DONNA D. RUBY
Dayton,OH
Summary
Results-driven managed care operations leader and subject matter expert (SME) with 20+ years of progressive experience across Medicaid, Medicare, Medicare Advantage, and Commercial lines. Recognized for building high-performing provider networks, leading Joint Operating Committees, and delivering measurable improvements in provider satisfaction, network adequacy, HEDIS outcomes, and Star Ratings performance. Brings specialized expertise in value-based contracting, contract configuration, fee schedule development, payment accuracy, and audit reporting, with competencies that directly protect network integrity and reduce operational risk. Experienced in grievance and appeals resolution, provider database management, and data-driven process improvement. Deep knowledge of CMS, URAC, and NCQA regulatory compliance with a proven ability to work independently, manage competing priorities, and drive cross-functional collaboration across all lines of business.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Sr Implementation Manager
Meritain Health
Remote
04.2025 - 11.2025
- Led end-to-end contract negotiations and agreement execution, optimizing network composition, specialty distribution, and geographic adequacy to support strategic growth.
- Served as subject matter expert (SME) and mentor to contracting staff, driving consistent performance standards and alignment with organizational objectives.
- Championed cross-functional collaboration to drive measurable improvements in provider satisfaction scores and implement key policy and program changes.
- Ensured full alignment of network strategy with CMS, URAC, and Medicaid/Medicare regulatory requirements while independently managing competing priorities.
- Led cross-functional teams to implement health plan solutions, ensuring alignment with client objectives.
- Streamlined project management processes to enhance operational efficiency and improve service delivery timelines.
- Served as a trusted advisor to clients during implementations, providing expert guidance and recommendations based on extensive industry experience and knowledge.
Provider Relationship Account Manager
UnitedHealthcare
01.2023 - 04.2025
- Managed a high-volume portfolio of provider relationships through proactive on-site and virtual engagement, building trust and long-term partnerships.
- Chaired Joint Operating Committee (JOC) meetings, facilitating resolution of complex operational and contractual issues while maintaining positive provider relations.
- Delivered targeted provider education on policies, programs, and operational changes, reducing friction and consistently improving first-contact resolution rates.
- Monitored provider performance against scorecards and quality measures, driving continuous quality improvement in alignment with regulatory requirements.
Provider Contract Specialist
UnitedHealthcare
01.2021 - 01.2023
- Translated complex contract language into precise system configurations, ensuring accurate payment processing, correct reimbursement rates, and full regulatory compliance.
- Developed, implemented, and maintained fee schedules across a diverse provider network, ensuring payment accuracy and alignment with contracted rates for all lines of business.
- Onboarded new providers end-to-end and conducted routine audits to identify discrepancies, protect network integrity, and maintain data accuracy.
- Partnered with cross-functional teams to proactively identify and resolve payment discrepancies, reducing financial risk and strengthening provider trust.
Medical Management Specialist II
UnitedHealthcare
01.2019 - 01.2021
- Coordinated clinical case intake, triage, and care coordination across internal and external stakeholders, ensuring seamless and compliant service delivery.
- Maintained thorough documentation and operated independently to manage caseloads in alignment with all regulatory and operational guidelines.
Grievance & Appeals Representative II
UnitedHealthcare
01.2017 - 01.2019
- Investigated and resolved complex provider and member grievances and appeals in full compliance with CMS and internal guidelines, consistently delivering timely and accurate outcomes.
- Analyzed and documented case details with a high standard of accuracy, ensuring audit-ready records and full regulatory compliance across all resolutions.
- Strengthened provider and member relationships through clear, professional communication and proactive follow-through on all outstanding issues.
Facets Configuration Analyst
CareSource
Dayton, OH
01.2011 - 01.2017
- Build and update Facets components including Group, Class, Plan (GCP), provider reimbursement, and benefits packages.
- Configure NetworX pricing rules and troubleshooting claim pend issues to ensure accurate, automated adjudication.
- Convert business rules, provider contracts, and CMS regulations into technical system configuration.
- Perform testing activities, including system integration testing (SIT) and user acceptance testing (UAT), utilizing SQL queries to validate backend setups.
- Maintain detailed records of configuration changes and workflows
- Analyzed system configurations to ensure compliance with industry standards and organizational policies.
- Developed and documented configuration management processes to enhance operational efficiency.
- Managed configuration changes by maintaining accurate records and version control of system settings.
- Conducted impact assessments for proposed changes, minimizing disruption to ongoing operations.
Senior Claims Analyst
CareSource
Dayton, OH
01.2007 - 01.2011
- Processed complex Medicaid and Medicare claims with high accuracy across eligibility verification, reimbursement, adjustments, and recovery.
- Managed provider inquiries and claim adjustments, maintaining strong relationships through responsive and accurate resolution of reimbursement issues.
Pre-Authorization Specialist II
CareSource
Dayton, OH
01.2003 - 01.2007
- Managed pre-certification, authorization, and referral processes while coordinating provider communications and ensuring compliance with benefit requirements.
- Served as primary point of contact for providers on authorization status and benefit inquiries, supporting efficient care coordination.
Education
Bachelor of Arts - Healthcare Administration
Indiana Wesleyan University
Skills
Facets
Provider Data Management Systems
Claims Processing & Adjudication
Medical Management Systems
Provider Relations & JOC Leadership
Payer-Provider Relations & Escalation Management
Network Strategy
Adequacy & Optimization
Network Development & Provider Onboarding
Contract Negotiation & Value-Based Contracting
Provider Education
Outreach & Dispute Resolution
Regulatory Compliance (CMS / URAC / NCQA)
Medicaid
Medicare
Medicare Advantage
HEDIS & Star Ratings
Managed Care Operations
Grievance & Appeals Management
Pre-Authorization & Utilization Management
Provider Database Management & Auditing
Fee Schedule Development & Payment Accuracy
Process Improvement (Six Sigma Green Belt)
Quality Improvement & Performance Monitoring
Certification
- Exploring Leadership Certification, 2016
- Certified Provider Enrollment Specialist 2019
Timeline
Sr Implementation Manager
Meritain Health
04.2025 - 11.2025
Provider Relationship Account Manager
UnitedHealthcare
01.2023 - 04.2025
Provider Contract Specialist
UnitedHealthcare
01.2021 - 01.2023
Medical Management Specialist II
UnitedHealthcare
01.2019 - 01.2021
Grievance & Appeals Representative II
UnitedHealthcare
01.2017 - 01.2019
Facets Configuration Analyst
CareSource
01.2011 - 01.2017
Senior Claims Analyst
CareSource
01.2007 - 01.2011
Pre-Authorization Specialist II
CareSource
01.2003 - 01.2007
Bachelor of Arts - Healthcare Administration
Indiana Wesleyan University