manager resume example with 20+ years of experience
JessicaClaire
Montgomery Street, San Francisco, CA94105609 Johnson Ave., 49204, Tulsa, OK
H: (555) 432-1000
C:
resumesample@example.com
Date of Birth:
India:
:
single:
:
Summary
More than 30 years' experience in the healthcare field and 8 plus years managing Provider
date and Contract configuration. Career objective is to manage and lead a team of
administrative healthcare professionals with the knowledge in the healthcare field.
Highlights
Microsoft Word, Excel, Access and Business Objects
KPMAS database/analytical tools (data warehouse reporting tool) Diamond, Epic and
Tapestry systems
MACESS
Accomplishments
Customer Service
Collaborated with a Third Party Administrator to ensure the delivery of over 2k provider records and contracts for the new Self funded product .
Consistently recognized by management and other regions for providing superior customer service in managing the Self funded product with the fewest provider errors in all regions.
Experience
Manager, 2008 - Current United Natural Foods Inc – Somers, CT,
Provider Network &Contract Management) /Providers Systems Administration (PSA) Managed several teams: Provider Updates, Quality Assurance team, Provider Configuration
team and Provider Disputes/Appeals team.
Responsibilities for Provider Updates team are to manage daily Provider Not Found (PNF)
request, monitor daily MACESS Service Form request from other internal customers.
Manage
monthly PCP panel reports, Health Connect provider loads and Self-Funding TPA provider
interface.
Manage the Self-Funding contract and fee schedule implementation project.
Ensuring essential provider data to support self-funding products and members.
Also
managed the nightly provider Place of Serves addresses extraction process.
Managed all
provider Data Quality reports and monitor data integrity.
Ensures Provider Code
Dictionary, Diamond, Health Connect and Cactus have consistent provider data.
Represent
department as SME for new product or systems.
Ensures that modifications /changes to
provider systems and or interfaces, meet new operational and business goals.
Responsibilities for Quality Assurance team is to manage weekly/monthly quality for
Provider updates team and Legacy contract configuration team.
Review departmental staffs
monthly quality to manage errors.
Responsibilities for Provider Configuration team are to oversee and ensure that all
contract configuration terms are loaded correctly in Diamond /Tapestry and support of the
contract implementation process, by ensuring that all contract terms and provider
demographics are loaded into Diamond/Tapestry systems.
Responsibilities for Provider Disputes/Appeals team are to monitor timeliness of case
processing as well as thoroughness of investigations and case resolution.
To ensure that
provider appeals are responded to and resolved within the compliance rate standard.
Responsible for review of Interested Provider contract decisions.
Responsible for maintaining interactive communication with external departments leads
to ensure interdepartmental handoffs function in an effective and efficient manner.
Coordinate with Contract Managers, Associated Assistant Medical Directors and other
departmental staff to resolve provider issues that may require contract clarification or
to ensure that contract configuration is set as stated in provider's contract.
Responsible for reviewing and configuring new provider contracts using the Diamond
pricing configuration system for professional and institutional contracts.
Responsible for loading new providers into diamond and creating provider numbers and
linking the providers address in the Epic/Tapestry system for referral purposes.
Support the claims department via MACESS ISF and CSF.
Support the Data Management Department with large provider load projects and handle any
provider contract issue that may occur.
Responsible for loading specialist provider contracts, maintaining and updating
contract renewals and fee schedule changes in the Diamond system.
Responsible for maintaining the EMS (Error Management System) and the Epic/Tapestry
system daily loads to ensure that all edits and updates are successfully loaded.
Also ensuring accuracy of provider contracted data via Access and Business Objects
reports.
Support the claims department via MACESS ISF and CSF.
Act as liaison between Configuration Department, Contract Managers, Provider Relations
Departments and Provider Services Center to ensure accuracy of contract terminology and
provider data.
Also responsible for overseeing the providers add/change logs and forms.
Reconciliation Capitation Specialist, 11/1999 - 11/2000 Kaiser Permanente Regional Office – City, STATE,
Responsible for the reconciliation analysis of Kaiser Permanente services, contract and
reporting of capitation data for internal and external business needs.
Supported contracted PCP and specialty provider capitation payments.
Created and
maintained databases for capitation reconciliation.
Supported the PCP capitation payment
processes including payments to the APCPN, KPNET, and PHO networks.
Assisted in maintaining appropriated capitation process documentation and supporting
other organizations capitation reporting requirements.
Clinical Review Coordinator, 01/1 - 01/1 Kaiser Permanente Regional Office – City, STATE,
Responsible for conducting system analysis on the Referral Management System and
Amisys to identify excessive cost's areas to target for review.
Implemented audits both concurrent and retrospective from AD500 reports.
Create spreadsheets on lotus, Excel and WordPerfect to indicate savings in addition,
overpayments for management.
Review and resolve provider and member appeal inquires.
Act as a liaison between Claims and Referrals with Contract and Network Management,
Membership Services, MAPMG and Legal Department.
Education
Diploma: Electronics Technology, Expected in 1984 - University of District of Columbia - Springfield, Virginia Washington D. C. GPA: Status - Electronics Technology
Skills
Business Objects, contracts, Contract Management, Data Management, data warehouse, databases, database, documentation, forms, Legal, lotus, Access, Excel, Microsoft Word, Network Management, Network, networks, pricing, processes, Quality, Quality Assurance, reporting, spreadsheets, Systems Administration, system analysis, WordPerfect
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