Diantha Ashford

• Negotiates, executes, reviews, and analyzes contracts and manages dispute resolution and settlement negotiations with provider groups, hospitals, and individual physicians.

• Manages contract performance in support of network quality, availability, and financial goals and strategies.

• Recruits providers to ensure attainment of network expansion and adequacy targets.

• Collaborates cross-functionally to contribute to provider compensation and pricing development activities and recommendations, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.

• Responsible for identifying and making recommendations to manage cost issues and supporting cost saving initiatives and/or settlement activities.

• Provides network development, maintenance, and refinement activities and strategies in support of cross-market network management unit.

• Assists with the design, development, management, and or implementation of strategic network configurations, including integration activities. Ensures resolution of escalated issues related, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.

• Interprets contractual requirements including federal and state regulations and NCQA.

Engage local hospitals, independent physicians, and build relationships to execute managed care agreements for participation in the Sonder Health Network. Identify new payor and strategic partner opportunities through relationship development. Facilitate agreement execution and maintenance of the contracted network with the ultimate goal of increasing the number of participating physicians and at-risk Medicare members in the Georgia’s market.

Selected Accomplishments:

- Engage and contract with independent physicians, hospitals, and provider groups to join the Georgia region.

- Negotiate, execute, and maintain contracts and financial arrangements with independent physicians, hospitals, ancillary providers, independent practice associations (IPA's), and large provider groups.

- Create solid relationships by continuous engagement with potential network participants to build and grow the Sonder business.

- Use knowledge of negotiating entities to improve and enable competitive advantage in network contracting process.

- Use knowledge of negotiating entities to improve and enable competitive advantage in network contracting process.

Client-facing lead for engagement management of interoperability initiatives. Work with external providers and healthcare systems on appropriate use of the network, adoption of point of care enablement technology, self-service adoption, affordability targets, and overall education. Provide day-to-day management of engagement activities, including project management, reporting, coaching, implementation, and problem resolution with defined service partners and other activities to assist in the facilitation of a successful relationship with providers/book of business.

Selected Accomplishments:

- Manage an extensive pipeline, to include over 200 individual providers, provider groups, and hospitals.

-established a pay-for-performance program that incentivizes providers based on quality metrics, improving patient satisfaction scores and increased adherence to preventive care guidelines like diabetes screenings.

- Successfully engage provider groups to support performance journey to High Performing Physician (HPP) status and coach to maintain status.

- Conducted a qualitative study utilizing statistically analyzed data collected by IRB approved surveys to prove the need for incorporating health information exchange features into the EHR while emphasizing the benefits of ensuring interoperability professionals are adequately trained, in an effort to develop and analyze sales strategies and results to increase overall productivity.

Managed the day-to-day management of all of Valley Health System contracting, including negotiation and development of payer agreements, monitoring of payer performance and adherence to contractual terms. Develops strategy and relationships with payers. Developed financial/clinical products and services to meet the specific needs of network customers, as well as the effective and timely delivery of quality financial/information products and services to Valley Health System customers.

Selected Accomplishments:

- Lead team of managed care professionals to manage complex contracts and negotiation strategies.

- Created and/or managed analytical tools, including contract management software that promote an environment of effective decision-making.

-Designed bundled payment programs for a specific conditions, defining the episode of care, negotiating a set price for the entire episode, and creating protocols and care pathways to ensure efficient and high-quality care within the set budget.

- Maintained tools to ensure accurate modeling and payment compliance within EPIC Professional Billing Reimbursements Contracts system.

- Supported Patient Financial Services operations in its revenue collection mission of ensuring over $294,000 in claims were paid through streamlining the adjudication processes.

- Supported corporate customers and patients, and support business analytics and clinical programs

- Collaborated with and supported providers, executives, entity and departmental leadership, corporate teams (provider credentialing, decision support, reimbursement/tax, budgeting, and service line leaders) in effort to improve the efficiency of internal administrative operations.

- Negotiated agreements that affects members across Virginia, West Virginia, and Maryland by providing input and rate analysis for corporate review, resulting in the payment of an extensive backlog of claims.

- EPIC Resolute Professional Billing Reimbursement Contracts Certification

Develop, evaluate, and negotiate contracts in compliance with company contractual policies by utilizing Emptoris and CLM contracting systems. Utilized reimbursement structure standards and other key processes. Negotiating carve-outs for high-cost cases. Established and maintained strong business relationships with physicians and groups, while ensuring the network composition includes an appropriate distribution of provider specialties.

Selected Accomplishments - Managed regional contracts and negotiations for Georgia, North Carolina, and South Carolina.

- Served as a key resource on complex and/or critical contracting issues.

- Managed Emptoris and CLM contracting System to create Medical Group Agreements, IPA Agreements, FQHC agreements, PHO agreements, Simplified Medical Group Agreements, and Simplified Physician agreements for Facility, Ancillary, Hospital systems

- Analyzed financial performance of clients prior to negotiations, incentivizing quality care and cost-efficiency through capitation, pay-for-performance and bundled-payment agreements.

- Evaluated and monitored financials according to current market.

- Supported Medicaid build for North Carolina market.

- Anticipated client needs and proactively develop solutions to meet them.

• Hired as a temporary employee to work on the Behavioral Health network expansion build for Georgia and Better Health of Texas Medicaid expansion build
• Accountable for all aspects of physician recruitment and contracting
• Fee-for-service, ACO, and value-based care contracting
• Provides network development, maintenance and refinement activities and strategies in support of cross-market network management units
• Considers the end-to-end flow of the business and each area's contribution to Optum's financial and competitive success.

Consults with business partners to ensure services are utilized per contractual agreements, educate and train on new products and policies. Utilized healthcare value-based concepts, Medicare payment methodology, rates, and fee-for-service reimbursement, and value-based contracting methodologies to negotiate and renegotiate group and individual provider contracts. Recruit groups and individual providers to enroll in networks.

Selected Accomplishments:

- Lead HEDIS projects to ensure all data was properly collected, documented, and updated in complex systems.

- Increased San Diego network provider book-of-business by securing and renegotiating approximately $30 million value of contractual agreements, while resolving claim issues which resulted in payment.