THOMAS EVERETT

Harwich, MA 02645 813-352-9570 everetttom2009@gmail.com

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HEALTH INSURANCE EXECUTIVE PROGRAM, CLAIMS & SERVICE OPERATIONS LEADER

Operations executive with broad based experience in health plan organizations with leadership roles in Benefit Programs, Claims,
Service, Analytics and Cost Containment solutions. Held primary roles designing strategic and tactical processes while leading high
performing teams managing key performance expectations for payer, provider and vendor operations. Demonstrated experience
with strong financial savings and process improvement accomplishments in the insurance industry serving commercial, Medicare
and Medicaid programs.
Account Product Management
Claims Service Operations
Medical Coding Analytics

Customer Call Center

Revenue Cycle Management
Contract Manager

P&L | Cost Containment Services

Claims Adjudication Systems
Process Innovation Lead

PROFESSIONAL EXPERIENCE
OmniClaim, Inc. Woburn, MA
Health care audit firm that identifies and coordinates savings between providers and payers.

April 2014 to Present

VICE PRESIDENT OF HEALTH CARE DATA MINING SOLUTIONS

Operations leader that conducts audit and analysis of payer medical claims expense that detects and recovers overspending.
Responsible for clinical and billing line of business team that services the largest health plans in the nation.
Selected Highlight
Create and implement a portfolio of 200+ clinical and coding policies with research tools that saves several millions of
dollars of paid inpatient, outpatient and professional medical expense annually.
WellCare Corporate Tampa, FL
May 2012 to April 2014
Large payer organization: a national insurer for Medicare Advantage and Medicaid lines of business across the nation.
SENIOR DIRECTOR OF CLAIMS CONFIGURATION, CODING, CREDENTIALING & OPS TESTING
Operations leader of departments that controls adjudication of 2.5M claims that pay at $0.5B each month for 3M+ lives. Sets and
leads annual corporate performance objectives and goals for key performance indicators: Claims Quality, Timeliness, Inventory, Cost
Savings, Inquiry to Savings Ratios, Vendor initiatives and growth projects.
Selected Highlights

Implement new lines of business for AZ, HI, MO, NJ and SC to expand the company by several hundreds of thousands of lives
in 2012 and 2013.
Implement new code compliance & billing system that increases annual medical cost savings by $30M.
Implement corporate risk assessment guide for strategic claims and cost containment projects value at $110M.
Improve claims denial rate from 13% to 10% annually that reduces adjustments and provider inquiries.
Implement new benefit programs Special Needs (SNIP) & Dual Enrollment.

Albany Medical Center Albany, NY

May 2011 to May 2012
Leading academic health sciences center: includes a 651-bed hospital, private medical school, and fundraising organization.
DIRECTOR OF FINANCE PROJECT SOARIAN FINANCIALS PATIENT ACCESS & BILLING MANAGEMENT
Lead a large organization change that transforms revenue cycle management operations to a new enterprise operating system.
Project Management Office coordination of Deloitte Consulting and AMC business and IT teams to complete initiation, design to preGo live implementation. Deliver project life cycle reports to senior team. Ensure that project resources, planning and tasks are timely
and resolution of gaps.

Thomas Everett

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everetttom2009@gmail.com

Selected Highlights

Achieve business and system design in 5 months with a new AGILE methodology to integrate with Siemens products:
Eagle, INVISION and Soarian Clinical at the enterprise level.
Align, inform and gain commitment to execute business plan with corporate leadership for both financial and clinical
stakeholders that protects $600M in revenue annually.

ConnectiCare, Inc. & Affiliates/Emblem Health Farmington, Connecticut

2002-2011
A leading nationally NCQA recognized health maintenance organization: Commercial, Medicare Advantage & Individual products
DIRECTOR, CLAIMS SERVICE CENTER
Business owner to direct claims operations for all product designs with 300K lives and $900M in medical spend annually. Lead and
improve claims processing to 94% automation rate, 90% electronic submission rate with 99.5% financial accuracy. Lead corporate
compliance and cost containment project to implement a new clinical coding system that decreases medical spend by $3M annually.
Selected Highlights
Achieve top 5 national service rank for health plan with best in class claims performance metrics in New England region.
Implement process improvements for Voice of the Customer Task Force through Lean Six Sigma methodologies.
Implement voice recognition technology to capture coordination of benefits information that increases medical expense
savings by $1M annually.
Implement new Cost Containment & Recovery application that improves productivity by 20% and collections by 0.5% of
overall medical claims expense annually.
Implement a Star Quality (Improvement) Idea program online for Operations that leads to better productivity.

Empire Blue Cross & Blue Shield Albany, New York

A large regional insurer located in the Northeast that handles all lines of business with national contracts.

1991-2002

DIRECTOR FEDERAL EMPLOYEE PROGRAM (1999-2002)

Lead the Service Center operations for Account Management, Claims, Call Center, Customer Service, Compliance and Systems to
exceed key performance indicators. Direct specific process improvement initiatives that raise service levels by 40% and enhance
client relations with Blue Cross Blue Shield Association. Manage both PPO and POS benefit plans with 175K lives with $400M in
medical spend annually.
Selected Highlights
Achieve $4.3M in new revenue, and an annual operating margin of 5%, by executing a multi-year business recovery plan.
Lead the turnaround plan in 2 years based on pay for performance service agreement with client that improves key
performance metrics by 40%.
National recognition as a High Performing Service Plan by BCBSA a significant improvement from provisional status.
Implement and lead a Quality (Improvement) Circle across Operations, Marketing and Finance.
DIRECTOR NYSHIP & FEDERAL Benefit Plans Claims & COB Operations (1991-1999)
Lead high-impact change initiatives for $1 billion-dollar in health plans with 1.3M lives and 500K claims monthly. Lead initiatives to
optimize and improve claims systems technology and modernize key adjudication and COB functions. Direct and control program
testing and oversight to ensure government compliance.
Selected Highlights
Lead a state-wide plan over 2 years that transforms 5 NYS Blue Cross health plans to use a single Customer Service and Claims
delivery system (ITS/Blue Card) in order to retain $600M in annual revenue.
Lead project teams to implement 2 new adjudication systems respective for each health plan that improves automation by 40%
to 85% and financial payment accuracy from 97% to 99%+ error free.

EDUCATION & EXPERTISE

Bachelor of Science Elmira College, Elmira, NY
Gerson Lehrman Group Council Educator Consultant, New York, NY
Lean Six Sigma, Strategic Delivery & Implementation Management & Model Office, and capital planning committee.
Commercial, Medicare and Medicaid program management includes member and provider service.
Strategic Planning, Enterprise Level Performance Reporting, PMO, Risk Assessment & Change Management.