Laura Breisch
Melbourne,FL
Summary
Leader of Risk Adjustment, STAR and HEDIS teams with experience on the vendor side along with health plan experience with an Insurance Tech Organization and previously with an Integrated Delivery Network, with specialized expertise in developing programs to effectively comply with the rules and regulations of federal oversight agencies. As a leader, developed teams of highly functional professionals who consistently exceed operational goals and customer service expectations. Highly skilled in implementing and maintaining governance, risk and compliance frameworks. Focus on strategy development, implementation of repeatable processes, and metrics-driven management. Expert and thorough knowledge of the guiding principles, financial requirements, operations, and regulations for:
- Risk Adjustment Operations and Auditing
- Medicare Advantage STAR program
- HEDIS
- ACA/QHP Marketplace
- Medicare Advantage Plans (Part C) - Prescription Drug Plans (Part D)
- Member Engagement
- Compliance/Regulatory
- Value Based Contracting/Provider Incentives
Overview
28
28
years of professional experience
1
1
Certification
Work History
Vice President of Risk Adjustment Coding Operations
Datavant
08.2023 - Current
- Oversee over 7,000 offshore and onshore coders.
- Manage coding vendor relationship and implementations.
- Responsible for monitoring and ensuring the client value and quality performance is met for each coding project.
- Provide feedback and direction on product enhancements and science model updates.
- Re-aligned the Coding Operations team and built a quality department to oversee vendor and client performance.
- Led strategic initiatives to enhance organizational efficiency and drive growth.
- Directed cross-functional teams to achieve operational excellence and improve service delivery.
Chief Operations Officer
Second Wave Delivery Systems
02.2023 - 08.2023
- Strategically re-aligned the operations team including Client Delivery and Coding Operations to be more efficient and effective.
- Implemented ACA and ACO lines of business for new product offerings.
- Launched client friendly and actionable reporting.
- Launched client implementation plans for new and existing clients.
- Built out client communication strategy and materials.
Vice President of Value Capture
Oscar Health
10.2019 - 02.2023
- Strategically built out the Value Capture Organization which includes, STARs, HEDIS and Risk Adjustment
- Implemented vendor solutions for coding activities and chart retrieval efforts
- Built an entire Value Capture team from the ground up
- Lead four directors, Senior Director of Revenue Operations, Director of STARs and Associate Director of Program Management, and an Associate Director of Analytics with a department size of 50 and still growing
- Engage and educate senior level staff members including Board members on STARs and Risk Adjustment.
- Launched various Risk Adjustment solutions such as Virtual Health Assessments, IHAs, member campaigns and point of care tools
- Established collaborative partnerships with providers to drive alignment on key strategic objectives
- Played a pivotal role in aligning provider incentives with organizational goals.
- Implemented a governance structure for STARS and Risk Adjustment
- Launched a STARS work plan
- Responsible for platform clients Risk Adjustment and STARS performance
- Manage the overall operations of coding activities, HEDIS abstraction, and chart retrieval efforts
- Monitor performance with daily reporting including our STARS measures
- Established performance metrics to evaluate program effectiveness, driving continuous improvement across departments.
Vice President of Performance Improvement
Health First Health Plans
10.2004 - 10.2019
- Optimize business performance by coordinating with internal and external partners as it relates to Risk Adjustment and STARs.
- Successfully integrated the STAR and Risk Adjustment Team under one executive oversight.
- Increased STAR score from 3.96 to 4.11 in one year.
- Implemented the STARs workgroups and the executive committee.
- Responsible for over 250 million dollars a year in Risk Adjustment efforts, with 75 million of those dollars due to Risk Adjustment prospective and retroactive programs.
- Strategically position the organization for success in terms of STAR ratings, Member Engagement, and Risk Adjustment revenue.
- Lead two directors, Director of Revenue Operations and Director of Member Engagement with a department size of 100 associates.
- Build and maintain a cohesive leadership team and front-line staff.
- Engage and educate senior level staff members including Board members on STAR and Risk Adjustment.
- Executive oversight of NCQA accreditation efforts.
- Partnered with stakeholders to operationalized value based contracts, integrating clinical, financial and quality metrics into performance framework for both employed and independent providers within our network
- Fostered partnerships with key stakeholders at the provider groups to align on goals and objectives
- Directed cross-functional teams to optimize member engagement and satisfaction metrics.
Director of Government Programs and Revenue Operations
Health First Health Plans
01.2010 - 12.2017
- Managed regulatory operations for a 160k member health plan which held a contract with the Centers for Medicare & Medicaid Services to administer a Medicare Advantage, Prescription Drug Plan, and Qualified Health Plan certification.
- Lead 9 regulatory professionals and 22 risk adjustment auditors in meeting state and federal laws, rules and regulations as well as the health plans’ contractual obligations with CMS and the State of Florida for the Commercial and Third Party Administrator lines of business.
- Responsible for the oversight of the HEDIS operations.
- Prepared and submitted annual MAPD bids.
- Interpreted regulations and implemented operational changes, policies and procedures to abide by newly enacted laws and updated guidance from governing bodies.
- Work with Corporate Compliance on high-risk areas through annual risk assessments and routine auditing of all health plan business, recommended process improvements, implemented corrective action and communicated with federal officials when self-disclosure was necessary.
- Prepared and submitted OIR state filings.
- Built and maintained positive relationships with governmental staff, state, and federal auditors to ensure the health plan’s position was positively and successfully represented.
- Prepared and submitted QHP/Marketplace filings.
- Actively participated in proactive decision making, presenting all regulatory concerns, and educating leadership on contractual obligations and potential areas of risk.
Compliance Manager
Health First Health Plans
01.2009 - 01.2010
Lead Compliance Analyst
Health First Health Plans
01.2004 - 01.2009
- Assisted in leading annual bid process.
- Responsible for all Medicare marketing materials.
- Subject matter expert for Medicare Advantage.
- Developed processes for Prescription Drug Event Data (PDE).
- Co-created the Medicare Risk Adjustment program. Hired and trained all coding associates responsible for auditing charts for loss revenue.
- Developed the annual financial bid in accordance with the CMS regulations as well as all supporting program documents including the Evidence of Coverage and Member Handbook.
Claims Supervisor
Hallmark Services Corporation (Blue Cross and Blue Shield of IL)
03.1999 - 03.2004
- Responsible for auditing and training associates on Underwriting and Claims Procedures.
- Participate in Risk Management weekly meetings.
- Responsible for re-underwriting individual policies for rescission review.
- Developed claims processing guidelines, production metrics, and information system build for the commercial and Medicare lines of business.
Claims Specialist
The Resource Group/AON Corporation
03.1997 - 03.1999
- Responsible for claims review for possible pre-existing and rescission
- Training of new staff
Education
Master of Business Administration -
Florida Institute of Technology
Melbourne, FL01.2020
Bachelor of Science - undefined
Marquette University
Milwaukee, WI01.1996
Bachelor of Science - undefined
St. Bonaventure University
Olean, NY01.1993
Skills
- Team leadership
- Relationship building
- Decision-making
- Critical thinking
- Coaching and mentoring
- Client relationship building
- Business development
- Strategic planning
- Results-driven
Certification
2007 Professional Academy for Healthcare Management (PAHM), America’s Health Insurance Plans
Accomplishments
- Effectively built out an operations team that consisted of client delivery and coding operations.
- Successfully integrated the Risk Adjustment, HEDIS, and medical record retrieval departments under one leadership.
- Implemented the STAR program for an Integrated Delivery Network.
- Built the foundation for the direct oversight of the STAR program- developed the 4 workgroups (Regulatory and Operations, Health Outcomes, Provider Engagement, and Member Engagement Committees), and chair the STAR Executive Committee.
- Developed the Medicare Risk Adjustment program, hired and trained all coding associates responsible for auditing charts for loss revenue.
- Built a team of over 100 employed risk adjustment coders who are responsible for auditing, coding production, and analytics. Successfully implemented Prospective Comprehensive Health Assessment along with the CDI program with the integrated delivery network for both Medicare Advantage risk adjustment and Marketplace risk adjustment.
- Led over 25 independent audits by both state and federal officials in all aspects of health plan business including CMS Medicare Bid (payor) audits, One-Third Financial audits, RADV audits, OIR financial examination without any significant findings.
- Implementation of the new Prescription Drug benefit known as Medicare Part D.
- Leadership of the Medicare Bid Team since 2005 which submitted and negotiated an annual Bid to the federal government allowing us to offer a successful Medicare Advantage product.
- Implementation of the new QHP/Marketplace product lines in 2013.
- Sought after speaker with federal and state legislators on a variety of health care and leading industry best practices topics.
Publications
- July 2013 – “Health Care Reform: Is Your Business Prepared”, Contributor, Space Coast Business Magazine
- October 2012 “Understanding the Financial Impact of Health Care Reform on Local Business”, Brevard County Commissioners
- RISE Conference – Speaker in AZ in December 2017, Topic NLP in Risk Adjustment
- Health Plan Alliance Speaker- Combining Risk Adjustment and HEDIS
- August 2019 Health First Instagram post- Importance of CHA in preventive healthcare
Vision
Adapt and adopt leading Medicare Advantage and QHP best practices in healthcare environments while balancing the needs of the customer with financial operations and regulatory expectations.
Other Work Experiences
Lilac Software
Advisor
July 2023 to Present
· Provide strategic insight and recommendations as it relates to STARS metrics.
Timeline
Vice President of Risk Adjustment Coding Operations
Datavant
08.2023 - Current
Chief Operations Officer
Second Wave Delivery Systems
02.2023 - 08.2023
Vice President of Value Capture
Oscar Health
10.2019 - 02.2023
Director of Government Programs and Revenue Operations
Health First Health Plans
01.2010 - 12.2017
Compliance Manager
Health First Health Plans
01.2009 - 01.2010
Vice President of Performance Improvement
Health First Health Plans
10.2004 - 10.2019
Lead Compliance Analyst
Health First Health Plans
01.2004 - 01.2009
Claims Supervisor
Hallmark Services Corporation (Blue Cross and Blue Shield of IL)
03.1999 - 03.2004
Claims Specialist
The Resource Group/AON Corporation
03.1997 - 03.1999
Bachelor of Science - undefined
Marquette University
Bachelor of Science - undefined
St. Bonaventure University
Master of Business Administration -
Florida Institute of Technology
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