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Response to RFP No. MED13002 State of West Virginia ... - DHHR

Response to RFP No. MED13002 State of West Virginia ... - DHHR

CHRISTINE CASTELLI

CHRISTINE CASTELLI Project Director An entrepreneurial executive with over twenty years of highly diverse experience in the Healthcare, Information Technology, and Legal industries. Her previous experience includes acting as point of contact for the Region C Recovery Audit Contractor (RAC) project with responsibility for Client Relations/Quality Assurance. Christine was also responsible for the Medicare RAC Demonstration Project in the States of New York and Massachusetts. She has been the Director of Operations for one of the largest Medicaid HMOs in the United States with responsibility for overseeing the Recovery and Auditing Departments for seven state Medicaid contracts. Christine has also worked in the legal field overseeing recovery opportunities within the areas of subrogation, personal injury, coordination of benefits and medical cost containment issues. Education/Professional Development • Peirce College. Philadelphia, PA • Certified Paralegal • Member – AHIMA Work Experience Thomson Reuters (Healthcare) Inc. ‐ Vice President, Client Services, Federal Operations President of Recovery Audit Solutions, Inc., Newtown Square, PA • Full oversight of daily operations of the Federal Civilian Healthcare Division responsible for all Thomson Reuters federal contracts, and Emerging Markets. Responsible for the Zone Program Integrity Contract (ZPIC) Zone 4 (4 states)/Medicaid Data Extract & Matching • Responsible for the ZPIC Zone 2 (14 states) & ZPIC Zone 5 (10 states) – Supported CMS’s anti‐fraud Medicare Integrity Program as part of the AdvanceMed Program Safeguard Contractor team. • Responsible for Medicaid Integrity Contractor (MIC) Task Order 1 (13 states and 1 territory) and Task Order 5 (8 states and 2 territories) ‐ Supported CMS as subject matter experts and developed algorithms that assist the CMS Audit MIC in identifying and recovering erroneous claim payments. • Business owner of a 100% Woman‐Owned Business with over 20 years of successful experience in all government and commercial sectors of the healthcare field specializing in the areas of Claim Recovery: Medical Chart Review (Pre/Post Payment), Claim Query Logic Development, Cost Containment, Coordination of Benefits, Pharmacy, Credit Balance, Third Party Liability, and Subrogation.

Principal at Connolly Healthcare Principal, CMS RAC Region C Project Connolly Healthcare Division Keystone Mercy Health Plan Director of Operations Support/Quality Improvement Division of Zurich Insurance Director of Risk Enterprise Management • Implementation Leader and Point of Contact responsible for the day‐today operations of the Recovery Audit Contractor contract (RAC) for the Centers for Medicare and Medicaid (CMS) Region C Project. • Responsible for full oversight of the contract and communication with several divisions within CMS Office of Financial Management providing project updates, recommendations for project improvements, and building partnerships. • Responsible for all RAC Region C Client Relations, including interface with CMS, Hospital Associations, Medical Societies, Providers, Professional Support Associations (Milliman, InterQual and MediRegs), Medicare Affiliated Contractors (MACs), Durable Medical Affiliated Contractor (DME MAC), Zone Program Integrity Contractors (ZPICs), and the Validation Contractor. Developed and implemented all Joint Operating Agreements (JOAs) with all MACs within Region C. • Responsible for oversight and reporting for cross‐functional teams: supervision of all IT Team members, oversight of the Quality Assurance Division, Project Department, internal Imaging Department, and the daily production of the identification of overpayments and underpayments of all claims data and project recommendations. • Project implementation leader successfully led the day‐to‐day oversight of the CMS RAC Demonstration project for the states of NY and MA. Responsible for the development and implementation of the Medical Chart Review Division and the Scan Station/Imaging Division. • Responsible for the daily operations and quality improvement for Medicaid Plans in seven (7) states, overseeing internal units that included Auditing, Subrogation, Third Party Liability, Cost Containment, Coordination of Benefits, Credit Balance, Pharmacy Recovery, and Quality Assurance Department. • Created and developed the company’s first subrogation unit. • Implemented and provided third party liability subrogation training for Claims, Member/Provider Services, Provider Contracting, and Utilization Department for all lines of business. Identified, minimized, and eliminated pay‐outs relating to third party liability issues. • Responsible for all legal research regarding company’s liability issues, both on federal and state oversight. • Responsible for claim system mapping that built efficiencies to increase productivity and provided accurate claim pay‐out. • Identified, analyzed and recovered on claim overpayments, worker compensation, personal injury, and medical malpractice cases. • Successfully took the office from 18th to 2nd in the company recovery PRGX USA, Inc. – Christine Castelli 2

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