provider engagement specialist resume example with 15+ years of experience
Jessica
Claire
resumesample@example.com
(555) 432-1000,
, , 100 Montgomery St. 10th Floor
:
Summary
Well-qualified Engagement Manager with demonstrated understanding of data analytics, risk mitigation and utilization improvements. Skills include project and implementation management. Focused, performance-minded manager with proven skills in project management, team building, stakeholder relations and campaign optimization. Ready to offer 12 years of experience to new role dedicated to achieving exceptional results on tight timetables.
Platforms: Windows, MacOS, Linux (Ubuntu, PopOS, Linux Mint), VMWare, Citrix, Tapestry/Epic AP and UM, Tableau
Competencies
Revenue cycle management
Utilization improvements
Data Analytics
Risk Assessments
Public Relations
Strategic planning
Market Positioning
Staff Management
Budgeting
Corporate Communications
Salesforce expertise
Strategic Planning and Alignment
Team Recruiting and Hiring
Complex Problem Solving
Product Development Consultations
Research and Development
Contract Negotiation
Training and Onboarding
Performance Evaluations
Salesforce CRM Software
Product and Service Specification
Relationship Building
Microsoft SharePoint
Verbal and Written Communication
Detail-Oriented
Root Cause Analysis
Cross-departmental Alignment
Microsoft Office
Reputation Management
Business Needs Analysis
Decision Making
Contract Management
Conflict Resolution
Complaint Resolution
Project Management
Education and Training
University of La Verne - La Verne, CAExpected in 12/2022 ā āBachelor of Science:Computer Science, Information Science - GPA:
Experience
Landmark Health - Provider Engagement Specialist , , 09/2015 - Current
Active engagement specialist with regional service area and National Claims Administration leadership
A trusted partner of the regional service area leaders and provider contracting teams to understand regional network strategies and challenges
Data analytics and validation to recognize trends in payment variances
Workflow and optimization creation for current state processes for transition and application for future workflows and processes
Direct contact for very escalated issues regarding all aspects of National Claims administration Issues
Root cause analysis and trending of known (and yet to be known) problems to resolve any delay regarding third party contracted providers
User Acceptance Testing (UAT) for development of in-house written applications to facilitate system wide deployment of tools used for the tracking, coordination, and trending of issues for internal and external stakeholders
Build and maintain relationships with external vendors to ensure good working relationships to highlight struggles to internal leadership
New hire training and development of training schedule for new hires
Lead and facilitate meetings for updates of known projects and complaint resolution
Provide in-depth analysis on claims payment issues and escalations
Research variances in claims payments and determine corrective actions for reduction and elimination of known issues
Provide customer service, including regular status updates, and establish relationships with both internal and external customers and vendors to highlight pain points and bring known issues to the attention of executive leadership
Quantify financial data and provide cost analysis that resultant corrective actions can alleviate and eliminate.
Apex Systems - Business Project Analyst , , 07/2010 - 10/2014
Receive, document and data enter member and provider complaints
Appeals, requests for retro-authorizations and any written or verbal grievances
Maintain all regulatory and state mandated time frame requirements (Erisa and Non-Erisa ASO accounts included) along with all Medicare timeframes for appeals, complaints, denials, reviews and Independent medical reviews pending regulatory approval
Specific care taken with regards to any complaints/appeals/provider inquiries relating to the Department of Managed Healthcare of California (DMHC) and the
Process improvement and workflow creation for
Send, document and save acknowledgement letters for all cases wherein the site for treatment mandated
All cases regardless of state were responded to within 5 business days and completed, in full, within 45 business from documented date of receipt
Maintain working up to date knowledge of revenue codes, ICD-9, CPT and Diagnosis codes for correct and prompt claims processing and payment
Verify eligibility for current clients and new members
Send, update, and verify urgent eligibility requests that are affected by current outpatient and inpatient admissions
Contact plan administrators and account managers for immediate tape and demographic information updates from employers
Directly edit member privacy and eligibility information, as applicable, at member's request
Advised providers about benefits and eligibility information, provide information regarding benefits, copayments, deductibles, maximums, verify if parity laws apply to member cases, and advise of appeals options for the member based on state mandates, Erisa and Non-Erisa ASO accounts with specific verbiage for Department of Managed Healthcare of California and California Department of Insurance Managed Cases
Write and produce correspondence to all members, provider's and business partners (as necessary) and document and relevant actions and correspondence produced within timeframes and in all required systems and documentation programs
Conduct training, provide case updates, and clarify actions to be taken for submitting and properly documenting all inquiries from customer care/call center staff regarding claims, appeals, complaints, denials and requests for medical reviews
Review, update, provide feedback, and quality assurance testing for all process workflows and desk level procedures for all job functions within our department
Staffed cases with medical staff (Triage Nurses and Doctors, utilization review and Care Managers) wherein a medical review was necessary to determine payout and/or processing of claims received
Wrote, edited, saved, documented, and reviewed in excess of 45+ unique cases per day
Self-evaluate and provide feedback to partners to ensure workflows are functioning as intended with a clear and concise purpose
Maintain, update and streamline processes and standard operating procedures
Oversaw projects relating to adjust of workflows based on audit results and industry mandated changes
Trained new hires to do essential job functions relating to our department.
St Century Insurance / AIG - Customer Services Representative / Insurance Specialist II , , 05/2005 - 11/2009
Clearly and concisely provided information regarding customer policy coverage's, claims and billing information
Edited, developed and condensed pre-formatted responses to be incorporated into standardized use to lessen response time to customer questions and emails
Summarized and determined appropriate responses to billing system inquiries based on the payment processor; internal or external payment processor
Assisted and provided service to multiple clients simultaneously via various
Educated of additional products and services available to our clientele
Up-sold Home Owners, Motorcycle, Boat and Renters insurance when opportunities arose
Step by step instructions to guide customers to use self-service web site
Technical instructions on basic browser operation and Internet navigation provided and user request or if deemed necessary to assist customer
Executed all changes and amended/corrected policy information for all customers at their request or to be in line with company underwriting guidelines
Worked through and provided support for corporate takeover when transitioning from 21st Century to AIG, and then to Farmer's through training and updated verbiage for all customers that were concerned this would adversely affect their policies.
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Resume Overview
School Attended
University of La Verne - La Verne
Job Titles Held:
Provider Engagement Specialist
Business Project Analyst
Customer Services Representative / Insurance Specialist II