Senior Consultant, Project Manager Resume Example
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SENIOR CONSULTANT, PROJECT MANAGER
Core Qualifications
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Accomplishments
Claims review and analysis for outstanding A/R issues
Experience
Senior Consultant, Project Manager09/2012 － CurrentAetna Inc.Bowling Green , OH
- Project manager for a large, multi-layered network development project for Medicare Advantage.
- Responsible for a team of leads and recruiters executing deliverables to the client to meet CMS guidelines for network approval in pre-determined markets.
- Established project protocols and guidelines based on the clients determined needs.
- Execute and deliver Medicare Advantage, market ready network to client in established time frames.
Regional Vice President, Payer Relations08/2007 － 07/2012University Health SystemSan Antonio , TX
- Responsible for negotiation of new and existing contracts with Payers, networks and managed care organizations in eight states including contract language evaluation and negotiation.
- Operations support for 170 Clinics and one centralized central billing office
- Claims review and analysis for outstanding A/R issues
- Complex financial analysis to assess impact of reimbursement models
Administrator, Network IPA Operations09/2006 － 08/2007Great American Insurance GroupSyracuse , NY
- Lead role in physician contracting, involvement in rate negotiations, follow up process
- Key responsibility for oversight of IPA network performance including development of monthly action plans
- Involvement in pro-forma budget preparation and implementation
- Management of provider relations representatives
National Director of Managed Care01/2005 － 05/2006CanalSan Francisco , CA
- Responsible for negotiating local, regional and national payer agreements
- Budget preparation and price increase forecasting for assigned markets
- Rate Performa preparation and analytic review of revenue impact for contract proposals
- Claims review and analysis for outstanding A/R issues *Company acquired by Fresenius Medical Care - position eliminated due to acquisition.
Manager, Provider Relations10/2000 － 12/2004BlueCross BlueShield Of Tennessee, IncCity , STATE
- Network development responsibility for physician, ancillary and hospital networks
- Management and staff development responsibilities for a large regional staff.
- Extensive project management experience through development, execution and implementation of assigned initiatives.
- Experience in data management, design and development of tracking databases.
Senior Provider Relations Representative08/1999 － 10/2000United Healthcare, IncCity , STATE
- Responsible for Provider Relations, Credentialing, Compliance & EDI in the Chicago market for a network of 16,000 providers.
- Managed multi-level staff including management, professional and bargaining unit staff.
- Redesigned and implemented credentialing process supporting provider networks for the health plan.
- Developed network management compliance program for managed Medicare programs.
- Implemented new educational program for network providers ensuring full compliance with contractual obligations.
- Managed a team of ten provider relations representatives.
- Organized Medicare+Choice compliance initiative for network management department statewide.
- Developed tracking databases to ensure timely credentialing and contracting of providers.
- Participated in the Medical Expense initiative to lower the cost of healthcare expenditures for the company.
- Responsible for credentialing and contracting network providers for assigned territories
- Coordinated large educational programs with key employer groups, including Nissan and Saturn
- Educational responsibility for providers to ensure contractual compliance
- Served as the liaison to the Medicare+Choice compliance committee
Marketing Representative09/1996 － 06/1997Horizon Mental Health At TCMCCity , STATE
- Developed strategic marketing plan for geriatric and medical psychiatric inpatient units
- Marketed to and developed referral relationships with key physicians
- Organized exhibit participation in trade show and professional organizations
- Developed new reporting system to measure productivity and marketing effectiveness
Director of Marketing02/1996 － 09/1996American Day Treatment CentersCity , STATE
- Responsible for strategic marketing and referral development with local physicians, hospitals and community based programs.
- Developed reporting mechanism for effectiveness of marketing activities
- Community Liaison for community mental health and professional organizations *Company went out of business - left to go back to Tennessee to take a position with my former employer.
Behavioral Marketing Associate/Managed Care Specialist01/1995 － 02/1996Tennessee Christian Medical CenterCity , STATE
- Responsible for marketing and strategic plan for inpatient and outpatient psychiatric programs.
- Developed referral relationships with physicians and community mental health providers
- Organized exhibit participation in trade show and professional organizations
- Assisted in the development of managed care strategies and data analysis
Ancillary Recruiter / Project Coordinator11/1991 － 01/1995FOCUS Healthcare Management, IncCity , STATE
- A division of United Healthcare, Inc.) (Multiple Positions)
- Supported client needs through electronic data interface
- Served as a liaison to clients and assisted with daily transfer of data via electronic media
- Oversaw and directed the development of a national Workers' Comp PPO
- Supervised a staff of 9 in network management, responsible for credentialing, data managment and execution of PPO contracts with providers.
- Negotiated with providers and provided guidance on language/rate requests.
- Developed national ancillary PPO network for workers' comp clients
- RFP Response Management. Developed and responded to business development requests, serving as the corporate liaison for RFP responses
Marketing/Communications Coordinator10/1990 － 07/1991HCA Southern Hills Medical CenterCity , STATE
- Developed marketing programs and materials and worked with physicians to expand community visibility
- Responsible for new business development projects & promotions management
- Served as the facilities public relations spokesperson responding to media requests for information
Assistant Director, Provider Relations06/1989 － 10/1990Nashville Memorial HospitalCity , STATE
- Facility marketing and public relations, newsletters and sales initiatives.
- Physician group public relations & program marketing
- Community relations liaison
Education
Master of Science:University of St. Francis - Health Services AdministrationCity, State, USMay 2004 Master of Science Health Services Administration University of St. Francis Joliet, Illinois
Bachelor of Arts:Eastern Illinois University - JournalismCity, State, USMay 1987 Bachelor of Arts Journalism, Speech Communication, and Political Science Eastern Illinois University Charleston, Illinois Community Activities & Memberships: Tennessee Medical Group Managers Association (TNMGMA) Middle Tennessee Healthcare Executives (MTHEA) Madison Kiwanis Club Nashville Kidney Association, Volunteer March of Dimes, Volunteer
The Goddard SchoolParent Advisory Committee, The Goddard School
Certifications
PMP
Professional Affiliations
Tennessee Medical Group Managers Association (TNMGMA)
Skills
Managed Care, Operations, Contracts, A/r, Claims, Medicare, Clients, Databases, Liaison, Billing, Financial Analysis, Marketing, Data Management, Project Management, Business Development, Cms, Content Management System, Leads, Project Manager, Project Coordinator, Recruiter, Rfp, Budget, Budget Preparation, Public Relations, Trade Show, Edi, Mental Health, Healthcare, Recruitment, Forecasting, Increase, Proposals, Strategic Marketing, And Sales, Assistant Director, Community Relations, Sales, Network Operations, Associate, Data Analysis, Marketing Analysis, Outpatient, And Marketing, Geriatric, Marketing Plan, New Business Development, Educational Programs, Access, Database, Database Management, Excel, Leadership Development, Microsoft Excel, Pmp, Strategic Planning, Training
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Resume Overview
School Attended
- University of St. Francis
- Eastern Illinois University
- The Goddard School
Job Titles Held:
- Senior Consultant, Project Manager
- Regional Vice President, Payer Relations
- Administrator, Network IPA Operations
- National Director of Managed Care
- Manager, Provider Relations
- Senior Provider Relations Representative
- Marketing Representative
- Director of Marketing
- Behavioral Marketing Associate/Managed Care Specialist
- Ancillary Recruiter / Project Coordinator
- Marketing/Communications Coordinator
- Assistant Director, Provider Relations
Degrees
- Master of Science : University of St. Francis - Health Services Administration
Bachelor of Arts : Eastern Illinois University - Journalism
The Goddard School
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