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implementation operations manager provider relations advisor resume example with 11+ years of experience

Jessica
Claire
resumesample@example.com
(555) 432-1000,
, , 100 Montgomery St. 10th Floor
:
Summary

Results-focused professional with strength in communication and collaboration. Adept at managing concurrent objectives to promote efficiency and influence positive outcomes. Well-versed in managing projects with a flexible and quality-focused mentality. Effective at gathering and reviewing information, conducting root cause analysis and updating records. Detail-oriented and decisive with remarkable work ethic. Known for effective process improvements and careful attention to operational procedures.

Skills
  • Project Management / Documentation
  • Data Management / Problem Solving
  • Process Improvement / Strategic Planning
  • High Profile Customer / Client oversight
  • Effective Communication / Team Building
  • Transformational Leadership /
Education and Training
Marywood University Scranton, PA Expected in MBA : Management Information Systems - GPA :
Pennsylvania State University University Park, PA Expected in Bachelor of Science : Insurance And Risk Management - GPA :
  • Minor: Legal Environment of Business
Experience
Hca - Implementation & Operations Manager / Provider Relations Advisor
Tacoma, WA, 01/2016 - Current
  • Strengthen end to end service operations and internal/extrnal relationships while successfully anticipating downstream impacts of the overall authorization process to HCPs, Customers and Clients.
  • EviCore’s lead matrix partner for the delegated Code Management Process applicable to supported segments.
  • Oversees the operations of key delegated services such as Medical Necessity Review, Pre-Certification, Claims, Network Management, and Coordination of Care.
  • Assesses risk and implements new partnerships, markets, delegated services, programs/policies.
  • Composes comprehensive project plans while also providing accurate, insightful assessments of performance and risks along with clear actions to improve.
  • Builds bridges between envisioned strategies, metrics and their improvement plans.
  • Applies business acumen/knowledge to articulate business cases to all levels of the organization.
  • Project Manager Implementation lead of the eviCore SSO portal and TSG owner.
  • Successfully works with diverse group of coworkers to accomplish goals and address issues related to our delegated eviCore programs and services.
  • Streamlined acquisition of reporting requirements and specifications to disseminate across multiple business lines including IT support teams.
  • Create, oversee, and update Cigna NAST policies, SOP guidelines, workflows on regular basis.
  • Revitalized Cigna NAST email process workflow by restructuring and redesigning workflows for high profile/priority issues (VIP, HHA Overturns, DOI, BBB, EOC) within assigned segment.
Cigna - Appeals Manager
City, STATE, 01/2015 - 01/2016
  • Effectively managed a virtual team of 25+ staff while balancing multiple team priorities to exceed NAO objectives including production, quality and competency metrics.
  • Adapted and operated extremely well in a fast-paced, changing environment, including implementing new products and workflow processes.
  • Executed and supported compliance measures with corporate policies as well as departmental and national quality initiatives and state regulatory bodies (URAC, NCQA) .
  • Exhibited managerial courage and consistently delivered transparent messages to staff and matrix partners.
  • Supported corporate initiatives such as the mentoring program, training and leadership development including Call/Claim MOS.
  • Collaborated well with matrix partners to ensure objectives and standards were met, policies and procedures followed, gaps identified/closed, communications were clear.
  • Collaborated with staff to maximize customer satisfaction, streamline procedures and improve bottom-line profitability.
  • Eliminated inefficiencies and process gaps to improve overall function of Appeals team.
  • Exceeded team progress metrics against performance targets by motivating staff and proactively resolving department-level issues.
Cigna - Claim Adjustment Manager
City, STATE, 01/2011 - 01/2015
  • Managed a virtual team of 30+ support staff members consistently exceeding team turnaround, production, and quality goals.
  • Developed new processes, streamlined workflows, updated SOP’s, improved system capabilities specific to increasing customer satisfaction.
  • Partnered with call center management and Global Service Partners creating a more customer centric environment which directly improved our overall Net Promoter Score.
  • Planned and implemented Facets reporting enhancements to promote efficiency and maximize space utilization.
  • Established ambitious goals for employees to promote achievement and surpass business targets.
  • Collaborated with leaders to determine client needs and complete assessments of business models and challenges.
  • Implemented unique methods and methodologies, which helped reduce and resolve issues.
Cigna - Provider Contract Auditor
City, STATE, 01/2010 - 01/2011
  • Conducted quality reviews of Practitioner, Ancillary and Facility contracts comparing data relative to provider, demographic and reimbursement submissions.
  • Daily assessment of provider data accuracy processed in accordance with SOP's and corporate procedures.
  • Assisted in the analysis and trending of audit findings and made recommendations for correction of unsatisfactory results.
  • Partnered with Audit staff, Network Operations, Health plans, Contracting, and other Quality Assessment Control matrix partners streamlining existing process workflows.
  • Responsible for inventory management such as assigning work to team members & workload balancing within various HUB sites.
  • Facilitated team conference calls and was a key partner in Focus/Work groups.
  • Ensures that expected Quality Review (QR) turn around times are adhered to and that batches progress appropriately through QR process.

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Resume Overview

School Attended

  • Marywood University
  • Pennsylvania State University

Job Titles Held:

  • Implementation & Operations Manager / Provider Relations Advisor
  • Appeals Manager
  • Claim Adjustment Manager
  • Provider Contract Auditor

Degrees

  • MBA
  • Bachelor of Science

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