Manager, Provider Relations Resume Example Independence Care System

MANAGER, PROVIDER RELATIONS

Professional Summary

Provider Relations Manager who excels in operations analysis and outstanding human relations and leadership skills. Proactive in flagging and developing solutions for process inefficiencies. Seeking to apply management talents to drive long-term company growth.

Education and Training

Masters, Public Administration Operations ManagementDec 2012John Jay College of Criminal Justice － New York, NY

Dean's List

Specialization in Operations Management

Bachelor of Arts, Political ScienceMay 2003Brooklyn College － Brooklyn, NY

Skill Highlights

Network Management
E-MEDS reimbursement fee schedule
Center for Medicare and Medicaid
Coordination of Benefits
Quality Assurance
Contracting (Negotiations &Interpretation
Preferred Provider Organizations
Quality Assurance
Credentialing and Re-credentialing

In-depth claims knowledge
Claims analysis and review specialist
Operations management
Policy/program development
Complex problem solving
Strategic planning
Provider & Office Staff Education and Training
Cactus, FACETS, Business Objects System

Professional Experience

Manager, Provider RelationsMar 2012 to Current
Independence Care System － New York, New York

Responsible for managing and supporting all aspects of provider relations for all reimbursement products including Medicare, Medicaid and all managed care plans.
Develop and Evaluate the provider network to ensure appropriate access for membership and develops/executes recruitment plans.
Create, verify and log in deadlines for responding to daily inquiries.
Effectively maintain relationships with other department managers and serve as main liaison between care management and care management coordinators.
Successfully establish effective systems for record retention by creating database for daily correspondence tracking.
Responsible for the effective management of servicing Hospital, Ancillary, and Managed long term Care providers for all products offered.
Active participation in escalated claims issues by facilitating meetings with providers and coordinate research of claims issues internally.
Provide continuous training to team members to ensure that they possess the required knowledge and information to effectively carry out their responsibilities.
Creation and maintenance of provider relations newsletter, provider directory, and provider manual
Manage the process of credentialing and re-credentialing.
Manage work plans for staff in order to accomplish objectives.
Develop provider network applications in order to efficiently run reports and manage network.
Ensure accuracy of HPN file submission to the New York State Department of Health.
Effectively interpret provider contracts to ensure accuracy of rates, policy and procedures.

Provider Relations Representative IIMar 2010 to Mar 2012
Amerigroup － New York, NY

Interpret claims and provider contracts to set up provider records to process claims accurately in a timely manner including appeals, denials, and retroactive payments.
Works cooperatively with Member services, Health Services, Claims, Marketing and other departments in resolving provider services issues
Analyze and resolve administrative appeal requests through review of benefit design, eligibility, care advocacy procedures, and claims payments as they relate to identified issues.
Effectively communicate potential compliance or process issues to supervisor, as applicable.
Quickly and accurately identify and assess individual member and provider needs and take appropriate action steps to satisfy those needs.
Reviews contracts for submission, completes credentialing check list assuring that all supporting documents are attached and current; keeps log of those submitted.
Coordinates New Office Orientations process for credentialing and re-credentialing cycle.

Senior Provider Relations AssociateJan 2004 to Mar 2010
Health Plus － New York, NY

Managed delegated provider network, federally qualified health centers (Article 28) and Hospitals.
Provided large groups of orientations to Hospital staff in claims, contracting, webportal, authorization, compliance, and quality assurance.
Knowledgeable in health care products; HCP, CHP, FHP, Medicare and Claims codes; ICD-9-CM diagnosis Codes, CPT or HCPCS, unlisted, and place of service codes.
Implements educational programs, to orient providers and provider office staff to Health Plus such as Pay for Performance, Advisory Board Dinners, Office Support Education program, etc.
Monitors provider corrective action plans; includes conducting After Hours Availability Surveys and customer focus cases.
Conduct provider office site visit ensuring that office meets state regulated standards.
Reviewing, maintaining appropriate documentation of cases conducting assessments and resolving member complaint regarding provider while meeting Department of Health Standards.
Interpret claims and provider contracts to set up provider records to process claims accurately in a timely manner including appeals, denials, and retroactive payments.
Review and educate providers by examining their quality assurance reports; hospital admission, Preventive care testing, and Medication Management
Conduct access and availability studies
Facilitate an environment that directs and supports providers and hospital to meet QARR measures
Recommend improvements to providers by identifying coding inaccuracies in order to improve QARR scores
Evaluate quality of care through provider performance analysis for targeted disease management and preventive care
Develop Provider Incentive programs that are designed to improve provider performance

Additional Information

Linked profile: http://www.linkedin.com/pub/angelica-trujillo-etienne-mpa/15 /5b2/118
Fluent in Spanish

Resume Overview

Companies Worked For:

Independence Care System
Amerigroup
Health Plus

School Attended

John Jay College of Criminal Justice
Brooklyn College

Job Titles Held:

Manager, Provider Relations
Provider Relations Representative II
Senior Provider Relations Associate

Degrees

Masters , Public Administration Operations Management Dec 2012
Bachelor of Arts , Political Science May 2003

Manager, Provider Relations Resume Example

Resume Score: 80%

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