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Paige Fiorillo20235 North Cave Creek Road Suite 104-449,
Phoenix, Arizona 85024(480) [email protected]
CAREER PROFILE
Proactive, dedicated and results-oriented professional, offering
extensive background in multiple managed care processes within a
well-developed healthcare organization. Proven track record of
success in driving productivity as well as exceeding business
standards and expectations by utilizing analytical, risk assessment
and problem resolution skills. Possess innate ability to maintain
establishedrelationships with all levels of professionals, with the
capacity to work bothindependently and collaboratively with a team.
Seeking a challenging career opportunity as Senior Health Care
Consultant, Senior Implementation Analyst or Senior Medicare
Advisor which will effectively utilize strong work ethics,
excellentmanagement skills, broad healthcare industry experience
and outstanding organizational leadership.
PROFESSIONAL EXPERIENCE
GORMAN HEALTH GROUP ~ WASHINGTON, D.C. ~ JAN 2007-JUN 2010
SENIOR CONSULTANT
- Accomplished team leader and individual contributor in the
healthcare industry; demonstrated ability to address and solve
complex business process improvementissues in clinical and
non-clinical areas.- Formulated and implemented work plans to
develop and enhance business efficiency while maximizing
productivity along with the rollout and implementation of work
plans.- Demonstrated expertise in compliance analysis, Medicare
regulation interpretation, process development, performance
evaluation, workflow redesign and resolution, forecasting workforce
requirements, and establishing/redesigning of departments and
organizations.- Proven track record in isolating the cause of
performance gaps and/or organiza
tional needs while simultaneously establishing productive
relationships with clients.- Provided counsel in business planning,
strategy, organization, health care finance and network design
operations.- Exemplified expertise and demonstrated skills in
Medicare, MA-PD, MA Special Needs Plans, PBM, compliance policy and
procedure development, PDE Reconciliation, claims, auditing,
compliance, operations, delegated oversight, finance, UM
coding/pricing, and business planning and development.
Notable Contributions:- Played an integral role as member on an
extensive PDE recovery project for amajor East Coast HMO that
attained targeted returns of over 21 million dollars;project was
brought in successfully and within budget.
- Functioned as key member of two additional PDE recovery
projects for two majorhealth plans, one located in the Mid-West and
the other on the East Coast thatsuccessfully resulted in CMS
reconciliation projects, recouping monies and reconciliation of
health plan systems for constant compliance and returns in
millions.- Worked as major participant in the coordination, writing
and development of Gorman Health Groups Policy and Procedure
library, which housed all the necessaryMedicare P&Ps for all
plan types, departments and operational procedures to guarantee
existence and achievement of all audit elements and regulatory
requirements.
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- Acted as key participant in the application process for a
regional multi-specialty group in Texas to generate an HMO and PPO
risk-bearing entity; ensured thedevelopment of an RFP to obtain a
PBM partner; and developed an RFP to outsourceoperational areas.-
Instrumental in the writing and submission of the CMS application
for a newlyformed MA-PD and Coordinated Care Plan (SNP), which was
successfully presentedto CMS in March 2008.- Collaborated in the
design and creation of a HMO and PPO risk-bearing companyin 10
states for a large national provider entity. Contributed in the
writingand submission of 10 applications to CMS to acquire
contracts in order to become MA-PD SNPs within 10 states
accomplished within 9 months.- Contributed successfully to an
existing large HMO with the Medicare Part D implementation,
including development of work plans, tracking and updating; lead
core team meetings and interfaced with their PBM.- Conducted
various mock CMS audits and readiness audits for HMOs prior to an
actual regulatory audit.- Carried out gap analysis with various
HMOs to evaluate its readiness pertaining to the Medicare
regulations to become a Medicare contractor and maintain an MA-PD
contract.
TRIWEST HEALTHCARE ALLIANCE ~ PHOENIX, AZ ~ JUL 2002-JAN
2007PROJECT MANAGER | SYSTEMS ANALYST
- Identified and formulated options for potential solutions to
ensure implementation of all government modifications to the
TRICARE Department of Defense contract.- Developed business
competency and efficiency, including the assessment of
interdepartmental processes to meet technical and business needs.-
Designed and implemented business policies and procedures, tailored
work plansand made modifications as appropriate to streamline
workflow to meet shifting needs and requirements.- Identified the
resources needed and allocated individual responsibilities while
simultaneously managing daily operational aspects of a project and
scope, including internal and external requirements and preparation
for benchmarking.- Effectively applied methodology and enforced
project standards through workingclosely with developers; delegated
contractor and various end users to guarante
e technical compatibility and user satisfaction.- Functioned as
liaison to delegated claims processor, regional contractors
andgovernment regulators on both the federal and state levels.
PROJECT MANAGER | INTERIM CLAIMS MANAGER
- Directed and oversaw systems analysts and claims research
analysts.- Successful in developing and maintaining the department
workflow, as well as oversight in the development of policies and
procedures and implementation of newprograms from contract to
inception.- Maintained Claims Department databases and managed
recoupment and analytical projects for the vice president.
- Implemented project plans and timelines for entire
departmental projects whileensuring implementation of new
strategies for improving processes and trackingof compliance and
report to the executive leadership on the status of plans.
ARIZONA HEALTHCARE COST CONTAINMENT SYSTEM (AHCCCS) ~ PHOENIX,
AZ ~ JUN 2000-OCT2001PROGRAM COMPLIANCE AUDITOR III
- Conducted financial analysis on quarterly health plan reports
to determine eco
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nomic viability in the continued administration of their AHCCCS
contract. Produced ongoing monthly analysis including reports to
management and Department Administrators.- Managed special and
yearly projects, HIV/AIDS audit, PIP audit and various other ad hoc
reports that required an in-depth knowledge of procedures on health
plans operations, CMS (HCFA) rules and state regulations.- Carried
out various responsibilities, which included data reimbursement
rate validation and changes according to CMS rules and
participation in health plan policy and rate setting.
EARLIER EXPERIENCE
INSURANCE OVERLOAD ~ PHOENIX, AZSENIOR CLAIMS AUDIT AND RESEARCH
ANALYST ~ NOV 1998-JUN 2000
PRICEWATERHOUSECOOPERS ~ SACRAMENTO, CAHEALTHCARE REGULATORY
SENIOR ASSOCIATE ~ NOV 1997-AUG 1998
FOUNDATION HEALTH ~ RANCHO CORDOVA, CASENIOR AUDITOR PROVIDER
COMPLIANCE ~ NOV 1996-NOV 1997CREDENTIALING AUDIT COORDINATOR ~ NOV
1995-NOV 1996
CLAIMS TECHNICAL SERVICES (FOUNDATION HEALTH) ~ RANCHO CORDOVA,
CA
CREDENTIALING SPECIALIST ~ AUG 1995-NOV 1995CLAIMS EXAMINER III
~ JUN 1995-AUG 1995
MANAGED CARE SYSTEMS, INC. ~ SACRAMENTO, CARESEARCH ANALYST |
CLAIMS LEAD | CLAIMS ANALYST ~ MAR 1992-MAY 1995
JORDAN JONES ADMINISTRATORS, INC. ~ SACRAMENTO, CACLAIMS
EXAMINER ~ AUG 1989-FEB 1992
EDUCATION
Bachelor of Arts in Communications
Minor in Business AdministrationCalifornia State University,
Sacramento, CA ~ 1995
PROFESSIONAL AFFILIATIONS
CPC Examination and Annual Conference ~ 2003-2006Member, AAPC ~
2003-2006HCFA Task Force Claims Compliance ~ 1996
PROFESSIONAL TRAINING
Certified Professional Coder ~ AAPC
