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

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

SALLY REEVES, CFE

SALLY REEVES, CFE Statistician, Over 20 years experience consulting on health insurance issues, from both the employer and payor perspective spans more than 20 years. Her specific experience encompasses a wide variety of underwriting and actuarial functions. Sally has as a wealth of knowledge in the areas of managed care operations, claims auditing and statistical sampling. Education • B.B.A. in Actuarial Science, The University of Texas at Austin • Certified Fraud Examiner , ACFE 2012 Relevant Experience Before establishing Sagebrush Solutions with her colleagues, Ms. Reaves was a Senior Manager in the managed care practice at Ernst & Young LLP. Prior to joining Ernst & Young in 1993, she worked as a group health actuary for William M. Mercer, Incorporated. Her career experience includes: • Electronic and statistical audit of numerous leading national and regional health care payors, including Commercial, Medicare and Medicaid • Managed care operational review and process improvement • Electronic and statistical evaluation of claims and capitation data, supporting provider risk pool settlements and negotiations • Due diligence reviews of managed care operations, supporting merger/acquisition activities • Providing expert witness testimony and litigation support in healthcare administrative disputes, including disputes between providers and payors and disputes between payors and the Federal Government • Benefit plan design, pricing and cost projections for numerous Fortune 500 companies • Valuation of payment processes and calculation of incurred‐but‐not‐reported reserves • Evaluation of managed care network efficacy • Works in close conjunction with audit manager • Responsible for sample selections • Develops predicative modeling scenarios • Extrapolates results of improper payments when determined appropriate PRGX USA, Inc. – Sally Reeves (Sagebrush) 1

FAITH GLOVER, RN, CFE Medical Records Reviewer, Experienced in all aspects of health care—from direct delivery of services to product development and management consulting. Responsible for medical and pharmacy coding and claims audits, including testing of samples, client interface and reporting. Faith is a Diplomate of the American Board of Quality Assurance and Utilization Review and has significant work experience in coding and claims auditing of inpatient, outpatient and pharmacy claims. Faith has served as a medical records reviewer for numerous Medicare Cost Report certifications and Agreed‐Upon Procedures reviews, including Capital Health Plan and Scott & White Health Plans. Faith has held responsiblity for coding claims from the medical records for an occupational medical organization. Education • Nursing Diploma ‐ Massachusetts General Hospital – RN#229598‐1 • Master of Business Administration ‐ New York University • Bachelor of Business Administration ‐ Marymount Manhattan College • ACFE Certified Fraud Examiner ‐2012 Relevant Experience Ms. Glover is the Chief Executive Officer of Sagebrush Solutions. Prior to founding Sagebrush Solutions, Ms. Glover led the development of Ernst & Young’s claims data warehouse & data analysis client server application ‐ EY/Decide. Directly before joining Ernst & Young, Ms. Glover served as vice president of health information services for a healthcare division of a Fortune 100 company. She was responsible for mainframe data processing operations, as well as applications development and maintenance, which supported claims processing, financial services, utilization management, and managed care product lines. Prior work experiences also include management positions in data analysis and health care information services for a large HMO and major data services organization. Her assignments have included: • Managed care data conversions, data warehouse design & implementation, • As a Registered Nurse, Faith was responsible for the abstraction and coding of claims for an occupational health group. • Development of electronic claims audit programs, • Managed care operations reviews and process improvement initiatives and • Completion of utilization review performance audits. PRGX USA, Inc. – Faith Glover (Sagebrush) 1

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