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network coordinator provider relations advocate resume example with 8+ years of experience

Jessica Claire
, , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary

Collaborative leader with dedication to partnering with coworkers to promote engaged, empowering work culture. Documented strengths in building and maintaining relationships with diverse range of stakeholders in dynamic, fast-paced settings.


Encouraging leader and analytical problem-solver with talents for team building, leading and motivating, as well as excellent customer relations aptitude and relationship-building skills. Proficient in using independent decision-making skills and sound judgment to positively impact company success. Dedicated to applying training, monitoring and morale-building abilities to enhance

employee engagement and boost performance.


Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

Skills
  • Staff Training
  • On-Site Visits
  • Contract Amendments
  • Conflict Management
  • Physician Recruiting
  • Provider Enrollment
  • Self-Motivated
  • Project Management
  • Multitasking Abilities
  • Decision-Making
  • Verbal and Written Communication
  • Exceptional Attention to Detail
Work History
03/2015 to 01/2020
Network Coordinator/ Provider Relations Advocate AETNA City, STATE, Sunrise, FL
  • Developed and maintained a positive relationship with 100+ providers by conducting site visits to contracted providers monthly.
  • Conduct audits on loaded providers within designated area for accuracy
  • Provided ongoing education to physicians, provider staff, and/or physician leadership on health plan initiatives, contracts, policies, and procedures
  • Collaborated with the claims, business configuration department to help resolve providers complaints and/ or questions, and provider education as needed
  • Worked closely with practitioners to help each obtain privileges at assigned healthcare facilities
  • Manage provider directory management
  • Provided training on new programs, Issue resolution and support for our provider self-service support online tool link
  • Prepare for and participate in meetings with providers and provider staff.
  • Demonstrated knowledge of Medicaid/Medicare fee schedules, contracting process, financial terms and metrics.
  • Negotiated and implemented value-based contracts with key medical groups in assigned territory
  • Ability to multitask and work in a fast-paced environment.
  • Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
  • Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
  • Tracked expiration dates on documents and communicated with appropriate staff to avoid late filing.
  • Assisted with physician recruitment by identifying specific providers within designated territories, negotiating rates for new physicians and distributing provider agreements.
  • Configured networks for smooth, reliable operation to meet business processes and objectives.
05/2014 to 03/2015
Referral Coordinator/ Provider Relations Rep Broward Health/ SFCCN City, STATE, Sunrise, FL
  • Monitor all Inpatient/Outpatient Referrals
  • Request medical records
  • Prepare weekly and monthly inpatient census reports
  • Enter retrospective authorization in CCMS/EPIC with accurate event status and dates of service
  • Investigate member grievances within network
  • Assist in end-to-end provider claims and help enhance call quality
  • Frequently accessed Epic/CCMS/Facets/HEDIS/ MED3000
  • Obtains timely and accurate primary source verification for all credentialing functions
  • Maintain current databases for all providers
  • Help implement training and development of external providers through education programs
  • Process new credentialing applications, renewals, and updates.
  • Maintained accurate records on in-progress and completed referrals, ensuring full data integrity throughout process.
  • Followed up with clients and specialists to inquire about experience and collect reports.
  • Called insurance companies to get pre-certification and other benefits information on behalf of patients.
  • Maintained accurate records on in-progress and completed referrals, ensuring full data integrity throughout process
  • Weighed patient need, provider availability and insurance coverage to determine optimal scheduling
  • Followed up with clients and specialists to inquire about experience and collect reports
  • Trained 10 staff on referral and intake process
  • Worked with senior case managers to coordinate team development activities and trainings
01/2013 to 05/2014
Customer Care/Provider Rep United HealthCare City, STATE, Miami, FL
  • Knowledge in Medicaid and Medicare guidelines, Managed Care and Third-Party Reimbursement
  • Expert with HIPAA
  • Conducts compassion training
  • Initiated cross-training with other departments to improve work flow and streamline project completion
  • Billing and payment issues
  • Explanation of Benefits (EOB)
  • Authorization for treatment
  • Support RN's and Case Managers
  • File Grievances and Appeals, while verifying claim status
  • Being responsible for any follow-up work needed for resolving and closing issues
  • Advanced knowledge and skill level with ICD, CPT, HCPC, UB04 and Revenue Codes
  • Supervising, evaluating, mentoring, and developing team members; managing agent's workload, and participating in hiring and promotion of agents.
  • Maintained excellent customer relations and developed customer rapport
  • Constantly meet established productivity, schedule adherence, and quality standards
  • Developed and established departmental policies and procedures to improve departmental workflows and communication.
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
  • Actively listened to customers' requests, confirming full understanding before addressing concerns
  • Created spreadsheets using Microsoft Excel for daily, weekly and monthly reporting
  • Increased customer satisfaction by resolving issues
  • Used critical thinking to break down problems, evaluate solutions and make decisions
04/2010 to 07/2011
Customer Service Agent / Team Support AT&T City, STATE, Miami, AZ
  • Respond to complex calls
  • Handle billing issues
  • Verify billing adjustments
  • Set up payment arrangements
  • Assist with collections on accounts
  • Schedule technician appointments
  • Team player
  • Assist with training new hires
  • Used consultative selling techniques to provide leads for telesales personnel
  • Reinforced benefits of being a customer by providing relevant offers that deepen customer engagement
  • Supervising, evaluating, mentoring, and developing team members; managing agent's workload, and participating with the hiring and promotion of agents
  • Build customer loyalty and trust through exceptional listening skills.
  • Adhered to company policies and scripts to consistently achieve call-time and quality standards.
  • Resolved over 100 customer issues per shift by researching and exploring answers, implementing solutions and escalating unresolved problems to upper management
Education
Expected in 06/2003
Diploma:
Hialeah High School - Hialeah, FL,
GPA:
Skills
  • Staff Training
  • On-Site Visits
  • Contract Amendments
  • Conflict Management
  • Physician Recruiting
  • Provider Enrollment
  • Self-Motivated
  • Project Management
  • Multitasking Abilities
  • Decision-Making
  • Verbal and Written Communication
  • Exceptional Attention to Detail
Work History
03/2015 to 01/2020
Network Coordinator/ Provider Relations Advocate
AETNA Sunrise, FL
  • Developed and maintained a positive relationship with 100+ providers by conducting site visits to contracted providers monthly.
  • Conduct audits on loaded providers within designated area for accuracy
  • Provided ongoing education to physicians, provider staff, and/or physician leadership on health plan initiatives, contracts, policies, and procedures
  • Collaborated with the claims, business configuration department to help resolve providers complaints and/ or questions, and provider education as needed
  • Worked closely with practitioners to help each obtain privileges at assigned healthcare facilities
  • Manage provider directory management
  • Provided training on new programs, Issue resolution and support for our provider self-service support online tool link
  • Prepare for and participate in meetings with providers and provider staff.
  • Demonstrated knowledge of Medicaid/Medicare fee schedules, contracting process, financial terms and metrics.
  • Negotiated and implemented value-based contracts with key medical groups in assigned territory
  • Ability to multitask and work in a fast-paced environment.
  • Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
  • Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
  • Tracked expiration dates on documents and communicated with appropriate staff to avoid late filing.
  • Assisted with physician recruitment by identifying specific providers within designated territories, negotiating rates for new physicians and distributing provider agreements.
  • Configured networks for smooth, reliable operation to meet business processes and objectives.
05/2014 to 03/2015
Referral Coordinator/ Provider Relations Rep
Broward Health/ SFCCN Sunrise, FL
  • Monitor all Inpatient/Outpatient Referrals
  • Request medical records
  • Prepare weekly and monthly inpatient census reports
  • Enter retrospective authorization in CCMS/EPIC with accurate event status and dates of service
  • Investigate member grievances within network
  • Assist in end-to-end provider claims and help enhance call quality
  • Frequently accessed Epic/CCMS/Facets/HEDIS/ MED3000
  • Obtains timely and accurate primary source verification for all credentialing functions
  • Maintain current databases for all providers
  • Help implement training and development of external providers through education programs
  • Process new credentialing applications, renewals, and updates.
  • Maintained accurate records on in-progress and completed referrals, ensuring full data integrity throughout process.
  • Followed up with clients and specialists to inquire about experience and collect reports.
  • Called insurance companies to get pre-certification and other benefits information on behalf of patients.
  • Maintained accurate records on in-progress and completed referrals, ensuring full data integrity throughout process
  • Weighed patient need, provider availability and insurance coverage to determine optimal scheduling
  • Followed up with clients and specialists to inquire about experience and collect reports
  • Trained 10 staff on referral and intake process
  • Worked with senior case managers to coordinate team development activities and trainings
01/2013 to 05/2014
Customer Care/Provider Rep
United HealthCare Miami, FL
  • Knowledge in Medicaid and Medicare guidelines, Managed Care and Third-Party Reimbursement
  • Expert with HIPAA
  • Conducts compassion training
  • Initiated cross-training with other departments to improve work flow and streamline project completion
  • Billing and payment issues
  • Explanation of Benefits (EOB)
  • Authorization for treatment
  • Support RN's and Case Managers
  • File Grievances and Appeals, while verifying claim status
  • Being responsible for any follow-up work needed for resolving and closing issues
  • Advanced knowledge and skill level with ICD, CPT, HCPC, UB04 and Revenue Codes
  • Supervising, evaluating, mentoring, and developing team members; managing agent's workload, and participating in hiring and promotion of agents.
  • Maintained excellent customer relations and developed customer rapport
  • Constantly meet established productivity, schedule adherence, and quality standards
  • Developed and established departmental policies and procedures to improve departmental workflows and communication.
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
  • Actively listened to customers' requests, confirming full understanding before addressing concerns
  • Created spreadsheets using Microsoft Excel for daily, weekly and monthly reporting
  • Increased customer satisfaction by resolving issues
  • Used critical thinking to break down problems, evaluate solutions and make decisions
04/2010 to 07/2011
Customer Service Agent / Team Support
AT&T Miami, FL
  • Respond to complex calls
  • Handle billing issues
  • Verify billing adjustments
  • Set up payment arrangements
  • Assist with collections on accounts
  • Schedule technician appointments
  • Team player
  • Assist with training new hires
  • Used consultative selling techniques to provide leads for telesales personnel
  • Reinforced benefits of being a customer by providing relevant offers that deepen customer engagement
  • Supervising, evaluating, mentoring, and developing team members; managing agent's workload, and participating with the hiring and promotion of agents
  • Build customer loyalty and trust through exceptional listening skills.
  • Adhered to company policies and scripts to consistently achieve call-time and quality standards.
  • Resolved over 100 customer issues per shift by researching and exploring answers, implementing solutions and escalating unresolved problems to upper management

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Resume Overview

School Attended

  • Hialeah High School

Job Titles Held:

  • Network Coordinator/ Provider Relations Advocate
  • Referral Coordinator/ Provider Relations Rep
  • Customer Care/Provider Rep
  • Customer Service Agent / Team Support

Degrees

  • Diploma

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