Manager, Provider Relations CurrentProvider Network Alliance － Boston, MAResponsible for Network Management, Provider Relations, Credentialing and Provider Data Management for all geographic areas. Make certain the provider network is cost effective, competitive and stable. Assists with physician recruitment by identifying specific providers within a designated territory, facilitating the distribution of provider agreements, negotiating rates for new physicians, and renegotiating contracts for existing physicians within established limits. Conducts geographical access analysis to identify gaps in the provider network and opportunities for recruitment. Responsible for hospital, physician and ancillary provider service agreements and satisfaction that facilitates optimal member access and successful business growth initiatives. Develop, modify and implement external relations, strategies and programs on an annual basis and monitor key metrics at staff level to ensure a high quality of service delivery and resulting Provider Satisfaction as measured by formal Provider Satisfaction Surveys in compliance with all NCQA Standards. Provide strategic direction, mentoring and leadership to the Provider Relation and IT teams to ensure exemplary provider service and satisfaction, including management and/or oversight of formal communication of policy changes and other pertinent information. Develop and execute recruitment strategies and lead network development and management processes for Provider Network Alliance providers. Ensure that the provider network is in place to service the needs of members consistent with benefit plan requirements. Responsible for coordinating the Plan's interaction with providers/practitioners to install a recognition and perception amongst providers/practitioners that the Plan is the premier provider servicing managed care organization in its region. Interface with providers to manage and improve quality metrics, develop and demonstrate an ability to manage complex relationships involving provider performance issues. Maintain regular contact with key provider organizations and serve as a liaison to internally resolve complex issues. Research and resolve escalated provider inquiries within contract guidelines. Educate providers on new protocols, policies, and procedures Manage the daily activity and workload of the Provider Relations staff. Oversee provider education activities including development of presentations for orientations and education. Manages the site visit process as part of provider credentialing. Recommends and drafts provider communications relative to health plan policies and procedures.
Manager, Provider Enrollment & Credentialing Steward Medical Group － Brighton, MAManage staff of six to ensure timely Enrollment, Credentialing and Recredentialing of 850+ Steward Physician, Mid-level and Hospitalist providers with 25 health care payers. This includes submission of Medicaid and Medicare Group Practice site applications, demographic updates, reassignments and additions to practices, changes in authorized officials, changes to provider and/or group practice information, and Medicare Revalidation. Complete and submit on behalf of Steward Providers Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) enrollment. Management of revenue-cycle operations and accounts receivable related to physician, mid-level and hospitalist provider enrollment. Work all credentialing related claim denials through resolution. Work closely with billing vendor to resolve any issues with claims submissions or transactions. Define policies, procedures and quality performance metrics to facilitate timely and accurate execution of enrollment submissions with the goal of generating efficiencies to make certain each physician and mid-level provider is bill-ready upon the commencement of their employment. Prepare and develop budget; analyze budget data and revise cost projections; analyze and monitor line item expenses; establish and project staff, salary and benefit costs; monitor salary and benefits as compared to actual expenditures; identify and resolve discrepancies. Actively and continuously analyze organizational structure, staffing assignments or other factors to ensure optimal performance; make recommendations and modifications, as necessary. Focus on continuous improvement and build customer relationships. Oversee Provider Enrollment systems including security, compliance and program integrity.
Manager, Quality Assurance DentaQuest － Charlestown, MAEstablish and implement an Enterprise-wide Quality Assurance Program to achieve quality assurance operational objectives by contributing information and analysis of strategic plans and reviews; prepare and complete action plans; implement productivity standards; quality and customer service standards; identify and resolve problems; complete audits timely and efficiently; determine system improvements. Assure consistent quality production by validating processes; providing documentation; manage staff; and created a dashboard to incorporate state and client specific requirements/metrics. Develop and define Enterprise policies & procedures; coordinate with other areas to ensure the highest level output is achieved. Lead Corporate Quality Assurance Committee with oversight of all departments' compliance with internal and external regulations. Implement processes and protocols for auditing of claims; customer service; clinical determinations; vision and credentialing files. Manage staff of 17 audit personnel at multiple locations. Prepare and develop budget; analyze budget data and revise cost projections; analyze and monitor line item expenses; establish and project staff, salary and benefit costs; monitor salary and benefits as compared to actual expenditures; identify and resolve discrepancies.
Manager, National Credentialing Database Operations WellPoint, Inc － Andover, MAManage staff of 49 credentialing personnel, including performance, quality, and productivity. Ensure compliance with WellPoint Corporate Policies and Procedures, internal processing standards, state and federal laws and regulations, as well as, NCQA and URAC accrediting standards. Support activities regarding credentialing preparation to achieve successful results of NCQA MCO and CVO accreditation surveys. Assure confidentiality and integrity of all aspects of the credentialing program and process vis-à-vis presentation of participating providers to Medical Directors, Credentials Committee and integral departments. Establish and implement consistent and efficient processes and maintain software data integrity on Cactus, the credentialing database system. Identify and establish best practices for the paperless credentialing system. Facilitate efficient communication with internal and external customers including office managers and providers. Create and distribute reports to support day to day operation of the department, including initial application turnaround times, recredentialing timeliness, inventory management and staff performance reporting. Manage staff in an equitable and professional manner to achieve desired department and Company results. 6/10/02 - Kelly Engineering Resources
Programmer/Systems Analyst January 1978 to July 1995Council for Affordable Quality Healthcare － Newark Boston Charlestown, N.J MAServing as Wellpoint's Corporate representative to CAQH for the Universal Credentialing DataSource initiative; primary participant in all State Rollout Teams tasked to guide and implement the CAQH credentialing application data system in each state; coordinate corporate plan roster and pre-population data submissions for each market launch and assure plan deadlines are met; serve as primary contact for administrative, system and operational issues; manage access to DAS System and define corporate parameters, as well as, contents of data elements to extract; integrate extracted data into internal system; customize queries, and review billing reports. Interact with key staff from areas impacted by CAQH; coordinate new Credentialing procedures to encompass the CAQH process. Responsible for account installation support activities, and the support of ongoing account management plans, for the Group Insurance Division's corporate clients in both the group long-term care insurance and group life insurance disciplines. Assisted in development of account installation task list and execution of installation activities, maintaining account operations, facilitating systems support, establishing management reporting, supporting future enrollment activities and acted as a liaison between the Group Insurance Division and clients or their representatives. Coordinate project for restatement of employee Summary Plan Descriptions (SPD) for high profile, large group client, Magna International. SPD restatement consisted of 68 union and non-union locations with various plan specifications, PPO, POS, Indemnity and/or Managed Care. Interpret, draft and amend policies and contracts for 44 administrative services only (ASO) and insured cases. Provide group policyholders with group insurance Policy and/or ASO Agreement and employee literature expressing underwriting intent and limit of Employer's or Insurer's liability to ensure resulting claim exposure and financial results occur as planned. Work in conjunction with Law Department to ensure Employer's booklets were in compliance with Federal regulations such as HIPAA, COBRA and ERISA. Work closely with Sales, Underwriting and Claims representatives. Conduct extensive research. Prioritize contract work to meet aggressive deadlines. Maintain and enhance client relations. Negotiate, interpret, and develop ASO and Flexible Spending Account Agreements for self-insured clients. Work closely with Home Office Legal Counsel, Consultants and Legal Counsel for client to ensure binding agreements mirrored client intent and were legally sound. Developed COBOL programs to implement system upgrades, revisions and enhancements on Group Contract System (GCS). Administered technical support to six field offices. Evaluated systems problems and provided trouble-shooting services to ensure quick resolution of customer calls. 9/80 - 3/87 Held several positions within John Hancock with increased responsibility.
Senior Contract Specialist, Ford Motor Company Account July 1995 to March 1997John Hancock Mutual Life Insurance Company － Boston, MAAssigned high profile Ford Motor Company Account. Developed and maintained policies and agreements, in addition to employee booklet certificates for 65 union and non-union locations, for the Ford account. Provided Ford with policies, amendments, riders, certificates, and notices in agreement with the group insurance laws of the applicable jurisdictions in which the company operated. Interacted daily with clients from multiple areas in the dedicated regional office.
Associates : Health Care AdministrationUniversity of Phoenix12/2011 Associates Degree Health Care Administration, University of Phoenix
Certificate : Employee Benefits Law, 1980Institute for Applied Management and Law － Newton, MA, US1979-1980 Attended Aquinas Junior College, Newton MA Institute for Applied Management and Law, Inc. Certificate in Employee Benefits Law Proficient in Microsoft Excel, Access, PowerPoint, and Visio; Athena Collector; Cactus; and IntelliApp.
HIPAA Certified Provider Credentialing Specialist (CPCS) Certificate in Employee Benefits Law
Provider Network Alliance
Manage the daily activity and workload of the Provider Relations staff. Oversee provider education activities including development of presentations for orientations and education
Access, Billing, Das, Rollout, Operations, Best Practices, Data Integrity, Database, Inventory, Clients, Claims, Legal Counsel, Contracts, Managed Care, Cases, Client Relations, Cobra, Erisa, Federal Regulations, Hipaa, Liability, Loans, Point Of Sale, Pos, Sales, Underwriting, With Sales, Metrics, Benefits, Budget, Recruitment, Accounts Receivable, Continuous Improvement, Credit, Eft, Medicaid, Medicare, Remittance, Security, Staffing, Audit, Auditing, Audits, Customer Service, Documentation, Quality Assurance, Receptionist, Retail Sales, Cobol, Systems Analyst, Technical Support, Trouble-shooting, Employee Benefits, Excel, Microsoft Excel, Powerpoint, Visio, Basis, Data Management, Mentoring, Satisfaction, Strategic Direction, Territory, Liaison, Its, Premier, Cpcs, Account Management, Annuities, Life Insurance, Systems Support