Resume category: HEALTHCARE

         HEALTHCARE CONSULTANT           Summary     Certified Spinning Instructor and personal trainer with the energy, skills and training necessary to keep clients motivated and moving toward their fitness goals.       Highlights          Certified Spinning Instructor  ACE certified Personal Trainer  CPR and First Aid certified  Energy, motivation and drive to push and motivate participants.      Microsoft Office  Team building  Personable and friendly  Dedicated  Responsible            Accomplishments     Success at building participants from struggling, low participant classes. Most recently built a class that averages 30 participants from a class that started out with around 6 within six months.       Experience      Healthcare Consultant    October 2014   to   Current     Company Name   －   City  ,   State      Network development for a new Medicare Advantage I-SNP in the northeast.  Identify and contract with providers to establish a network that meets CMS time/distance standards.  Subject matter expert for a study on Medicare Advantage best practices for provider engagement.          Cycle Instructor    September 2012       Company Name   －   City  ,   State     Provide a high-energy, safe indoor cycle experience for participants.  Lead, motivate and push participants.  Prepare new routines and new music weekly to ensure participants don't get bored or uninspired.  Incorporate various types of formats into my classes (Tabata - HIIT, interval and resistance training, speed work).         Provider Group Engagement Manager    September 2012   to   October 2014     Company Name   －   City  ,   State      Responsible for establishing, maintaining and overseeing various MSO and engaged provider relationships Oversaw and directed MSO partner activities and internal implementations in order to ensure a successful launch of a gated, referral-based provider network in the Atlanta market.  Initiated and provided ongoing support and financial performance data for various strategic relationships, including MSOs, PCP practice acquisitions, direct provider engagement agreements and other clinic developments.  Coordinated and provided detailed analysis, reporting, training, and education to large, engaged provider groups in order to promote improvement in clinical, quality, coding and financial performance.  Successfully facilitated and implemented various initiatives with provider groups around HEDIS, STARS, etc.  Served as the contact for provider risk group questions regarding financial settlement, delegation, claims adjudication and funding.  Managed and directed staff of 4 Provider Network Consultants.  Lead and directed the committee responsible for improving employee engagement within the Southeast Region.          Regional Director    September 2010   to   April 2012     Company Name   －   City  ,   State      Network Services - Southeastern Region Responsible for managing and directing all contracting and provider relations activities within the Southeast Identified and executed strategies for network development and improvement.  Managed and directed a regional contracting and provider relations staff.  Provided in-depth knowledge of Southeastern region and participated in strategic planning.  Managed and oversaw complex contract negotiations.  Identified new areas for expansion by conducting in-depth market and financial analyses.  Maintained positive relationships with providers and facilitated prompt resolutions to contractual issues.          Manager, Managed Care    January 2004   to   January 2010     Company Name   －   City  ,   State      Responsible for the negotiation and maintenance of major managed care contracts, as well as managing WellStar's credentialing department.  Negotiated favorable contract language and rates to meet business targets and objectives for Georgia's largest integrated healthcare system, consisting of five hospitals, ancillary services, and over 1000 affiliated physicians.  Increased profitability on three key payor contracts over 20% for the system.  Maintained contractual relationships and facilitated resolution to problems arising from the contract.  Managed allcredentialing department activities and staff.  Implemented processes and procedures to shorten the enrollment process with the government payors, which cut the enrollment time down to an average of 50 days.  Successfully obtained delegated credentialing with all contracted payors, which resulted in 100% delegation and an average of 90 days shorter loading time with the payors.  Consistently averaged 99% in delegated payor audit scores.  Continuously implemented and developed strategies to improve and drive employee satisfaction.  2010 Gallup surveys indicated a 48% increase in employee satisfaction over two years in the Managed Care department.  Developed and implemented improvements and best practices for credentialing department in order to align with system goals.  Implemented "Lean Thinking" and techniques in the credentialing department which streamlined processes, facilitated transparency and led to better overall satisfaction with the department.          Provider Reimbursement Specialist    January 2000   to   January 2004     Company Name   －   City  ,   State      responsible for the implementation and quality assurance of various provider contracts successfully in Blue Cross Blue Shield of GA's computer system and assisting with system-wide initiatives.  Managed all internal reimbursement-related activities for multi-million dollar monthly capitation payment process, including analysis, implementation and reporting of capitation data.  Collected and analyzed provider contracting data and computer system data to ensure timely and accurate reimbursement implementations.  Performed quality assurance measures on reimbursement implementations.  Identified and recommended system modifications to advance provider contracting strategies and best practices.  Managed multiple reimbursement projects by determining business intent, estimating and communicating implementation timetables and parameters, and distributing project results and final documentation.  Served as a capitation subject matter expert in the development of the WellPoint Enterprise Data Model.          Senior analyst    January 1997   to   January 1999     Company Name   －   City  ,   State      responsible for the implementation of various provider contracts successfully in Blue Cross Blue Shield of GA's computer system.  Developed and distributed professional fee schedules based on Medicare rates.  Produced ad hoc reports and analyses for management on reimbursement data and provider database content.  Presented project results and recommendations to management and project teams.  Created project documentation and reports to be distributed throughout the organization.  Loaded contracts into Pathways Contract Management system.  Provided leadership and training to a department of ten.          Health Systems Analyst    January 1997   to   January 1999     Company Name   －   City  ,   State      Responsible for the implementation of various provider contracts successfully in Blue Cross Blue Shield of GA's computer system.  Implemented preferred reimbursement methodologies (physician, facility and ancillary).  Managed multiple projects and collaborated with teams to achieve results.          Report Specialist    January 1996   to   January 1997     Company Name   －   City  ,   State      Responsible for reporting quality data.          Client Services Representative    January 1995   to   January 1996     Company Name   －   City  ,   State      Responsible for assisting clients with authorizations and insurance questions.          Education      Master of Business Administration					Bachelor of Science   :   Business Administration/Management Health Services Administration  ,   2000    Kennesaw State University   －   City  ,   State  ,   USA             Bachelor of Science   :   Health Services Administration  ,   1994    Auburn University   －   City  ,   State  ,   USA            Skills     acquisitions, CMS, content, contract negotiations, contracts, Contract Management, clients, database, directing, documentation, estimating, financial, government, insurance, leadership and training, managing, market, negotiation, Enterprise, Network, processes, coding, quality, quality assurance, reporting, strategic, strategic planning