Resume category: ADVOCATE

         MEMBER ADVOCATE         Education and Training     2009     University of the Incarnate Word  City  ,   State      Bachelor of Business Administration             2011     University of the Incarnate Word  City  ,   State      Master of Business Administration                Professional Experience     01/2012   -   Current     Company Name   －   City  ,   State    Member Advocate        Represent DentaQuest at community events and meetings to provide information to low-income populations about the dental benefits available to Medicaid and CHIP eligible members.  Establish, develop, and maintain partnerships with community organizations to identify and coordinate outreach opportunities that will facilitate growth in enrollment.  Conduct presentations to promote preventative dental care through good oral hygiene practices and compliance with Texas Health Steps checkups.  Provide case management to members in need of care coordination and assist members with claims issues and appeals.         01/2012       Company Name   －   City  ,   State    Provider Relations Specialist        Served as a liaison between the Medicaid and CHIP Managed Care contractor and health care providers.  Responsible for establishing and maintaining working relationships with the existing provider network.  Researched and resolved provider inquiries to include credentialing, claims issues, complaints and grievances.  Educated providers on new protocols, policies, and procedures to facilitate process improvements.  Ensured provider database and documentation was up to date, accurate, and complete.  Assisted with the development and implementation of provider training programs.         01/2011       Company Name   －   City  ,   State    Business Development/Admissions Coordinator        Responsible for the development of admission statistics in a long-term acute care hospital setting by developing referral sources and converting referrals into admissions.  Responded to inquiries from hospital discharge planners, families, and other referral sources.  Conducted facility tours and informed families of potential patients of admission criteria, insurance coverage, and other costs associated with patient care.  Verified insurance benefits, obtained prior authorizations, and ensured that all potential barriers to claims payment were addressed and resolved prior to admission.  Coordinated the admissions process from start to end and alerted department heads of projected admissions, bed changes, discharges, and protocols for compliance with the patient's managed care insurance requirements.         01/2004   -   01/2009     Company Name   －   City  ,   State    Beneficiary Services Representative        Acted as a liaison between TRICARE beneficiaries and health care providers.  Provided customer service support to beneficiaries that visited the local TRICARE Service Center by responding to benefit inquiries, resolving claims issues, and assisting with appeals, complaints, and grievances.  Advised beneficiaries of health and dental plan options and processed enrollments, disenrollments, primary care provider assignments, and other plan changes.  Provided customer support to the local military treatment facility administrative and clinical staff and assisted case management team with referrals and prior authorizations.  Traveled within the state of Texas to conduct benefit and enrollment presentations to different military groups, such as active duty service members transitioning to retirement, new active duty service members and base transfers, and National Guard and Reserve members called to full-time active duty services.  Provided health care providers with assistance on claims issues, appeals, complaints and grievances.         01/2002   -   01/2004     Company Name   －   City  ,   State    Office Coordinator        Served as administrative and clinical support in various office settings throughout hospital organization to include outpatient physical, occupational, and speech therapy, inpatient skilled nursing, and outpatient wound care services.  Acquired insurance authorizations for patient services.  Prepared all required claims documentation including referrals, treatment plans, and other required correspondence to reduce incidence of denials.  Assisted other areas of hospital by investigating and resolving claims discrepancies in order to collect on unpaid patient accounts.  Played key role in the opening of hospital's new wound care center by assisting director in all areas of development, including creating policies and procedures, creating forms for clinical and billing staff, and obtaining insurance credentialing for providers.         01/1999   -   01/2001     Company Name   －   City  ,   State    Business Office Manager        Managed business office for skilled nursing, rehabilitation, and long-term care facility.  Billed Medicaid, Medicare, and private insurance companies for services rendered to patients.  Managed facility's accounts receivables and accounts payables.  Prepared administrative reports for directors, Chief Financial Officer, and Chief Executive Officer.  Responsible for interviewing, hiring, training, and termination of office personnel.          Skills    accounts payables, accounts receivables, administrative, benefits, billing, oral, customer service, customer support, database, documentation, Financial, forms, hiring, insurance, director, meetings, office, network, nursing, personnel, policies, presentations, protocols, speech, statistics, training programs