Sharron Mackey
Oakley,California
Summary
Over thirty years of operational experience in the managed care arena with a strong background in negotiating contracts. Experienced and skilled contract negotiator with a wealth of accomplishments building provider networks. Diverse expertise in managed care working with private and public health care programs. Experience expanding and strengthening provider networks, community partnerships and membership growth nationally for all product lines. Understand the facets of health care to saving health care dollars through utilization review and medical case management. Strong ability to ensure provider satisfaction for a range of health care services from contracting claims adjudication claims resolutions, provider relations and credentialing of providers to ensure a quality network for better access to healthcare.
Overview
30
30
years of professional experience
Work History
Chief Executive Officer
01.2018 - Current
- Redesigned the infrastructure by building key operational units: Appeals & Grievances, Behavioral Health, Clinical Quality Auditing, Health Equity and Administration
- Created an infrastructure for Compliance Oversight that for over 20 years had 1 person to a team of 10
- Training for the staff – Five Star Training – onboarding for managed care
- Doubled the size of the staffing – by creating a new job family of program managers to assist in the business
- Key implementer of Cal AIM with the Enhanced Care Management
- NCQA reaccredited 3 times
- HEDIS scores in the 90th percentile nationwide
- Created access to care for over 300,000
- Designed a Quality-of-Care system to ensure top quality health care
- Transformed an antiquated health systems into a managed care delivery system
- Created an outsourcing strategy with national companies to close the major deficiencies for a business operation
- Managed an operating budget of over 1 billion dollars with a staff of 300 employees.
Chief Operations Officer
Contra Costa Health Plan
01.2017 - 01.2018
- Created policies and operational procedures that ensured the stability of the Provider networks for over 6,000 providers in Contra Costa County
- Designed an Auditing Oversight program that addressed payment deficiency trends for the provider network
- Designed a Provider Training program for provides that had high Payment Denials and Appeals
- Reduced the payment dispute actions by over 80% within a six month period with two large provider delivery systems
- Reorganized the Claims Rules in the health plan’s Information Claims Adjudication System to ensure that new provider contract rates were updated annually
- Implemented a provider visitation program with providers with network and claims issues to prevent hostile relationships between the plan and providers
- Designed quarterly training programs both for Provider Relations and Claims Examiners to educate the team on benefits and reimbursement rules
- Solved major billing problems with the Behavioral Health provider network by enforcing the contract requirements with the plan’s Clearing House
- Improved communications with the Behavioral Health Team and Clearing House staff by facilitating quarterly meeting to track issues and ensure solutions were in place
- Serves as the major player with legal issues in regards to the provider networks in dealing with Claims Payments and Provider Appeals for Medical Necessity
- Designed a provider negotiations strategy that performs a deep dive of the provider network and access to timely specialty care based on member health care needs.
Program Manager
Blue Shield of California
01.2011 - 01.2016
- Designed the first BSC Home Visitation Program for over 60 Care Management nurses, developed the operating procedures and infrastructure for sending referrals to a community based organization that covers all 58 counties
- Assisted in the redesign of the Care Management operating model which included outreach and engagement process that gives nurses more time to focus on the clinical needs as opposed to administrative work
- Lead a team of clinical social workers, health educators and health coaches and created the first Shield Community Resources electronic guide that allows the Case Manager to connect with community resources state-wide
- Developed cost containment strategies for out-of-network spend of over $400 million dollars
- Created strategic opportunities to reduce the cost of health care from abusive provider billing practices.
Director of Managed Care
EK Health
01.2010 - 01.2011
- Provide leadership and guidance for over 75 case managers and utilization review nurses
- Oversee the quality management function for a Utilization Review Organization for worker’s compensation
- Creating and designing the first Medical Provider Network for Worker’s Compensation in California for a URO
- Managing the Provider Relations functions to ensure well educated providers to meet the regulatory requirements of California’s Department of Worker’s Compensation.
Director of Contracting
Children First Medical Group
01.2007 - 01.2010
- Managed the contracting and physician recruitment of over 500 providers in Alameda County and signing managed care contracts with local and national employer groups
- Leadership and management of seven staff members with oversight for three major departments: Contracting, Provider Relations and Credentialing that provides services for over 500 physicians in the East Bay
- Successfully negotiated 10 new managed care contracts within 18 months that expanded the pediatric specialty network with over 30 specialists
- Performed an analysis on the financial performance of all managed care contracts to ensure profits were solid
- Initiated cost saving strategies by shifting the majority of the financial risk to Health Maintenance Organizations for pediatric services
- Created the infrastructure for contracting administration for over 500 pediatric sub specialist
- Creatively managed all aspects of network management for 45 Preferred Provider contracts that represents over 1 million lives
- Performed analysis on the various reimbursement methodologies and ensured the best rates for all new and renegotiated contracts
- Review of all contract language thereby minimizing the financial risk based on the legal obligations of the managed care contracts.
Regional Network Manager
Health Net of California
01.2006 - 01.2008
- Orchestrated the Joint Operations Meetings for Rural Health and Federal Qualified Health Centers which significantly improved relationships; setting the stage for potential membership increase
- Increased the provider network for the Healthy Kids product in six counties creating access to care for thousands of uninsured children
- Outstanding analytical skills on network strength ensured Health Net’s selection as the Healthy Kids provider for several counties
- Lead the network development effort for Merced County setting the stage for expanded Medi-Cal opportunities a critical win for future growth
- Added over 25 new safety net providers which will improve access to care in rural communities.
National Medicaid Director
Coram Health Care System
01.2005 - 01.2006
- Directly managed a staff of 45 personnel that was responsible for the operations of billing, collecting and quality assurance
- Developed the infrastructure for billing 49 Medicaid Programs with a 48 million dollar budget in account receivables
- Created the policy for Quality Assurance the first ever program that ensured auditing of pharmacy claims
- Researched and prepared policy documents to ensure compliance with each state rules for billing infusion therapy and pharmacy
- Extracted the Billing and Quality Assurance guidelines for 49 states for audit purposes
- Created the first training for Branch Managers and Billing Staff ensured correct billing the first time in 25 branches
- Built the first national Medicaid team for home infusion and pharmacy expertise and created a team of Billers, Collectors, Quality Assurance staff.
Senior Health Promotions Specialist
Anthem Blue Cross
01.2000 - 01.2005
- Responsible for connecting health promotions activities county-wide for over 80,000 Blue Cross Medi-Cal and Healthy Families Program members
- Establish Health Education networks for preventive healthcare services in Sacramento County
- Developed marketing strategies to expand the Healthy Families Enrollment program
- Performed several leadership roles with health plans to promote health education and the HFP
- Organized and operated a joint community advisory committee that focus on cultural and linguistic services for 160,000 Medi-Cal members in Sacramento County
- Performs educational seminars for over 300 providers to increase their knowledge of HMO services and to assist in channeling patients for health promotions services.
Professional Review Manager
Interplan Corporation
01.1998 - 01.2000
- Directly supervised the utilization management and claims analysis functions for a clinical and support staff of 25 personnel with an operating budget of $1.5 million
- Provided outstanding leadership for case management, prenatal care, inpatient utilization and medical cost analysis for more than 100 clients in California’s Central Valley
- Created the operational structure to assist in determining medical necessity for more than 3,000 patients monthly
- Designed a Prenatal Program for high-risk patients to promote educational awareness and avoid high cost Inpatient stays
- Directed several outreach seminars for case management services and enrolled 3,000 patients with catastrophic illness.
National Negotiations Manager
Foundation Health Systems
01.1997 - 01.1998
- Improved the market savings in California by negotiating educational reimbursement out of managed care contracts of 13 major teaching facilities
- Created the infrastructure for managed care contracting at the corporate headquarters for Foundation Health Federal Services
- Performed the first analysis of the Veterans Affairs facilities to determine their capacity to expand their network to include the TRICARE Health Maintenance Model
- Established the TRICARE Senior Prime comprehensive network within 4 weeks to service the Medicare population in San Diego county.
Senior Contract Negotiator
First Health Corporation
01.1995 - 01.1997
- Developed hospital and physician networks for over 1200 national clients in Georgia, Florida and Kentucky
- Successfully negotiated over 100 hospital managed care contracts
- Established procedures for contracting physicians in 15 Physician Hospital Organizations and Individual Physician Associations consisting of over 3,000 physicians.
Education
M.H.S. Health Services Management -
Golden Gate University, Sacramento, California
01.1993
B.S. Criminal Justice/Mass Communication -
University of Alabama in Birmingham
01.1993
M.P.A. Public Administration -
Golden Gate University, Travis Air Force Base, Fairfield, California
01.1989
Skills
- Organizational Leadership
- Executive Leadership
- Risk Management
- Staff Management
Websites
City
Oakley
State
California
Military Service
United States Air Force Major, Military Officers Association (Contra Costa County Chapter), Air University – Squadron’s Officers School, Professional Military Education, 1990, Maxwell AFB, Montgomery, AL
Gardening, painting, tennis, volleyball
A renaissance woman who is passionate about skills and artistic.
Timeline
Chief Executive Officer
01.2018 - Current
Chief Operations Officer
Contra Costa Health Plan
01.2017 - 01.2018
Program Manager
Blue Shield of California
01.2011 - 01.2016
Director of Managed Care
EK Health
01.2010 - 01.2011
Director of Contracting
Children First Medical Group
01.2007 - 01.2010
Regional Network Manager
Health Net of California
01.2006 - 01.2008
National Medicaid Director
Coram Health Care System
01.2005 - 01.2006
Senior Health Promotions Specialist
Anthem Blue Cross
01.2000 - 01.2005
Professional Review Manager
Interplan Corporation
01.1998 - 01.2000
National Negotiations Manager
Foundation Health Systems
01.1997 - 01.1998
Senior Contract Negotiator
First Health Corporation
01.1995 - 01.1997
M.H.S. Health Services Management -
Golden Gate University, Sacramento, California
B.S. Criminal Justice/Mass Communication -
University of Alabama in Birmingham
M.P.A. Public Administration -
Golden Gate University, Travis Air Force Base, Fairfield, California
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