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John has more than 10 years of consulting experience within the healthcare industry, and has concentrated his efforts in helping clients respond to the variety of regulatory, financial, and operational issues for health plans and insurers. He specializes in the analysis of large volumes of financial, operational, pricing, and reimbursement data to solve complex issues for his clients.
Professional Experience
Representative examples of John's engagement experience include:
Claims System Reviews and Assessments
Developed business and function requirements for claim adjudication and billing systems.
Assessed accuracy of provider pricing, claim data entry, prior authorizations, coordination of benefits, and membership eligibility.
Reviewed enrollment and billing functions to identify process enhancements to improve performance metrics and/or achieve cost savings.
Performed post conversion testing and analysis on claim system performance.
Performed focused claim operations reviews including delegated functions such as ASO billing.
Cost Containment Analyses and Recoveries
Extract and analyze eligibility, claim and pricing data from numerous sources and systems; perform sophisticated analyses and models to identify sources of cost savings.
Extensive experience with both compliance issues and recovery related to Medicare coordination of benefits.
Responsible for the development of proprietary tools to expedite analysis with limited burden to our clients.
Identified operational and process solutions to prevent mistaken payments from continuing to occur and allow client to achieve ongoing savings.
Federally Funded Healthcare Contracting and Compliance
Strategic reviews to assess the impact of potential contracting changes of Medicare Contract Reform.
Review and assessment of Cost Accounting Standards (CAS) compliance and gap analysis.
Developed organization and team structures to maximize operating effectiveness and minimize compliance risk.
Project management for preparation of all aspects of the business proposal submission including the coordination of deadlines, management of subcontractors, and proposal deliverables.
Developed financial cost and pricing models that comply with the contractual requirements and provide real time information to management on the impact of operational decisions.
Performed various projects associated with the Cost Accounting Standards, including cost impact proposals, CASB disclosure statement preparation, and CAS compliance reviews and disputes.
Civil False Claims Act Contracting Issues including dealing directly with the Government agency and Department of Justice.
Financial and Operational Consulting
Redesigned the administrative cost allocation systems of various commercial segment health insurance companies to achieve reliable customer and product level P&L determination on an enterprise-wide basis.
Performed several investigations related to regulatory compliance including negotiation and resolution of these matters.
Worked under direction of counsel to properly calculate the financial impact of claims and billing system errors, including identification of root cause and making recommendations to resolve the issues.
Education & Certifications
Bachelor's Degree, Finance, University of Illinois at Champaign-Urbana, Champaign, IL
Master of Business Administration, University of Chicago, Chicago, IL
Speaking Engagements
Speaker on various Medicare issues for the BlueCross BlueShield Association | 