Paige Fiorillo

20235 North Cave Creek Road Suite 104-449, Phoenix, Arizona 85024
(480) 234.6323
paigefiorillo@gmail.com

CAREER PROFILE
Proactive, dedicated and results-oriented professional, offering extensive backg
round in multiple managed care processes within a well-developed healthcare orga
nization. Proven track record of success in driving productivity as well as exce
eding business standards and expectations by utilizing analytical, risk assessme
nt and problem resolution skills. Possess innate ability to maintain established
relationships with all levels of professionals, with the capacity to work both
independently and collaboratively with a team. Seeking a challenging career oppo
rtunity as Senior Health Care Consultant, Senior Implementation Analyst or Senio
r Medicare Advisor which will effectively utilize strong work ethics, excellent
management skills, broad healthcare industry experience and outstanding organiza
tional 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 improvement
issues in clinical and non-clinical areas.
- Formulated and implemented work plans to develop and enhance business efficien
cy while maximizing productivity along with the rollout and implementation of wo
rk plans.
- Demonstrated expertise in compliance analysis, Medicare regulation interpretat
ion, process development, performance evaluation, workflow redesign and resoluti
on, forecasting workforce requirements, and establishing/redesigning of departme
nts and organizations.
- Proven track record in isolating the cause of performance gaps and/or organiza
tional needs while simultaneously establishing productive relationships with cli
ents.
- Provided counsel in business planning, strategy, organization, health care fin
ance and network design operations.
- Exemplified expertise and demonstrated skills in Medicare, MA-PD, MA Special N
eeds Plans, PBM, compliance policy and procedure development, PDE Reconciliation
, claims, auditing, compliance, operations, delegated oversight, finance, UM co
ding/pricing, and business planning and development.
Notable Contributions:
- Played an integral role as member on an extensive PDE recovery project for a
major 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 major
health plans, one located in the Mid-West and the other on the East Coast that
successfully resulted in CMS reconciliation projects, recouping monies and recon
ciliation of health plan systems for constant compliance and returns in millions
.
- Worked as major participant in the coordination, writing and development of Go
rman Health Groups Policy and Procedure library, which housed all the necessary
Medicare P&Ps for all plan types, departments and operational procedures to guar
antee existence and achievement of all audit elements and regulatory requirement
s.
- Acted as key participant in the application process for a regional multi-speci
alty group in Texas to generate an HMO and PPO risk-bearing entity; ensured the
development of an RFP to obtain a PBM partner; and developed an RFP to outsource
operational areas.
- Instrumental in the writing and submission of the CMS application for a newly
formed MA-PD and Coordinated Care Plan (SNP), which was successfully presented
to CMS in March 2008.
- Collaborated in the design and creation of a HMO and PPO risk-bearing company
in 10 states for a large national provider entity. Contributed in the writing
and submission of 10 applications to CMS to acquire contracts in order to becom
e MA-PD SNPs within 10 states accomplished within 9 months.
- Contributed successfully to an existing large HMO with the Medicare Part D imp
lementation, including development of work plans, tracking and updating; lead co
re team meetings and interfaced with their PBM.
- Conducted various mock CMS audits and readiness audits for HMOs prior to an ac
tual regulatory audit.
- Carried out gap analysis with various HMOs to evaluate its readiness pertainin
g to the Medicare regulations to become a Medicare contractor and maintain an MA
-PD contract.

TRIWEST HEALTHCARE ALLIANCE ~ PHOENIX, AZ ~ JUL 2002-JAN 2007

PROJECT MANAGER | SYSTEMS ANALYST
- Identified and formulated options for potential solutions to ensure implementa
tion of all government modifications to the TRICARE Department of Defense contra
ct.
- Developed business competency and efficiency, including the assessment of inte
rdepartmental processes to meet technical and business needs.
- Designed and implemented business policies and procedures, tailored work plans
and made modifications as appropriate to streamline workflow to meet shifting n
eeds and requirements.
- Identified the resources needed and allocated individual responsibilities whil
e simultaneously managing daily operational aspects of a project and scope, incl
uding internal and external requirements and preparation for benchmarking.
- Effectively applied methodology and enforced project standards through working
closely 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 and
government 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 o
versight in the development of policies and procedures and implementation of new
programs from contract to inception.
- Maintained Claims Department databases and managed recoupment and analytical p
rojects for the vice president.
- Implemented project plans and timelines for entire departmental projects while
ensuring implementation of new strategies for improving processes and tracking
of compliance and report to the executive leadership on the status of plans.

ARIZONA HEALTHCARE COST CONTAINMENT SYSTEM (AHCCCS) ~ PHOENIX, AZ ~ JUN 2000-OCT

2001
PROGRAM COMPLIANCE AUDITOR III
- Conducted financial analysis on quarterly health plan reports to determine eco
nomic viability in the continued administration of their AHCCCS contract. Produ
ced ongoing monthly analysis including reports to management and Department Admi
nistrators.
- Managed special and yearly projects, HIV/AIDS audit, PIP audit and various oth
er ad hoc reports that required an in-depth knowledge of procedures on health pl
ans operations, CMS (HCFA) rules and state regulations.
- Carried out various responsibilities, which included data reimbursement rate v
alidation and changes according to CMS rules and participation in health plan po
licy and rate setting.

EARLIER EXPERIENCE
INSURANCE OVERLOAD ~ PHOENIX, AZ
SENIOR CLAIMS AUDIT AND RESEARCH ANALYST ~ NOV 1998-JUN 2000
PRICEWATERHOUSECOOPERS ~ SACRAMENTO, CA
HEALTHCARE REGULATORY SENIOR ASSOCIATE ~ NOV 1997-AUG 1998
FOUNDATION HEALTH ~ RANCHO CORDOVA, CA
SENIOR AUDITOR PROVIDER COMPLIANCE ~ NOV 1996-NOV 1997
CREDENTIALING AUDIT COORDINATOR ~ NOV 1995-NOV 1996
CLAIMS TECHNICAL SERVICES (FOUNDATION HEALTH) ~ RANCHO CORDOVA, CA
CREDENTIALING SPECIALIST ~ AUG 1995-NOV 1995
CLAIMS EXAMINER III ~ JUN 1995-AUG 1995
MANAGED CARE SYSTEMS, INC. ~ SACRAMENTO, CA
RESEARCH ANALYST | CLAIMS LEAD | CLAIMS ANALYST ~ MAR 1992-MAY 1995
JORDAN JONES ADMINISTRATORS, INC. ~ SACRAMENTO, CA
CLAIMS EXAMINER ~ AUG 1989-FEB 1992

EDUCATION
Bachelor of Arts in Communications
Minor in Business Administration
California State University, Sacramento, CA ~ 1995

PROFESSIONAL AFFILIATIONS
CPC Examination and Annual Conference ~ 2003-2006
Member, AAPC ~ 2003-2006
HCFA Task Force Claims Compliance ~ 1996

PROFESSIONAL TRAINING
Certified Professional Coder ~ AAPC