Michael Krusen
Mount Ephraim,NJ
Summary
Performance-driven Vice President with 20+ years of experience aligning systems with business requirements, policies and regulatory requirements. Passionate about applying excellent organization and communication skills to manage and lead teams. Results-oriented individual well-versed in interfacing and consulting on business processes to drive results based on sound overall business judgment.
Overview
27
27
years of professional experience
Work History
Vice President, Provider Network Operations
Jefferson Health Plans (formerly Health Partners Plans)
09.2019 - Current
- Lead 60 staff member network management team responsible for managing provider relations, credentialing, provider data management and provider reporting functions for network of more than eighty thousand provider records
- Develop and manage multi-million-dollar budget
- Developed, implemented and currently lead integrated provider engagement strategy, which has led to increased participation, improved quality scores and shared goals between payor and provider
- Developed and manage value-based payment relationships, with critical focus on contract performance and return-on-investment
- Co-led multi-state network development initiative to expand all product lines, more than tripling size of network, with responsibility for contracting, credentialing and provider data management functions
- Developed and implemented process improvements in credentialing and provider data management to allow for improved turn-around on data loading
- Implemented monthly review of claim denial trending to determine changes related to provider data setup, improving proactive identification and resolution of issues prior to being notified by providers
- Implemented routine provider setup reconciliation process with key provider groups, reducing back-end claim and authorization issues
- Designed, implemented and manage provider portal functionality to ensure appropriate diagnosis coding to manage risk of members, resulting in increased revenue
- Developed, implemented and manage credentialing and provider management functions, supporting MCOs successful obtainment of NCQA accreditation through 5 consecutive surveys
- Integrated membership growth focus into key provider relationships, working with sales and marketing leadership to develop partnerships that fuel growth for both provider and payor
- Implemented and facilitate joint operating committees with key health systems and large provider groups, working with executive and senior leaders to analyze quality and financial performance and collaborate on program enhancements and collaborative opportunities.
- Demonstrated proficient leadership skills to motivate employees and build competent teams
- Analyzed industry trends and tracked competitor activities to inform decision making
Director/AVP, Provider Network Management
Health Partners Plans
02.2009 - 09.2019
- Direct oversight of diverse provider relations and credentialing teams responsible for servicing of network as well as all credentialing and recredentialing functions
- Developed and implemented robust provider education approach using web-based technology to reach broader audience
- Increased provider engagement across network and enhanced overall provider experience
- Developed and implemented process improvements to improve credentialing and provider data entry turn-around-time and improve provider experience
- Created provider data validation process to meet CMS standards which improved accuracy of provider data in directories
- With 65% response rate to quarterly outreach, improved accuracy of directory data by 70%
- Implemented portal-based functionality to manage diagnosis coding on claims to improve risk scores across multiple products
- Created NCQA compliant processes allowing for optimal performance on required standards.
- Established performance goals for department and provided methods for reaching milestones
- Mitigated regulatory risks by overseeing adherence to CMS, DHS and DOH regulations
Field Account Representative
NaviMedix
Boston, MA
05.2005 - 02.2009
Provider Relations Representative
Cigna
Jersey City, NJ
08.1996 - 05.2005
Skills
- Budget Oversight
- Process Optimization
- Policy and Procedure Development
- Project Oversight
- Account Management
- Complex Problem-Solving
- Analytical and Critical Thinker
- Operational Analysis
- Change and Growth Management
- Coaching and Mentoring
- Process Improvement
- Performance Monitoring
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Quote
Far and away the best prize that life offers is the chance to work hard at work worth doing.
Theodore Roosevelt
Timeline
Vice President, Provider Network Operations
Jefferson Health Plans (formerly Health Partners Plans)
09.2019 - Current
Director/AVP, Provider Network Management
Health Partners Plans
02.2009 - 09.2019
Field Account Representative
NaviMedix
05.2005 - 02.2009
Provider Relations Representative
Cigna
08.1996 - 05.2005
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