Katherine Lugo-Delgado

Develops the provider network through contract negotiations and relationship development with complex providers which includes large institutional providers, large medical groups and ancillary providers, value-based concepts understanding and support, and providers in areas with strong competition or where greater provider education around managed care concepts is required.

• Establish high-level provider-specific contracting strategy for product/network development and expansions into other markets for multiple health plans
• Interpret Cost of Care and Access reports to develop cost initiatives to meet financial goals; renegotiated a facility contract of $6M that tied into a Value-Based Payment (VBP) resulting in future cost savings for in-patient services
• Model complex high level reimbursement financial cost reports to determine impact to cost, membership and network Commercial and Government product lines
• Drive Value-Based Payment (VBP) agreements to reduce in-patient cost of care
• Collaborate with multiple internal business areas such as Medical Economics, Clinical, Provider Relations, and Claims to ensure all needs are met
• Spearhead complex contract negotiations across national markets, driving strategic partnerships and optimizing provider networks
• Create customized reimbursement schedules to support terms negotiated such as case rates, bundle rates, and specialized services
• Monitor government updates nationally to ensure contracts are within compliance according to regulatory guidelines of that state

Serves as the single point of contact for Provider Relations and Cost of Care staff for Provider Operations. Manages the end to end process related to the development, configuration and loading of provider reimbursement and demographics in order to maintain provider networks and contracting initiatives

• Executes on provider specific contracting strategy for Product/Network development and expansion
• Review data to evaluate rate increase requests and provider recruitment
• Identify root-cause issues to determine cause and possible solution recommendations (ICPR Model)
• Respond to requests from clinical, grievance & appeals, and providers
• Ensure government lines of business are loaded to the correct benefits and services are configurated appropriating according to state guidelines.

Ensure provider contracts are operationalized according to the correct reimbursement methodology negotiated. Lead governmental projects and ensure teams are educated on regulatory requirements. Identify network service gaps within government lines of business to address client need.

• Reviews pricing methodology in provider contracts to ensure it is administratively feasible.
• Validates fee schedules to ensure they are systematically operationalized
• Develops and maintains relationships with Provider Data Management, Provider Pricing, Healthcare Analytics, and Cost of Care staff to ensure successful and proficient daily operations; Audit previously negotiated contracts to find potential cost savings
• Identified $3M in cost savings within Federally Qualified Health Centers Article 28 in New York State.
• Project lead for government integrated services such as Adult and Children Home & Community Based Services, Opioid Treatment Programs, Mobile Crisis, and Children Foster Care Services
• Responsible for all development and implementation of the provider network such as independent practitioners, providers, and other specialized service providers
• Utilize market driven data to develop favorable contract arrangements for organization
• Monitor provider contract claim activity and prepare reports in conjunction with the finance department
• Coordinate contracting efforts with clinical, quality management, network, finance, and claims departments

• Negotiated contracts and manage relations between Emblem and over 3,000 statewide ancillary providers in accordance with budget and network development goals and initiatives. Negotiated rates and language terms of agreements, ensuring accurate contract and rate load implementations.
• Developed provider contracting strategies and identify provider reimbursement methodologies and trends. Drafted strategic reports and analysis, developing detailed financial models for contract negotiations.
• Recommend innovative contract strategies to maximize cost containment, access and quality; and identified contract opportunities and needs within network based on quality, access, and financial metrics.
• Developed network recruitment strategy for Managed Long-Term Care (MLTC) and Fully Integrated Duals Advantage (FIDA) lines of business for long-term care population.
• Obtained credentialing documentation and collected reporting data for NY State Health Provider Network (HPN).

• Negotiated contracts in conjunction with clinical and marketing communication; and negotiated corporate-level agreements with ancillary services.
• Participated in all aspects of provider identification and network recruitment, including credentialing.
• Performed network analysis to ensure compliance with NYS and primary care capacity and specialty access availability requirements. Facilitated provider recruitment and education for Comprehensive Primary Care Initiative (CPCI).
• Provided network analysis regarding all NYS Healthcare Effectiveness Data and Information Set (HEDIS) and NYS Quality Assurance Reporting Requirements (QARR).
• Worked with physicians to identify any technological incompatibilities with systems; and assisted legal counsel in executing agreements, ensuring that provider profiles were loaded accurately.
• Assigned to ancillary recruitment project for state implementation; Recruited and managed network sufficiency of ancillary providers for all counties for specialty services (long-term care network).
• Handled contract negotiations for ancillary providers such as DME services, Consumer Directed Personal Assistance Program (CDPAP), skilled nursing facilities, meals on wheels, and transportation services

Developed and implemented marketing strategies to promote health plan services and increase enrollment in targeted communities. Represented the organization at community events, facilitated enrollment in NYS-sponsored health insurance programs, and provided ongoing support to members in understanding and utilizing their plans. Developed and presented health plan information to community-based organizations.