Manoj John Tarachand
Frisco,USA
Summary
Results-driven and resourceful professional with extensive experience in developing and negotiating value-based care contracts and fee-for-service rate progress to boost enterprise revenue. Transformational leader with proven expertise in optimizing daily plans, driving process improvements, and integrating enterprise payer / product initiatives with marketplace tactics. Successful in offering sound advice to network partners on Fee for Service, value-based and other negotiations, deal terms, and best practices while enhancing provider performance and partnering with local market to ensure pathways to performance against business and team objectives. Expert negotiator with proficiencies in devising and executing managed care strategies aimed at adapting ongoing healthcare payment reforms and emerging payment methodologies. Able to tactfully negotiate with health plans, MCO, ACO, and Provider FFS and VBP contracts on cost-effective terms. Possess a strong strategic mindset with the ability to see ahead to future possibilities and translate them into breakthrough strategies through utilizing sharp cognitive and logical thinking abilities.
Experienced with strategic planning, team leadership, and operational excellence. Utilizes these skills to drive corporate initiatives and ensure organizational success. Knowledge of fostering collaborative environments and delivering impactful results.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Corporate Director and Administrator Managed Care, Payer Relations, Contracting and Networks
PAM Health Hospital, Voyages Behavioral Hospital System and Professional Group Medical Care
01.2023 - 01.2025
- Led a team of directors, negotiators, and consultants to optimize overall network competitiveness, service, and profitability for the assigned facilities, hospitals, professional care, medical group, multi-specialty practice anesthesiology, Oncology, Ancillary, PBM and other specialty care. Oversees all network management functions, including payer contracting, service, strategic relationships, plan management, and the traditional and value-based contracting strategy for growth. Expertise in the end-to-end aspects of provider contracting, including modeling, configuration, utilization management, claims, and analytics. Directed day-to-day network management functions, including payer, ACO, and Managed Care Organization contracting, service, strategic relationships, plan management, and contracting strategy for growth. Built and maintained relationships with external and internal care providers and their organizations.
- Oversaw the financial analysis of revenue forecasts as per contractual rates with providers, negative trends, terms, and relevant suggestions to drive revenue and potential impact on the financial and economic condition. Disseminated provider-by-network-product participation information for all signed contracts, under-negotiation contracts, and non-negotiated plans. Ensured adherence to contract requirements and resolved reimbursement issues by working closely with revenue cycle groups.
- Initiated, led, finalized, and improved the process of negotiation and completion of new and existing Professional and facility-based agreements and reimbursement with Payor Plans, managed care organizations, and TPAs, which resulted in a revenue Increase of $300M
- Developed Single Case agreements, Letter of agreement, and authorization of care request with various payors to authorized patients to access specialized or out-of-network care while still receiving in-network benefits, ensuring continuity of care and potentially reducing costs, minimizing the risk of Surprise billing, and complying with state and federal governing regulations.
- Work closely with Revenue Cycle, clinical integrity, and the admissions department to maximize total reimbursement yield and ensure that PAM Health, Voyages Health, and Provider Services remain essential to payors.
- Assisted the revenue Cycle Department, Team, and leadership in coordinating with Various Payor executives to ensure claims payment and Reprocessing of Payments are being reviewed and finalized for maximum payments, which resulted in a revenue increase of $100M
- Integrate and align payer strategy with PAM Health's growth and strategic Objectives, including value-based contracting strategies, revenue cycle initiatives, consumerism, digital health, service line development investments, operational process improvement initiatives, and various M&A activities.
- Research and monitor the Insurance Industry, State and Federal regulations, and reform initiatives to inform and improve various department processes, including Managed Care, Admissions, Clinical Care, and Legal services
- Assume leadership role in complex, high-impact negotiations with key payers to ensure financial Viability and optimized contractual terms.
- Create a sustainable managed care structure, process, procedure, and Matrix to ensure (a) proper training, (b) resources for admissions of care, authorizing claims submission, accounts payment, and payor contracting process.
- Oversee the development of a monthly financial dashboard for key performance insight.
- Create clear reports, such as quarterly reports, to summarize managed care negotiations and agreements at the division and individual market levels.
- Lead the development of tools shedding light on the performance of the key contacts and the Payor relationship.
- Coordinated with the Legal department and team in all aspects of lawsuits, arbitration, mediation, and settlements
- Ensure the managed care team is closely aligned with operations to develop and implement relevant managed care initiatives that support areas of growth and opportunity.
- Conduct reviews of the provider network to ensure that cost, coverage, and growth perspectives align with the organization's strategy.
- Assist the Credentialing department in the application process and reenrollment services for professional, individual, and hospital facilities. The payor credentialing Process includes both delegated and traditional procedures.
Director Provider Network Management and Contracting
Elevance Health (Formerly Anthem)
01.2022 - 01.2023
- Led a team of directors, negotiators, and consultants to optimize overall network competitiveness, service, and profitability for the assigned territory. Oversees all network management functions including provider contracting, service, strategic relationships, plan management, and the value-based contracting strategy for growth. expertise in the end- to-end aspects of provider contracting from modeling, configuration, utilization management, claims and analytics. Directed day-to-day network management functions, including provider contracting, service, strategic relationships, plan management, and value-based contracting strategy for growth. Built and maintained relationships with external and internal care providers and their organizations.
- Adopted value-based payment models through working with the VBC network team while directly leading teams to develop, negotiate, and manage complex value-based and Accountable Care (ACO) relationships.
- Accumulated detailed understanding of medical cost issues and medical cost ratios (MLRs) and implemented appropriate action to manage improvement initiatives and scoreable action items.
- Contributed to achieving market and segment goals by providing network strategy support to sales and marketing and assistance on community relations-related items.
- Created collaborative initiatives to improve quality results and manage costs through reviewing analytics with medical economics and working with providers.
- Successfully negotiated complex, competitive contractual relationships with providers as per prescribed guidelines to facilitate achievement of enterprise and local strategies.
- Established provider network through executing strategies for provider recruitment, contract negotiations, and relationship development for large health systems and affiliated physician groups, including employed and hospital-based and hospital-owned ancillary providers.
Director of Managed Care, Contracting, and Networks
Apria HealthCare
01.2021 - 01.2022
- Evaluated ROI and P&L reimbursement goals and outcomes by reviewing payor reimbursement proposals, including deliberating and analyzing Medicare Advantage, commercial, HMO, PPO, exchange, Tricare, dual, and other product plans and member populations.
- Optimized care delivery quality and provider support by determining and qualifying growth prospects and coordinating with payor, providers, ACO, TPA, and service partners.
- Enabled the creation of enterprise-wide clinically integrated networks aligned with defined clinical areas and DME, primary care, multi-specialty, acute and clinical service lines by leading cross-functional and cross-segment teams.
- Launched care models, assessed performances, and eliminated barriers in alliance with the operations department as well as designed and executed effective strategies to attain provider adoption and success.
- Monitored institutional contract approval and review function as per anticipated business and financial needs and examined contract conditions for renewal and termination prior to execution by the authorized authorities.
- Developed and administered revenue integrity functions, including capturing services charge captures while performing ongoing analysis of revenue usage, and identifying continued opportunities aimed at boosting revenue.
VP of Managed Care, Contracts, Credentialing and Networks
Providence Health Care, Sonora Medical, Hunt Hospital Systems and Health Plan
01.2005 - 01.2021
- Informed and discussed operational issues as well as created and followed up plans to address issues by maintaining constant communication with relevant departments involved in the contract process. Supervised network development staff and external consultants to grow provider networks throughout expansion markets to achieve desired outcomes. Administered initial and re-credentialing for medical professionals, facilities, and auxiliary services with health insurance and managed care organizations.
- Met and surpassed expectations of all parties through ensuring fulfillment of contractual obligations, including data exchange, quarterly business reviews, performance milestones, and credentialing.
- Conducted periodic analysis of provider network with cost, coverage, growth perspective, and provider contracting rates with a focus on aligning with targeted company strategy.
- Facilitated forecasted product or service development by remaining well-informed with industry, technology, market, and product trends as well as consistently delivering updates/information to the management.
- Established account-specific goals for facilitating an overall strategic managed care business plan consisting of the potential financial impact of multiple scenarios/circumstances in alliance with the Field Managed Care team.
- Spearheaded the administration of Accountable Care Organization contracts agreement and ACO model program along with networking and contracting with multiple primary care physicians, specialists, and ancillary services with numerous fees for service and value-based payment methods.
Senior Airman
United States Airforce
01.1998 - 01.2004
Education
Bachelor of Science - Business Management
De La Salle University
Philadelphia, PAMaster's Degree - Public Health, Epidemiology
Capella University
Minneapolis, MN01.2017
Skills
- Microsoft Office Suite (Word, Excel, PowerPoint, and Outlook) Sun Coast Epic Allscripts
- Experian Contracts Management Solutions Lawson's SHP Salesforce CONCUR
- CAQH & ECHO Credentialing & Contract Software NextGen Network 360 NCQA Website
Accomplishments
- Generated $800M revenue by directing negotiation of traditional FFS, Value-Based Payment contracts with Health plans and ACOs, involving bundles, shared savings and risk, and the Global and Professional Direct Contracting Model.
- Improved revenue up to $400M by negotiating, and revising agreements, traditional FFS, value-based care model programs, payment system agreements, and care processes between health plans.
- Boosted HEDIS Quality Measures Performance Star Rating and maximized members' satisfaction by optimizing network providers' accessibility / state GAP coverage policies and maintaining sufficient contracted providers including primary care, specialist, acute, and post-acute continuum care.
- Worked with numerous providers, including hospitals, facilities, behavioral care, physicians, physician groups, anesthesiology providers and ancillary providers while utilizing various payment methodologies.
- Managed network gap by establishing preferred provider as well as minimized administrative cost of utilization management programs by focusing on the highest-value intervention.
Certification
- Hospital, PCP, Provider ACO, and Value Base Webinars by CMS, Ongoing
- Public Health Epidemiologist Service Certification, 2020
- UHC Optum Managed Care Network and Contract Optimization
CORE COMPETENCIES & AREAS OF EXPERTISE
- Health Care Contracting Models including Value-based Care, Fee for Service and Bundle Payments
- Health Care Contracting / Credentialing
- Risk Exposure Management
- Reimbursement Business Analysis
- Program and Business Expansion
- Regulatory Compliance Review
- Process Optimization
- Team Training & Leadership
- Relationship Revenue
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Timeline
Corporate Director and Administrator Managed Care, Payer Relations, Contracting and Networks
PAM Health Hospital, Voyages Behavioral Hospital System and Professional Group Medical Care
01.2023 - 01.2025
Director Provider Network Management and Contracting
Elevance Health (Formerly Anthem)
01.2022 - 01.2023
Director of Managed Care, Contracting, and Networks
Apria HealthCare
01.2021 - 01.2022
VP of Managed Care, Contracts, Credentialing and Networks
Providence Health Care, Sonora Medical, Hunt Hospital Systems and Health Plan
01.2005 - 01.2021
Senior Airman
United States Airforce
01.1998 - 01.2004
Master's Degree - Public Health, Epidemiology
Capella University
Bachelor of Science - Business Management
De La Salle University
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