Harry Mapanda
Oxnard,CA
Summary
Proactive and adaptive Operations Leader with more than 15 years of experience in the healthcare industry. Detail-focused team leader who leverages strong analytical and critical thinking skills, utilized and sharpened over the years. Experienced leader with strong background in guiding teams, managing complex projects, and achieving strategic objectives. Excels in developing efficient processes, ensuring high standards, and aligning efforts with organizational goals. Known for collaborative approach and commitment to excellence.
Overview
22
22
years of professional experience
Work History
Healthcare Consultant
Self-employed
02.2023 - Current
- Research of Direct Primary Care model for physicians in the area
- Assisted with regulatory issues such as compliance.
- Created and implemented organizational policies and procedures.
- Consulted with healthcare professionals on business decisions.
- Produced detailed business plans and relevant reports for use in making business decisions.
- Spearheaded the development and execution of marketing strategies for healthcare organizations, raising brand awareness and attracting new patients or clients.
- Implemented process improvements that increased efficiency and reduced waste within client organizations'' operations.
Director of Claims Operations and Claims Compliance
Network Medical Management MSO
05.2022 - 02.2023
- Primarily responsible for all claims operations activities, claims auditing, PDRs and claims compliance for 13 IPAs and 1,2mil members
- Immediately implemented an action plan to reduce aged inventory by over 90% in a 90 day period
- Constructed a new organizational chart based on membership and function to ensure efficiency of processes
- Streamlined processes by function between claims and PDRs
- Created claims metrics and targets and introduced terms such as Days Receipts on Hand (Hand), age timeliness and quality goals
- Forecasted staffing for the PDR and claims compliance teams while also introducing metrics to ensure we meet acknowledgment ad resolution timeframes
- Introduced a claims quality program that the examiners and managers/supervisors would be evaluated against
- Introduced a claims monitoring program to self audit and proactively correct mistakes before any Health Plan audit
- Championed a training program which resulted in NMM hiring a Claims Trainer to draft a plan and deploy it
- Spearheaded the need for a vendor to assist with our inventory management based on current staffing levels
Director, Operations Oversight and Network Development
AmericasHealth Plan
10.2018 - 11.2020
- In conjunction with the CEO strategies, was responsible for MSO operations oversight of claims, customer services and all health plan compliance reporting
- Establishing of operational key performance indicators
- Creating and recommending of operational efficiencies
- Recommendation of inventory action plans where necessary
- Creation and implementation of Electronic Funds Transfer (EFT) by working across departments
- Initiate and implement workflows for contracting, provider relations and communication with departments
- Assist compliance officer with all operational functions and questions
- Assist compliance officer and MSO operations on regulatory preparedness
- Preparing of corrective action plans to the MSO where applicable
- Creation of robust provider relations function including policies and procedures, key metrics and provider engagement through joint operations meetings and discussions
- Assessment of network adequacy
- Filling of provider gaps through network development
- Creating and implementation of a provider directory process
- Initiate and implement policy and procedures related to provider relations and network management
- Analyze and update of the provider manual
- Initiate project for website enhancements
- Initiate and complete project for phone tree efficiency
- Assumed outreach and member enrollment responsibilities and by creating a path to increase enrollment, was able to increase enrollment by 5.4% over 6 months
- Working with parent Plans to create annual strategies that allow for member retention
- Key contributor to organizational growth strategy
Director, Management Administration and Operations Oversight
Adventist Health Plan
04.2018 - 06.2018
- Responsible for the operational oversight of the vendor used to administer services, including claims, UM, grievance and appeals, quality and credentialing
- Ensured that the service level agreement was adhered as well making sure that state guidelines were followed
- Implemented the case management program between the two entities
- Initiated the 340B program that has now been implemented
- Created communication channels between the two entities to ensure we were all on the same page and moving in the same direction
- As the mediator between the two entities, it was my responsibility to understand the vendor processes but also understand what the plan wanted and find ways of fusing the two to be successful
- Involved in provider related issues in relation to claims and UM concerns
- Assisted the Director of network management in find ways to increase access through plan to plan partnering as well as provider contracting
Network Operations Manager
Gold Coast Health Plan
04.2015 - 04.2018
- Overall responsibility of the provider relations function which included providers, access and availability, provider directory, provider manual, provider database, provider projects
- Creating policies and procedures for provider relations staff and ensuring there were job aid manuals available
- Understanding and implementing state regulations
- Creating training and education programs for providers to ensure state guidelines are being followed
- Creating of workflows and documentation related to provider site visits and provider orientations
- Institution of joint operations meetings with our big providers
- Provider network development
- Involved in the bringing in of critical contracts based on network adequacy gaps
- Ensuring that we had all the data needed to contract with the right specialists to close access gaps
- Monitoring and ensuring we were meeting access and availability standards
- Point-person for all regulatory audits i.e., DHCS and HSAG audit with year over year improvements with zero findings in 2017
- Business lead on all provider related regulatory projects i.e., SB137 (directory), Managed Care Data Improvement Program (274 Transaction)
- Personnel development and training resulting in career progression for 50% of my staff
- Claims and communication training of staff
- Process improvement business lead
Senior Claims Manager
Wellpoint/Anthem
01.2008 - 01.2015
- Primary focus is the management of claims metrics through managing staff and inventory
- Managed up to 60 associates as well as another 60 offshore vendor associates
- Claims’ metrics included timeliness, aged, and quality which was broken down into financial and statistical goals
- Goals were based on state requirements i.e.: 90% processed within 30 days, as well as internal goals, such as 5% volume over 30 days, 5 days’ work on hand (DWOH)
- My team achieved consistent results of over 99% timeliness 30 days over a 2-year period as well as an average of 1% aged over a 1-year period
- Quality scores achieved were over 99%
- All of these metrics exceeded state and internal goals
- Provider relations direct point of contact: Handled high profile providers in California; assisted with provider training and education; face to face meetings with hospitals/providers to reduce provider abrasion and promote confidence in the organization
- Handled claims compliance reporting for several states
- Point of contact and department representative for state audits
- Created action plans necessary to ensure associate and department metrics were achieved
- Directly involved in any enterprise and organizational projects involving systems migrations, configuration, and pricing
- Helping write and test requirements for systems migrations/upgrades
- Heavily involved in staff development
- Succeeding in promoting 50% of the associates within the department
- Achieved high manager effectiveness ratings from associate surveys and had extremely low attrition from my team
- Strong communication and motivational skills as well as being able to create a team that wants to work together to be successful
- Conducted thorough investigations of complex claims, gathering evidence to support decision-making processes.
- Improved claims processing efficiency by implementing streamlined workflow procedures.
- Developed training materials to ensure consistent handling of claims across the department.
- Negotiated settlements with claimants, achieving fair outcomes while controlling costs.
- Mentored new hires on company policies/procedures enabling them to quickly become proficient in managing claims.
Claims Associate I-Senior
Wellpoint/Anthem
02.2003 - 12.2007
- Primary focus: processing claims
- Processing all claims types including specialty and coordination of benefits
- Training and auditing new hires and existing associates
- Helping write and test requirements for migrations and system upgrades
Education
BS - Healthcare Management
Western Governors University (WGU)
12-2025
Skills
- Managing/Training Associates
- Issue resolution
- Communication/Motivation
- Claims Processing
- Microsoft Office
- Several different claims systems eg WGS/STAR/Facets, QuikCAP EZCAP
- Compliance
- Regulatory Requirements
- Healthcare Policy
- Healthcare Training
- Healthcare Auditing
Timeline
Healthcare Consultant
Self-employed
02.2023 - Current
Director of Claims Operations and Claims Compliance
Network Medical Management MSO
05.2022 - 02.2023
Director, Operations Oversight and Network Development
AmericasHealth Plan
10.2018 - 11.2020
Director, Management Administration and Operations Oversight
Adventist Health Plan
04.2018 - 06.2018
Network Operations Manager
Gold Coast Health Plan
04.2015 - 04.2018
Senior Claims Manager
Wellpoint/Anthem
01.2008 - 01.2015
Claims Associate I-Senior
Wellpoint/Anthem
02.2003 - 12.2007
BS - Healthcare Management
Western Governors University (WGU)
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