Nicole L. Sheese

Responsible for New York Commercial market benefit expense performance and management through the analysis of medical trend and its underlying drivers including large alternative funded accounts to identify new projects for cost of care savings and opportunities

• Manage local savings process to meet expected 4.9% medical Cost of Care Commercial Market Savings, aligned to accountable attributes within plan
• Develops and manages Cost of Care strategy development and operations for New York Commercial Market to support short- and long-term benefit expense mitigation for fully insured members representing approximately 300k in members for $2.3B in medical expense
• Local market strategic function lead for reporting & analytics
• This workstream includes leading multiple analytic teams and multi-market coordination on existing data tools, reporting, and other gaps identified participation, multiple-market coordination, feedback, and accountability
• Create transparent reporting, dashboards, and medical trends opportunity identification at both the Local and Enterprise leadership levels through Health Solutions, Finance, Operations, and local partners for multi-year financial trends and current year performance against plan expectations
• Hold 30-day ideation sprints with local teams where persistent market trends and gaps exist for opportunity identification in coordination with annual and 6+6 financial planning process
• Lead local leadership team, health solutions team including clinical, operations, pharmacy, and other internal and external partners to support and drive ongoing benefit expense reduction ideation and execution.

Responsible for the development of membership projections, medical expense forecast and budget and monitor monthly variances to identify trends for CareSource's largest product Ohio Medicaid that represents 1.3M members, $7B annual expense and over 70% of total revenue

• Analyzing utilization and financial trends, costs, revenues, financial commitments, and obligations incurred to predict future revenues and expenses
• Understand financial impacts of decisions and communicate those to management
• Manage the development, production, and validation of reports from detailed claims, eligibility, pharmacy, and clinical data
• Create data queries using SQL Developer, SAS EG, and SAP EPM BPC to generate reports from multiple source databases
• Responsible for analyzing, compiling, and submitting all regulatory reporting to the Ohio Department of Medicaid including quarterly and annual cost reporting, annual rate surveys, analyzing changes, researching, and responding to any ODM observations.

Responsible for meeting regularly with the Market on VBR needs, including review and working them about VBR regulatory requirements and options

• Served people of different backgrounds with polished people and project management skills, and advanced analytic abilities.
• Conduct industry research about alternative payment models and present recommendations to stakeholders
• Created new queries via SQL Developer and SAS EG to generate reports from multiple source databases, including Facets, EDW, Incentive Manager, and custom databases
• Complete detailed analysis and made recommendations for the markets to help identify opportunities as we continue to expand VBR
• Provide financial analysis, ad hoc, and investigative reporting as needed
• Configure and ensure VBR agreements can be administered via the custom Incentive Program Manager application
• Review the accuracy of reports, data files and validate results from source systems as needed
• This included validation of all quality measures, such as NCQA HEDIS, Medicare Stars, and Marketplace QRS
• Responsible for coordinating with IT teams to ensure requirements are clear, field questions, and resolve issues
• Attended and participate in all Agile ceremonies, including Sprint Planning and Review, story grooming sessions, and daily standup's
• Perform UAT & Post-Production testing in HPI and database
• Generate payment reports, send files to accounts payable for payment, reconcile payments, and assist with resolving payment issues.

Project Manager for standard cost review for all materials managed by Global Supply Chain in Rental, Direct Sales Strategic Markets and Facility Services divisions totaling over $400 million in spend

• Coordinate with Strategic Sourcing Category Managers, GSC, Senior Leadership, Master Data, Manufacturing, and Accounting to develop costs and hold them accountable for meeting all established and strict timelines
• Present in-depth analysis and insight into most impactful cost changes to senior leadership
• Ariba Spend Management, SAP Enterprise Central Component (ECC) ERP System for material analysis, Business Information Warehouse BEx and SAP Business Objects Analysis reporting tools used for spend analysis
• Functional leadership, coaching, and mentoring to team members in multiple SAP functional areas as well as technical guidance and business process expertise
• Validate all GSC savings initiatives with more than $100k annual impact.

Managed entire process, documentation, and workflow for Clinical Quality Value Analysis (CQVA) department that for all Premier Health facilities

• Queried databases for information needed for report processing.
• Coordinated with suppliers on all clinical new product requests for products ranging from low dollar supplies to high dollar medical devices and capital with over $2 million potential financial system impact
• Calculated and presented financial impact of product changes to CQVA, RFPs and large projects to core teams which includes Senior Leadership, Physicians, and Clinicians
• Provided support, pull, organize and present spend analytics for clinical savings initiatives and new contracts to determine impact to meet or exceed organizational savings objectives of more than $10 million each year
• Developed New Supply Chain financial forecasting model for senior leaders
• Lawson, Oracle SQL Developer, Excel, and Access database used daily for financial insight, and opportunity analysis.

Responsible for business development through strategy creation, market analysis, and data analysis to assist in market growth in all entities including Physician Networks, Service Lines, Business Development and Operations.

• Complete and review market research for new opportunities with Premier Health leadership.
• Track and forecast Orthopedic, Sports Medicine, Spine, Neuroscience, and Emergency Services service lines in the fast-growing Greater Dayton region healthcare markets with total market value of $5.3 billion.
• Monitor competitor activities and healthcare market trends for all major healthcare systems within Southwest Ohio for opportunities, leakage, and outmigration.
• Analyze and report physician relationships with Premier Health and expand opportunities to expand referrals to Physician Relationship Management team and leadership.