Motivated Provider Relations Manager with demonstrated knowledge of healthcare best practices and operations. Proven skills in enhancing productivity, efficiency, building relationships with providers/cross functional teams and bottom-line profits with forward-thinking leadership. Bringing 11 years of experience in field and ready to take on challenging, growth-oriented roles.
Skills
Familiar with Federal HIPAA and CMS regulations
Provider Relationship Management
Tableau and Salesforce experience
Proficient with
MS Word, Excel, PowerPoint, Outlook, Access
Expert level of knowledge of claims analysis, review specialist, Healthcare Billing and Medical Coding (ICD-10 and CPT)
Staff development
Cross-functional collaboration
Customer relations
Contract development and management
Presentation skills
Network Management
5+ years of provider relations and/or managing a team
Over eleven years of experience in Practice Management, Customer Service and Healthcare
Proficient in Medicaid/Medicare Management Information Systems
Exceptional presentation, written and verbal communication skills
HEDIS knowledge-Quality improvement competency
Planning & Strategic Planning
Contract negotiations
8+ years of call center leadership experience
Time Management
General knowledge of Medicare Risk Management
Provider relationship management
Familiar with Federal HIPAA and CMS regulations
Provider Relationship Management
Tableau and Salesforce experience
Proficient with MS Word, Excel, PowerPoint, Outlook, Access
Expert level of knowledge of claims analysis, review specialist, Healthcare Billing and Medical Coding (ICD-10 and CPT)
Experience
04/2022 to 05/2022
Manager, Provider ServicesExcela Health – Delmont, PA,
Led the Provider Services team members and functions. Responsible for the daily operations of the department working collaboratively with other operational departments and functional business unit stakeholders to lead or support various Provider Services functions with an emphasis on education, outreach and resolving provider inquiries.
Oversees and lead the functions of the external provider representatives, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards.
Managed and directed a team of 6 Provider Services staff including hiring, training and evaluated performance.
Assisted with ongoing provider network development and the education of contracted network providers regarding plan procedures and claim payment policies.
Responsible for overseeing appropriate and timely intervention/communication when providers have issues or complaints (e.g., problems with claims and encounter data, eligibility, reimbursement, and provider website).
Ensures appropriate cross-departmental communication of Provider Service's initiatives and contracted network provider issues.
Assist with recredentialing contracted network providers.
Established and created training programs to enhance employee knowledge of best practices, resulting in improved customer satisfaction.
Delegated work to staff, setting priorities and goals.
Assist with any AHCA complaints and provide an adequate network for members
Obtain and and submit all credentialing applications statewide for Provider Services
Built relationships with internal team members and external partners to enhance effectiveness of team's work and boost customer service.
05/2021 to 12/2021
Value Base Care ManagerDATALINK FUND SOLUTIONS – City, STATE,
Communicate with provider groups on benefits of Value Base Care and how to increase their Quality and Risk scores using Evoke 360
Increase user engagement across all provider groups to improve clinical and financial outcome
Lead Value Based Care strategies to increase quality metrics for Medicaid or Medicare line of business
Monitor and manage key deliverables of physician office implementation and onboarding processes
Educate providers on products enhancements and new releases
Created plans and communicated deadlines to ensure projects were completed on time
11/2015 to 05/2021
Sr. Physician Business ManagerOPTUM PART OF UNITED HEALTH GROUP/WELLMED MEDICAL – City, STATE,
Responsible for managing, developing and maintaining accounts for physician groups in the Medicare Advantage Plan
Physician and customer service delivery system, activities included provider contracting, credentialing, and network growth within Polk & Hillsborough counties
Manage assigned territory with resolving contractual issues strengthening the relationship between Managed Care Plan (Medicare Advantage Plan) and the provider
Create and develop action plans to achieve goals in Hedis, coding, and financial performance of physician pools
Plan and attend JOC meetings and help create agendas for discussion points through collaboration with cohort teams
Administer incoming applications, obtain credentialing documentation and perform site visits when applicable
Conduct Monthly/Bi-Weekly Provider Visits and In-Services for newly approved providers
Conduct web portal trainings for all new providers and annual refresher trainings with staff
Manage provider/facility demographic updates, changes and terminations
Liaison for resolution of Claims, HEDIS and web portal issues
Medical Chart retrieval for HEDIS
Help to troubleshoot individual provider issues, questions, or complaints by researching each individual incidence, and tailoring the WellMed model to their respective needs
Train and educate physicians and office staff personnel on our entire WellMed system, from computer input to data submission
Serve as project manager in a variety of special initiatives that dealt with problem resolutions in multiple areas of the Medicare Advantage population
Increased provider satisfaction scores 85% by collecting and credentialing demographic updates, investigating claims and inquiries and overseeing network integrity
Onboarding and train new staff to keep team efficient and prepare team members to effectively handle demands of simultaneous and large-scale contracts
Worked closely with cross-functional team, case managers to resolve any provider issues, and to educate them on contract addendums and changes.
01/2011 to 11/2015
Practice ManagerIGNACIO SALZMAN – City, STATE,
Managed staff of 5 personnel by implementing company policies, protocols, work rules and disciplinary action
Process daily encounters and charge sheets as well as posting payments and batching
Maintain and oversee employee continuing education program
Review and submit employee time sheets for all office personnel processed bi-weekly through Paychex
Evaluate employee performance quarterly and recommended merit increases
HEDIS training with doctors and medical staff
Guarantee Medicare, Medicaid, and Insurance compliance regarding claim filing, coding, and medical documentation
Responsible for hiring, training, coaching, and counseling
Established staff schedules and assignments based on office needs
Achieved high staff morale and retention through effective communication, prompt problem resolution, efficient supervisory practices and facilitating proactive work environment
Collaborate with doctor to ensure proper maintenance of up-to-date medical certifications
Developed policies and procedures for effective practice management
Trained interns and newly hired team members on office procedures and computer system
Ordered all office supplies and kept check on inventory levels
Consulted with healthcare professionals on business decisions.
Education and Training
Expected in 12/2022
Bachelor of Science: Healthcare Management Rasmussen University - Tampa, FL GPA:
Expected in
: Medical Billing/Coding Florida Technical College - Kissimmee, FL GPA:
Languages
English:
Native/ Bilingual
Negotiated:
Spanish:
Native/ Bilingual
Negotiated:
Accomplishments
Used Microsoft Excel to develop tracking spreadsheets.
Achieved 4.5 HEDIS Star Score Rating from a 1.5 through effectively helping with getting members seen and closing quality gaps.
Trained provider and staff out of paper charts into new EMR System
Bravo Awards for building relationships and meeting 85% goal for the month
Organizing a successful event for October Breast Cancer
Help build Provider Service Team/Inhouse Department
Consistently maintained high customer satisfaction ratings.
Resumes, and other information uploaded or provided by the user, are considered User Content governed by our Terms & Conditions. As such, it is not owned by us, and it is the user who retains ownership over such content.
How this resume score could be improved?
Many factors go into creating a strong resume. Here are a few tweaks that could improve the score of this resume:
