Category: ADVOCATE

         MARKET CONSULTANT - HEALTHCARE ADVOCATE           Professional Summary    Ambitious and dedicated managed care professional with robust organizational, communication and customer service
skills. Multi-disciplinary industry expertise with an emphasis in provider outreach, research\analysis and data integrity. Seeking a position to partake in new and innovative improvement processes and proactive provider education efforts.      Education and Training      BBA   :   Business Administration Human Resources Management      University of New Mexico   －   City  ,   State      Business Administration Human Resources Management        Skill Highlights                 Government relations knowledge  Provider education and communication   Personal and professional integrity  Database management         Relationship and team building  Organizational planning  Sound decision making   Excellent research skills   Claims analysis and review specialist  Project management               Professional Affiliations    Member of Alpha Chi Omega Sorority      Professional Experience      Market Consultant - Healthcare Advocate    August 2015   to   Current     Company Name   －   City  ,   State      
    Provides in the
    field
    market
    by market strategy,  expertise, &
    execution on Risk Adjustment  &
    Clinical Quality Programs (HEDIS/Stars) 
    prospective and retrospective programs for Providers.
       Acts
    as a designated resource for the Provider group to gain engagement.  
    Performs
    data analytics to help identify high risk members and to develop a strategy and
    plan for the practice.  Consults
    to help improve coding accuracy, documentation and management of patient
    assessment information.  Facilitates
    access to medical records for chart review purposes.
      Utilizes programs such as SalesForce, Tableau, Concur, and SharePoint to track various activities and reporting.          Provider Network Specialist    February 2014   to   August 2015     Company Name   －   City  ,   State      Supported contracting efforts to "close the pricing gap" for both the Blue Community HMO and Blue Advantage HMO networks for the health insurance exchange, along with involvement in the beginning stages of additional exchange network implementations for 2015.  Validated designations for all Essential Community Providers contracted with both exchange HMO lines of business.  Strengthened and maintained provider relationships located within the Northeast region of New Mexico, including the Taos PHO and La Vida IPA.  Audited monthly rosters received from the Taos PHO and La Vida IPA to insure correct system representation within PPW and Provider Finder.  Validated credentialing status, network and pricing links utilizing Vistar, PPW, Legacy Premier and Premier Pricing.  Utilized Blue Chip, PRAP and PQRS for additional claims issues review.  Collaborated amongst peers to create provider training presentations and informational provider packets.  Created standard contracts and amendments for all lines of business.  Completed Single Case Agreements Assisted with maintaining Centennial Care and Medicare Appeals and Grievances.  Participated in Behavioral Health Roster Project and Lovelace named Medicare Advantage Contract project.          Claims and Third Party Liability Supervisor    December 2013   to   February 2014     Company Name   －   City  ,   State      Ensured compliance with HIPAA regulations and requirements.  Maintained daily operations and processes within the department by monitoring employee workflow and distribution.  Championed compliance with all departmental policies, as well as interface with Quality Assurance regarding procedure compliance.  Streamlined departmental and individual performance metrics and took proactive action when necessary on a timely basis to maintain desired workflow outputs.  Developed and implemented system and operational changes to improve service and production efficiency.  Collaborated with the Training and Quality Review team to implement new and revised procedures.  Strengthened the claim approval process including, but not limited to, providing assistance and support to negotiators with complex and/or difficult claims to determine negotiation leveraging points.  Collaborated, coordinated, and communicated across various disciplines and departments.  Championed internal audit rebuttal reviews and one-on-one feedback to direct staff.  Boosted company efficiency and client satisfaction by streamlining processes deemed inefficient.  Attended Lean Six Sigma and Rapid improvement events to identify optimal value stream maps.  Identified process boundaries and determined opportunities to automate processes and functions.          Provider Relations Field Representative    November 2012   to   December 2013     Company Name   －   City  ,   State      Conducted visits to participating Fee for Service New Mexico Medicaid Providers.  Enhanced and delivered formal trainings, webinars, and other provider-related outreach.  Applied knowledge of established procedures to resolve escalated provider questions, or management requests.  Acted as the initial contact for escalated issues from the provider relations support staff.  Examined claims and reports to ensure proper recoding of transactions and compliance with state and federal regulations.  Investigated claim processing outcomes.          Supervisor    September 2011   to   November 2012     Company Name   －   City  ,   State      Facilitated the enrollment process for all prospective employees and vendors seeking participation within the Mi Via Self-Directed Waiver program.  Maintained relationships with Employers of Record (EORs) to ensure all prospective employees and vendors completed and provided all necessary documentation to begin employment.  Demonstrated enrollment oversight and ensured enrollment processes met participant expectations and state regulations.  Allocated resources appropriately to meet deadlines.  Organized workflow between other departments to ensure efficient and accurate outcomes.          Recruitment Specialist    February 2010   to   September 2011     Company Name   －   City  ,   State      Generated qualified candidates for open positions.  Presented job opportunities to qualified customer service care representatives, along with senior leadership positions.  Guided prospective candidates and negotiated contract terms.  Screened potential candidates through in house and external interviews.  Performed reference checks, exit interviews and other background verifications for all candidates.  Facilitated training and on-boarding of 120 employees, for new client 2nd Quarter, 2010, bringing a projected $25,000 monthly revenue to the site.  Bolstered recognition from client and internal transition leads.  Excelled within deadline-intensive environment, ensuring the accurate and on-time completion of all recruitment efforts.  Reduced employee attrition by 2% 4th quarter 2010.          HRIS Administrator    September 2008   to   November 2010     Company Name   －   City  ,   State      Managed the Leave of Absence and FMLA process.  Determine eligibility, processed employee requests, tracked FMLA leave taken and remaining hours for approved intermittent use and close-out file upon completion.  Coordinated Workman's Compensation claims from initial accident reports through medical treatment and return to work documentation.  Acted as a liaison between Liberty Mutual, SITEL and claimant.  Supported benefits administration for on site and home based employees, including open enrollment, new hire orientation and qualifying events.  Guided on site employee recognition programs including, employee referral bonus and service awards ceremonies.  Mediated, documented and resolved employee relations issues.  Maintained personnel file compliance for both on site and home based employees.  Championed campaigns for community outreach; Juvenile Diabetes Research Foundation (JDRF), United Way, Toys for Tots and Road Runner food bank.  Initiated employee involvement and participation.          Skills    Premier, automate, Behavioral Health, benefits administration, contracts, Critical thinking, client, client 2, customer service, Database management, decision making, Diabetes, documentation, employee relations, Government, HIPAA regulations, insurance, internal audit, team building, leadership, exchange, negotiation, network, networks, Organizational, personnel, policies, presentations, Pricing, processes, Project management, Quality, Quality Assurance, recruitment, Research, Six Sigma, Sound, workflow