Manager Management
Resume:
Joe Nihom
PO Box ****, Santa Ana, CA *****
abin72@r.postjobfree.com
Objective: A Position with a Leading Health Care Team Utilizing my Breadth
of Education and Experience
Profile
. Over 25 years experience in health care administration and management.
. Experienced Health Plan and IPA contracting and provider network
development specialist
. Comprehensive experience in all aspects of Medicare Reimbursement and
Regulations
. Risk Adjustment Program Development and Training
. Managed a consulting firm, a Urology clinic and ASC and 150 Million
Claims Budget
. Extensive health care financial management experience
. Excellent Microsoft Office, Database Administration and Programming
skills.
. Goal-oriented individual with strong mentoring and leadership
capabilities.
. Organized, highly motivated, and detail-directed problem solver.
. Proven ability to work in unison with senior management, employees,
volunteers, and board of directors in a variety of settings.
Education
M.B.A., Finance, Portland State University
B.A., History, Regents Scholar, University of California
Relevant Experience & Accomplishments
Provider and Third Party Payer Contracting
. Negotiated, implemented and administered provider, facility and ancillary
services contracts for a designated Health Plan Market.
. Negotiated third party payer contracts for a diverse number of IPAs,
physician and ancillary provider groups
. Worked with Federal, State and County Agencies as well as providers in
preparing for Managed Care networks and contracting including the co-
authoring of workbooks on managed care
. Have conducted numerous educational workshops on provider contracting at
conferences and other venues
Medicare/Medicaid
. Extensive Risk Adjustment Experience
o Created Training Material for Health Plan Employees and
Providers
o Developed Data Collection and Reporting Methodologies
o Developed Risk Adjustment Program for a California based Health
Plan
o Authored Workbook and produced video on implications of Resource
Based Relative Value Schedule (RBRVS) and the associated
Relative Value Units (RVU)
. Developed SQL/Access/Excel databases and applications to collect and
extract information requisite for cost reporting requirements. Automated
Medicare eligibility and Working Aged Member communications.
o Instrumental in recovering $35,000,000 in Institutional
underpayments based on data mining and negotiation with HCFA
. Worked with Federal, State and County Agencies as well as providers in
the Mental Health/Substance Abuse areas in preparing for Medicaid Managed
Care Reform
. Claims Representative with the Social Security Administration
Management/Supervision
. Managed over 50 managers, supervisors and employees for a 6 store men's
clothing chain.
. Managed supervisors and staff of 24 employees in a Medical Clinic and
associated Ambulatory Surgery Center
. Managed programmers and data entry clerks
. Directed staff of 6 professional consultants.
. Responsible for $150,000,000 claims budget and 8 member team
Training and Education
. Adjunct Instructor in Finance at the Graduate and Undergraduate levels at
Portland State University, Washington State University - Vancouver campus,
University of Portland, and Linfield College.
. Risk Adjustment Education for Providers and Health Plan Employees
. Presented at numerous workshops and seminars on Managed Care Economics
and Finance sponsored by CSAT, Washington State Urological Society and
various State Medicaid Agencies
. Co-authored two manuals on Managed Care for the Department of Health and
Human Services
. Conducted workshops throughout Kaiser Permanente Northwest Region on
RBRVS and RVUs
. New employee training for a Medicare Risk services company
. Staff training on Medicare, Parts C & D
Employment
Manager Provider Outreach/Risk Adjustment, Care 1st, Monterey Park, CA
2010-2010
. Conduct outreach and help direct team outreach to all levels of provider
medical groups, from administrators to medical records clerks
. Influence provider decision makers to collaborate with Care1st to
maximize risk scores
. Manage all Medicare and Medi-Cal (Medicaid) risk adjustment activities
. Manage multiple programs for different lines of business
. Manage vendor relationships
. Provide guidance on risk adjustment projects to maximize risk scores
. Ensure timeliness and accuracy of HCC data submissions to CMS
. Work with executive management team to suggest creative solutions to
complex risk adjustment and data collection challenges
. Improve the completeness and quality of the data submitted to Care1st by
provider groups
. Analyze reports and present findings to senior management
. Contribute to disease management data collection
. Participate in CMS user group calls and regional meetings
Senior Business Analyst, Ingenix, Santa Ana, CA
2008-2009
. Facilitate communication between the Medicare Risk provider outreach,
analytical, coding and clinical initiative teams.
. Help each team understand the resources and requirements of the other
teams.HH Train staff on health insurance, Medicare Risk, computer
hardware and software, provider relations, etc.
Practice Manager, Bellevue Urology Associates, Bellevue, WA
2005-2007
. CEO of a medical clinic and associated ambulatory Surgery Center
Senior Medicare Consultant Kaiser Permanente, Portland, OR
1999-2005
. Supported Department's financial analysis, database programming via
Access, Excel, SQL, SAS and compliance needs.
Instructor, Portland State University, Portland, OR
1998-2004
. Instructor of Finance at the Graduate and Undergraduate levels
Principal, JPJ & Associates, Ocean Park, WA
1994-1999
. Consultation in Managed Care economics, finance, network creation,
provider contracting and the preparation for Medicaid Managed Care Reform
for state, county and local agencies
Outside Care Specialist, Kaiser Permanente, Portland, OR
1987-1994
. Negotiated, implemented and administered contracts with non-plan
providers in the Longview, WA market.
. Responsible for Annual Claims budget
Statistician, Blue Cross Blue Shield of Oregon, Portland, OR
1985-1987
. Calculation of community, service and specialty rates and calculation of
reserves for trust accounts.
. Developed Lotus program allowing sales representatives to quote insurance
rates for mid sized groups on site as opposed to bringing the information
in-house for rate determination by the underwriters
Community Involvement
Washington State Urological Society Managers Group, Treasurer, Board of
Directors
Astoria Co-operative, Treasurer, Board of Directors
Water Music Festival, Board of Directors
Kai-Perm Northwest Federal Credit Union, President, Board of Directors
References Available Upon Request
Contact this candidate