SUMMARY:

Provider Relations, network development, contract negotiations, member services, customer service, provider education and healthcare relations.

OBJECTIVE:

Seeking position where my acquired experience can be applied effectively to achieve company goals.

PROFESSIONAL EXPERIENCE:

Confidential, Monterey Park, CA

Manager Contracts

Responsibilities:

• Developed collaborative processes to work with network operations and finance to ensure upload of contracts are implemented within time line of the effective dates.
• Developed Joint Operations meeting with Hospital to promote partnership, educate and collaborate with Hospital partners.
• Developed preferred provider logs as resources for Utilization Management to ensure the most appropriate referral sources are being utilized.
• Insure compliance with company’s contracting standards, including reimbursement standards, provider set - up rules, exception process and use of model contract language.

Confidential, Tacoma, Washington

Sr. Manager of Network Development and Provider Relations

Responsibilities:

• Manage, supervise, and direct activities to facilitate financial performance of the provider network.
• Including developing and implementing budgets, market planning, and provider contracts, and network development.
• Provide support to Utilization Management and Quality Assurance process and regulatory reporting.
• Direct supervision of network development, contracting, credentialing, provide Data Management, provider relations, and support of participating hospitals, physicians, ancillary providers and internal departments.
• Development and implementation of provider trainings of products, policy and procedures.
• Coordinate information for providers with financial analytics and medical management team to identify opportunities to improve quality, care coordination and cost efficiency, which would include implementation of new health plan products, reimbursement models, and quality improvement programs.
• Successfully developed Network for CMS filing for Medicare resulting in gainfully adding Medicare Product to health plan’s line of business.

Confidential, McAllen, Texas

Manager of Provider Relations

Responsibilities:

• Responsible for oversight of the Provider Relations department which includes provider education, provider orientations and presentations, claims resolution, and health plan relations.
• Perform training and coaching for performance improvement within physician practices. Contract interpretation and implementation.
• Manage the Provider Relations department which included provider assessment and approval processes for primary Care, specialist and ancillary providers.
• Oversight of provider compliance with regulatory requirements of Commercial, Medicare, and Medicaid health plans.
• Create work processes to insure staff understands policies and responsibilities.
• Implemented process to track and trend Network holes and work with Network
• Implemented process for tracking the completion of claims projects submitted by Provider Relations to other department.

Confidential, Pasadena, California

Director of Provider Relations

Responsibilities:

• Responsible for oversight of the Provider Relations department which includes physician and ancillary network management, PCP network development, provider education, and health plan relations.
• Created and implemented the company’s provider assessment and approval processes for primary Care, specialist and ancillary providers.
• Responsible for ensuring provider compliance of regulatory requirements for Commercial, Medicare, and Medicaid health plans.
• Maintained provider visits tracking database, credentialing packets, contracting and contract implementation for PCP’s and Specialist.
• Leadership role in expanding the value added benefits of PA’s PCP exclusivity program.
• Successfully created database to track and trend provider relations Provider office visits
• Implemented claims resolution processes and procedures.

Confidential, Costa Mesa, California

Director of Managed Care

Responsibilities:

• Management of the overall contracting functions for Health Plan, Physician, Ancillary and Hospital contracting.
• Negotiate, analyze, maintain, and interpret risk contracts to obtain the most favorable contract terms and rates that are advantageous financially and administratively to generate revenue.
• Insure that the negotiations result in the unit cost targets expected and that they duplicate the objectives of the Company.
• Evaluate and monitor financial performance of contracts and give recommendations for improvements.
• Responsible for the Provider Relations, Credentialing and member services departments. Track and coordinate re-negotiation dates of all health Plan and provider contracts.
• Develop, coordinate and implement hospital and physician networks. Develop and implement policies and procedures as they relate to managed care contracting, provider relations, member services, and credentialing.
• Oversight of provider compliance with regulatory requirements of Commercial, Medicare, and Medicaid health plans.
• Lead system implementation for provider contacts, health plan benefits, eligibility and billing to accurately adjudicate claims.
• Insure compliance with company’s contracting standards, including reimbursement standards, provider set-up rules, exception process and use of model contract language.
• Lead and develop staff of professionals in contract analysis, negotiations, and provider relations and credentialing administration.