MICHELLE RUSH
Managed Medicaid Executive
Savannah,GA
Summary
Healthcare executive that successfully manages process improvement projects and interfaces with stakeholders to deliver strategies on operational compliance; ensuring provider organizations are compliant with State and Federal regulations. Exceptional communicator who effectively interacts with internal and external partners to define appropriate approaches, identify best practices, and solutions while continually influencing others to embrace organizational change.
Overview
18
18
years of professional experience
Work History
Director, Medicaid State Operations
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2018 - 02.2024
- Responsible for continuing operations of Georgia Health Plan; direct development, planning, prioritization, approval, implementation, and compliance of program under general guidance of Health plan president Oversight for Credentialing Verification Organization (CVO) loads, Applied Behavioral Analysis (ABA) designations, provider terminations, Provider Operations Strategy, Health Plan Reporting and Analytics, Claims processing , Statement of work approval , Research , Pricing updates, State Continuous improvement committees (CPI) plan representative , Vendor oversight , Encounters , GAHIN, IT account management liaison, RCR IT plan liaison, GEO production and maintenance, Access and availability surveys, Medical Advisory Committee, Quality Management Committee and run SQRC committee and Network Data Support
- Implemented Data Transfer Utility (DTU) to link and unlink medicaid ids
- Implemented Provider Withhold at direction of Dept of Community Health (DCH)
- Participation in Continuous Process Improvement (CPI) Workgroup with State of GA
- Created and maintain various Provider communications, i.e.; newsletters, provider directories, provider manuals, and Quick Reference Card (QRC)
- Effectively meet needs of State customers by continuously aligning internal and external resources to prioritize and improve provider's administrative experience
- Ensure implementations are executed per specifications of State's requirements and/or provider contracts
- Responsible for certifying all provider contracts and amendments are configured to be reimbursed to providers' negotiated agreement requirements
- Perform Medicaid reimbursement analysis to confirm alignment with State Medicaid requirements
- Oversee system configurations of professional, facility and ancillary providers' reimbursement updates
- Responsible for identifying opportunities to improve efficiency and effectiveness of Operations Unit within Georgia Health Plan
- Serve as liaison between health plan's Contracting Department and National Services to ensure negotiated contracts and administrable within claims adjudication system
- Demonstrate proficiency in understanding all methods of physicians, hospitals and ancillary reimbursement methodologies, as well as implementation of these reimbursement methodologies into claims payment system
- Program Management: Support complex processes - coordinate and support fair hearings, process annual updated provider reimbursement rates and Amerigroup Configuration Change Request submission resulting in User Acceptance Testing (UAT)
- Lead successful implementation of Pathways Product
- Design and Implement contracts to assist HCMS with Healthcare
- Telehealth SME for market own majority of relationships in place
- Oversight of all delegated vendor relationships: Avesis, DentaQuest, Logisticare, Language, AIM , Ground Game Health , Live Health Online, Kare Mobil, GA partnership for telehealth , GAHIN, OneSource, etc.
- Cultivated positive work environment that fostered employee engagement, increased retention rates, and boosted overall team morale.
- Evaluated company documentation to verify alignment with regulatory requirements.
- Leveraged professional networks and industry knowledge to strengthen client relationships.
- Established culture of continuous improvement by fostering open communication channels and empowering employees to voice their ideas.
- Secured key partnerships that contributed to company's overall growth strategy and market reach.
- Proactively identified potential risks and implemented mitigation strategies to minimize negative impacts on projects or business operations.
- Cultivated and strengthened lasting client relationships using strong issue resolution and dynamic communication skills.
- Negotiated favorable contracts with vendors for reduced costs and improved service quality.
- Self-motivated, with strong sense of personal responsibility.
- Exercised leadership capabilities by successfully motivating and inspiring others.
Director, Network Development Network Operations Vendor Oversight (NOVO)
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2014 - 01.2018
- Managed team of 5 SME to oversee vendor relationships , complete and maintain all regulatory requirements for plan Provider Service Organization (PSO)
- Oversight and coordination of all PSO audits: i.e., HSAG, ISCAT, and NCQA
- Coordinated all Provider communications, i.e., newsletters, provider directories, provider manuals, and (QRC)quick refrence card.
- Ownership of design and maintenance of provider website
- Oversight of all delegated vendor relationships: Avesis, DentaQuest, Logisticare, OneSource, etc
- Liaison between corporate procurement department and Health Plan for new vendor agreements
- Responsible for all PSO Medicaid regulatory reporting
- Developed and oversaw all geographic (GEO) access development process
- Oversaw implementation of new products.
AVP, Network Management
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2012 - 01.2014
- Lead team of 60 associates to service state of GA building and maintaining relationship with Providers to educate them on Medicaid managed care
- Cultivated strategic relationships with internal constituents and built new relationships with external providers and provider networks to promote organizational goals and growth
- Drove Network Management and Provider Services to achieve and surpass performance metrics, profitability, and business goals and objectives
- Led employee compliance and effectiveness of all Business Standards of Practice, including project management and other processes, internal and external
- Provided timely, accurate, and complete reports on network operating conditions
- Developed policies and procedures for Network Management and Provider Services
- Spearhead collaborative efforts related to network development, communication, and implementation of effective growth strategies
- Led implementation of innovative programs and services
- Motivated and led high-performance management team; trained, developed, coached, and retained employees while fostering success-oriented and accountable environment
- Assured compliance and consistent application of laws, rules, and regulations, and company policies and procedures for Network Management and Provider Services
- Coordinated, managed, and maintained all contractual, legal, delegated, and alignment agreements with participating providers and provider groups
- Developed and implemented Provider Relations projects and assignments to support local Health Plan and corporate goals
- Developed and implemented provider servicing model later used as a best practice across entire enterprise.
- Collaborated with CEO and entire health plan senior management team to determine plan's provider contracting needs
- Partnered with CEO and other appropriate senior management to develop business plan, strategies, and goals related to network expansion, and provider contracting, education, communication, policies, procedures, and services
- Supported health plan's CEO in strategic analysis and negotiation of complex provider contracts
- Collaborated with Medical Finance department and other national departments to review health plan's financial information
- Monitored local market trends for provider contracting, reimbursement, and services; made recommendations to modify processes and assisted in implementing necessary updates
- Developed, implemented, operated and oversaw provider marketing efforts with Marketing leader and team
- Collaborated with senior management to resolve escalated provider issues by implementing strategies for issue resolution and monitored progress.
Regional Director of Operations
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2006 - 01.2012
- Opened Savannah Amerigroup office in August of 2006
- Oversaw day to day operations of filed office as well as managed network team
- Directed new market network development, expansion, and acquisition initiatives; and execution of provider network development strategies
- Coordinated marketing efforts with regional headquarters
- Responsible for development of relationships and negotiations with providers, provider organizations and community leaders to promote continuing provider servicing and education
- Coordinated interdepartmental network development and implementation processes and project plans management
- Directed new market, network, and provider research and analysis
- Prepared provider network recommendations and projections
- Successfully led recruiting efforts to develop Provider Medicare Network and secured major healthcare systems contracts
- Developed Provider Relations training manuals for onboarding employees
- Oversaw all State reporting functions for Provider Relations, including Geo Access reports and response to Corrective and Preventive Action (CAPA) plans issued by DCH quarterly Provider Access and Availability Survey process
- Responded to External Quality Review Organization (EQRO), ISCAT and NCQA audits.
- Created general communications for provider network distribution, and maintained and updated provider manuals to meet State requirements
- Analyzed business operations and implemented strategies to improve operational cohesiveness.
Provider Experience Representative
Humana Military
- Negotiated favorable contract terms with providers, ensuring mutually beneficial agreements that contributed to long-term partnerships.
Education
Skills
- State Medicaid (MCOs)
- Contract Compliance Management
- Government Relations
- Provider Service and Network Development
- Organizational Project Management
- Client and Vendor Relationship
- Risk Management - Tracking and Resolution
- Strategic Planning
- Analytical and Critical Thinking
- MS Office
- PaySpan, Emptoris, Salesforce, SPS, Facets, Macess
Timeline
Director, Medicaid State Operations
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2018 - 02.2024
Director, Network Development Network Operations Vendor Oversight (NOVO)
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2014 - 01.2018
AVP, Network Management
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2012 - 01.2014
Regional Director of Operations
Elevance Health (Formerly Anthem ~ Amerigroup Community Care)
01.2006 - 01.2012
Provider Experience Representative
Humana Military
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