SUMMARY of QUALIFICATIONS
A proven professional with senior level health care contract, operational, and advisory experience. Extensive background in all phases of contracting, managed care operations, reimbursement, and account management. Extensive project management experience in with risk based arrangements.
EXPERIENCE
AC+C 2009-Current
A consulting firm specializing in Medical Coding and Billing
Manager
* Managed the consulting efforts in the Managed Care contract analysis segment including Workers Compensation and Medical Device
* Served as Government account manager and implemented the process to access Government contracts and bid opportunities including the VA, CMS, and Medicaid
* Revenue cycle management and process analysis; business case development and recommendations based on client needs and goals.
* Prepared marketing plan to assist regional sales specialist in their development of account level strategy and management.
Banner Health 2009-2010
A self-funded health plan based in Phoenix, AZ
Provider Relations
* Provide strategic leadership to streamline the contracting process; which includes the modification of the process that notifies insurers (Aetna, UHC, Beech Street) of additions and terminations in the network
* Create LOAs as needed to reduce cost with providers that are out-of-network
* Monitor and update Physician Hospital Organization (PHO) on quarterly changes and compliance issues in the Pay for Performance (P4P) program with United Health Care Medicare HMO.
* Led the negotiations of all ancillary provider contracts aligned with company reimbursement goals
Roche Diagnostics Corporation, Fishers, IN 2004 - 2009
A leading global research-focused pharmaceutical and diagnostic company.
Contract Analyst
* Develop and maintain appropriate government and commercial contractual relationships which allows sales to reach its optimum potential, specifically in the Anticoagulation therapy and Insulin infusion product lines, e.g., CoaguChek® and AccuChek®
* Negotiate and administer new and existing, distributor and Managed Care contracts nationwide, including PBM, Medicare and Medicaid; provide timely communications with field sales and marketing teams to ensure alignment of contracting and sale efforts
* Lead subject matter expert for the Federal government Request for Proposal Process (initial bid to contract award); Managed newly acquired VA national contract, that was projected to be in the $500,000 to $1,000,000 range
* Managed the ongoing analysis of current contract reimbursement, and the review historical data extractions to effectively manage compliance issues relating to payment. Managed the pricing and contracts in the TIMS system
* Prepare documentation for the IFF (Industrial Funding Fee) quarterly incentive rebate process
Wheeler M. Hughes – page two
EXPERIENCE (cont.)
Matrix Healthcare Consulting, Indianapolis, IN 2002 - 2004
A consulting firm specializing in general business process improvements.
Consultant
* Retained Consultant for managed care contract analysis, medical group revenue cycle evaluation, and Medicaid contract analysis and administration
* Reviewed and analyzed individual and group Primary Care provider revenue cycle management issues
* Provided recommendations regarding contractual practicality, process analysis and technology solutions
* Provided revenue stream recommendations; increased monthly revenues in the range of $2,500-$4,500.
Financial Marketing, Inc., Indianapolis, IN 1999 - 2002
A marketing company providing Business Process Outsourcing services (BPO).
Manager
* Responsible for business development and organizational expansion of the Business Process Outsourcing (BPO) services to companies in the medical, pharmaceutical, financial, and telecommunications; services included marketing research, target marketing, electronic medical records, electronic claims filing, and contract development
* BPO service clients would see a zero percent (0%) increase in their operating cost or a substantial reduction of cost in areas where processes were externalized.
IntraCorp, Schaumburg, IL 1995 - 1998
A workers compensation managed care company providing employers with disability case management solutions; a subsidiary of Connecticut General Life Insurance (CIGNA).
Regional Contract Administrator
* Regional manager for multi-specialty Workers Compensation managed care provider network and contract operations in a twelve state region (OH, IN, IL, MO, IA NE, MT ND, SD, MN, WI, and MI)
* Managed regional operations development, imp...
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