions to all affected departments
- Participate in determining appropriate configuration of claims payment process in appropriate subsystem of claims payment information system in conjunction with health plan, claims and corporate management and information systems staff
- Drive timely performance results and team proficiency with a continuous improvement mindset in achieving consistent delivery of core performance targets and system processes: iCertis Review and CR Submission = 100% in 3 Calendar Days Non-iCertis or DMAP CR Submission (new or update to configuration is needed) = 100% in 3 Calendar Days CenProv PIX Workbasket = 98% in 3 Calendar Days and 100% in 5 Calendar Days Achieve 100% completion of updates (include DMAP) prior to effective date or within 15 Calendar Days from notification
- DMAP Review and Resolution (Submission of CRs) = 100% in 5 Calendar Days
- Collaborate with CLs to submit projects within 2 business days from system fix/enhancement
- Collaborate with department Business Analyst on any DMAP or iCertis changes that could impact the benefit setup
- Proactively connect with matrix partners (PDE, PDM & Configuration) to achieve resolution on Fee schedules, PIX, Pay Class and Pricing Updates
- Contribute to achieving financial targets through timely issuance of provider payments by reviewing and processing CIA Workbasket pended claims (IS, PM, XZ) Turnaround Time = 100% in 10 Calendar Days Show a commitment to quality through consistent and collective actions to achieve error proof outcomes for our internal and external customers
- Deliver complete and accurate research and implementation of pricing outcomes: with no more than 2 internal quality errors per year based on Internal Audit Findings
- Achieve 100% pre and post-UAT review of code/pricing changes to avoid down-stream claim pricing impacts (partner with CLs in review of UAT claims)
- Achieve 98% SharePoint Accuracy Response Rate (Based on # of responses and # of repeat identical issue) Create and maintain Configuration Requests tracker capturing key submission, resolution and UAT dates and summary of key findings
- Provide supporting documentation when submitting root cause findings to customers (using Best Practice Root Cause Response Formats that are measured through tools (SharePoint tracking), Internal Audit results, and monitoring by immediate leadership
- Meet all compliance expectations set by role and organization by conducting business ethically, transparently, and in compliance with federal and state laws, regulations, and administrative rules, holding self, team, and colleagues accountable
- Prompt reporting of all good faith compliance concerns consistent with the Business Ethics & Code of Conduct.
Manager, Revenue Cycle Management Compliance
NextGen Healthcare
St Louis MO (Remote)
12.2021 - 07.2022
- Developed and maintained quality compliance program that measured current activities, assessed possible gaps and recommended and/or implemented remediation strategies
- Identified and maintained current information from all external regulatory agencies/organizations
- Provided detailed updates on relevant compliance and regulatory matters, trends and developments
- Supervised and lead small team in researching, reviewing and responding to compliance and coding topics and questions
- Educate management and staff on current and necessary updates to compliance policies and procedures
- Reviewed and updated as necessary Annual Regulatory Compliance Trainings related to Medicare QMB process and provider education, OIG Workplan, Provider and Vendor Exclusion and Sanction process, Client and Provider Bankruptcy process and FQHC Medicare Secondary Payer process
- Oversight of client Process Agreement Letters for provider coding, billing and payment processing per client contract to assure proper billing standards
- Created Client Process Agreement Letter Templates for standardized letters
- Processing and submission of CSAT and FNL monthly Client adjustments for write-offs considered moderate risk for lost revenue.
- Managed and motivated employees to be productive and engaged in work.
- Established team priorities, maintained schedules and monitored performance.
Manager, Regulatory Compliance
Centene - Pennsylvania Health & Wellness
Harrisburg
10.2019 - 11.2020
- Successfully maintained organizational and compliance insuring agency policies and operational procedures are current, accurate, and appropriately implemented
- Partnered with internal and external stakeholders, including Compliance Audit and Compliance Monitoring and Testing, to develop and execute programs
- Worked cross functionally to ensure compliance requirements are managed and timely implemented
- Created and executed project work plans to meet changing needs and requirements
- Successfully identified potential areas of compliance vulnerability and developed corrective action plans to rectify them Supported Internal Auditing with internal, external and audit readiness reviews
- Maintained visible presence for compliance team across organization
- Ensured Compliance Team was appropriately resourced and skilled to deliver departmental objectives with excellence
- Identified and monitored regulatory issues and concerns assuring proper documentation and successful resolutions
- Provided best practice advice on key Regulatory processes
- Identified conflicts of interest and breaches of confidentiality for next step processes
- Reviewed existing compliance activities for continued team development and improvement
- Successfully achieved 100% timeliness for regulatory and compliance related reports submissions.
Managing Partner
Ascend Management Group
Philadelphia
04.2018 - 10.2019
- Business Development & Leadership Training for non-profits and for-profit organizations
- Developed pre-employment screening and interview process to assist in aligning “best fit” candidates to receive offers
- Facilitated and managed new business start-ups for and increased online marketing presence
- Successful outcomes in leadership development and discovery workshops
- Small Business coaching and mentorship development for new start-ups and existing business.
- Increased revenue by 38% with successful promotional strategies and reductions in costs.
- Reduced labor costs by $2800 per year by reworking schedules, operations standards, and workflow.
Manager, Regulatory Compliance
Health Partners Plans
Philadelphia
02.2015 - 02.2018
- Successfully monitored organizational Compliance activities ensuring issues are properly documented and elevated to senior management to assess and manage risk, maintain a positive reputation, and avoid lawsuits
- Collectively developed audit objectives and procedures for internal audits, reviews and special projects as assigned
- Communicate audit findings to audited departments and senior leadership to ensure audited entity's understanding of matters identified
- Strong support in identifying potential areas of compliance risk and vulnerability and developed internal corrective action plans to rectify any issues
- Effectively communicated regulatory outcomes to senior management addressing all compliance, corrective action and audits related concerns
- Prepared and delivered internal compliance and risk management trainings
- Assisted in identifying, investigating and documenting HIPAA breaches
- Reviewed existing compliance activities for continued team development and improvement
- Partnered with leaders and teams to ensure organizational policies and operational procedures are current, accurate, and appropriately implemented
- Researched regulatory and administrative changes to CMS, State, or commercial programs to advise senior management as to their effect on company
- Responsible for oversight of multiple key compliance initiatives, including credentialing, FWA attestations, HIPAA training and enrollment of new hires, primary source verification, tracking licensure renewals
- Communicated audit findings to audited departments and senior leadership to ensure audited entity's understanding of matters identified
- Redesigned Compliance monitoring and audit tools, policy revisions and supports internal audits and assists with external audit readiness reviews.
Senior Provider Contracting Specialist
Health Partners Plans
Philadelphia
05.2012 - 05.2015
- Identified and recommended solutions for Provider and Vendor issue resolutions for identified deficiencies in contract performance
- Developed and performed Contract language review assessment and implemented necessary changes to process to assure compliance with all federal and state regulatory guidelines
- Effectively facilitated implementation and contract negotiations of Behavioral Health delegated vendor and Children’s Health Insurance Programs
- Successfully managed and assisted in renegotiation of Laboratory contract resulting in companywide yearly cost savings of $150,000
- Developed templates and standardized documents used across various types of contracts simplifying creation process.
- Optimized customer experience by delivering superior services and effectively troubleshooting issues.
- Implemented innovative procurement strategies that resulted in cost reductions while maintaining high-quality standards for projects.
- Ensured proper documentation was maintained throughout entire lifecycle of contract from initiation through closeout.
- Managed multiple contracts simultaneously, prioritizing tasks effectively to meet deadlines and client objectives.
Provider Contracting Specialist
Health Partners Plans
Philadelphia
07.2010 - 05.2012
- Conducted and coordinated Vendor and Provider contract requirements for entire Managed Care Provider Network
- Completed and analyzed Provider rate negotiations and contract renewals with hospitals, physicians, and ancillary providers
- Managed oversight of Delegated Vendor Services Relationships ensuring regulatory compliance to all State and Federal guidelines, policies and procedures through reporting, analysis and annual or as needed vendor monitoring.
- Maintained relationships with vendors and service suppliers.
- Successfully oversaw vendor contract relationships with internal and external providers.
- Maintained database systems to track and analyze operational data.
Delegated Vendor Manager
Health Partners Plans
Philadelphia
02.2006 - 07.2010
- Team Leader for delegated provider groups, ensuring compliance with established required contracted providers and vendor service performance
- Developed monitoring tools that measured Delegated Vendor compliance
- Implemented and oversaw corrective action plans to assure maximum level of performance
- Investigated and resolved provider and vendor issues in accordance with departmental policies and procedures.
- Developed comprehensive vendor management policies, ensuring consistency in vendor selection, evaluation, and performance monitoring across organization.
- Analyzed and solved multi-faceted problems that effected executive leaders and business initiatives.
Education
Master of Science - Masters, Human Services Administration
Lincoln University of Pennsylvania
Philadelphia, Pennsylvania05.2013
Some College (No Degree) - Bachelor, Business Administration
Strayer University Philadelphia
Pennsylvania, PennsylvaniaAssociate of Science - Biology
Cheyney University of Pennsylvania
Cheyney, Pennsylvania05.1997
Skills
- Technical Analysis
- Stakeholder Management
- Requirements Gathering
- Business Analysis
- Project Documentation
- User Acceptance Testing
- Remote Office Availability
- Quality Assurance
- Organization and Time Management
- Team Collaboration Troubleshooting
- Critical Thinking
References Available
True
Core Professional Skillset And Knowledge
- Government Programs
- Project Management
- Vendor Management Oversight
- Monitoring, Auditing & Review
- Vendor Procurement
- Contract Renewal and On Boarding Contract Negotiation
- Policy Interpretation
- Team Development
- Business Development
- Contract Negotiation
- Internal Audits
- Process Improvement
- Managed Care
- Auditing
- Interviewing
- Data Analysis
- Program management
- Contracts
- Compliance management
Timeline
Contract Implementation Analyst
Centene - Delaware First Health
10.2022 - Current
Manager, Revenue Cycle Management Compliance
NextGen Healthcare
12.2021 - 07.2022
Manager, Regulatory Compliance
Centene - Pennsylvania Health & Wellness
10.2019 - 11.2020
Managing Partner
Ascend Management Group
04.2018 - 10.2019
Manager, Regulatory Compliance
Health Partners Plans
02.2015 - 02.2018
Senior Provider Contracting Specialist
Health Partners Plans
05.2012 - 05.2015
Provider Contracting Specialist
Health Partners Plans
07.2010 - 05.2012
Delegated Vendor Manager
Health Partners Plans
02.2006 - 07.2010
Master of Science - Masters, Human Services Administration
Lincoln University of Pennsylvania
Some College (No Degree) - Bachelor, Business Administration
Strayer University Philadelphia
Associate of Science - Biology
Cheyney University of Pennsylvania