Looking for a job

John Romines

@johnromines

I lead health plan operations, modernizing enrollment, billing, claims, and member services for large-scale healthcare organizations.

United States

Message

What I'm looking for

I'm seeking an opportunity to leverage my health plan operations, revenue cycle, and specialty pharmacy expertise with a cutting-edge company committed to innovation and excellence.

At Capital Blue Cross, I led enrollment, billing, and claims operations supporting more than 800,000 members while overseeing departmental budgets exceeding $1M.

I modernized paperless explanation-of-benefits and billing processes, developed electronic medical-claim submission, strengthened vendor performance, and built KPIs, staffing models, and SLA-focused operating practices.

Across health plans, specialty pharmacy, infusion intake, and hospital admissions, I've improved benefits investigation, prior authorization, claim adjudication, care coordination, and member service operations.

Experience

Work history, roles, and key accomplishments

Director of Health Plan Operations

Capital Blue Cross

Jan 2021 - Dec 2025 (4 years 11 months)

Accountable for strategic oversight of multiple operational teams servicing an 800,000+ member base, managing budgets exceeding $1M, and leading modernization efforts including paperless processing and advanced EOBs.

Health Plan Operations Revenue Cycle Management Budget Planning KPI development Six Sigma Salesforce Power BI CMS Regulations HIPAA SLA Management

Manager of Member Services

Capital Blue Cross

Jan 2020 - Dec 2021 (1 year 11 months)

Directed a team of supervisors and representatives using Salesforce to manage member inquiries and case resolution, improving NPS and customer satisfaction.

Salesforce CRM Agile Project Management Data Analysis Customer Satisfaction NPS

Supervisor of Member Services

Capital Blue Cross

Jan 2017 - Dec 2020 (3 years 11 months)

Oversaw daily contact center operations and real-time queue management, coaching staff on system utilization and benefits structures to meet quality and productivity benchmarks.

Call Center Operations Queue Management Coaching CRM Benefits Administration

Supervisor of Specialty Infusion Intake Operations

Pentec Health

Jan 2014 - Dec 2016 (2 years 11 months)

Managed intake department for benefits investigation, prior authorization, and onboarding of complex home infusion therapy programs, optimizing processes to reduce time-to-therapy.

Specialty Pharmacy Benefits Investigation Prior Authorizations CPR Process Optimization Care Coordination

Customer Care Supervisor

CoramRx Specialty Pharmacy

Jan 2013 - Dec 2014 (1 year 11 months)

Led specialty pharmacy intake operations team for benefits investigation, authorizations, patient onboarding, and refill management, serving as point of contact for VIP clients.

Specialty Pharmacy Benefits Investigation Prior Authorizations Patient Onboarding Refill Management Client Relations

Lead Customer Care Specialist

CoramRx Specialty Pharmacy

Jan 2012 - Dec 2013 (1 year 11 months)

Verified insurance coverage and secured prior authorizations for high-dollar specialty drugs, completing intake and onboarding within CPR+ and serving as SME for claim adjudication.

Insurance Verification Prior Authorizations CPR Pharmacy Claim Adjudication SME

Admissions Coordinator

Southwest Healthcare System (UHS)

Jan 2002 - Dec 2012 (10 years 11 months)

Managed surgical admissions across two hospital campuses, overseeing insurance verification and prior authorization, and improving upfront collections by contacting patients pre-procedure.

Insurance Verification Prior Authorizations Patient Collections Admissions Healthcare Operations