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Yyyyyy x. yyyyyy

1356 East 87th St. | Xxxxxx, XXXXXX xxxxxx xxx-xxx-xxxx |


Confident, ambitious and client-centered Provider File Operation Expert with more than 20 years of diversified healthcare sector experience. Focused specifically in the area of Provider Data Maintenance, including management of delegation and daily operations. Adept in multitasking to adhere to deadlines in a fast-paced environment. Supervisor and mentor with superb interpersonal acumen; often acknowledged for building and sustaining productive relationships with stakeholders at all levels and across all functional areas. Team-focused with a mindset driven by big-picture visions. Possess strong ability to communicate clearly in both written and verbal format. Quick learner with the ability to work both independently and with a team. Eager to continue a successful career as a leader and integral staff member. In search of a supervisory or managerial opportunity in the healthcare industry with a focus on current field; open to new sectors as well in the interest of career growth.


Areas of Expertise


Provider Data Maintenance | Credentialing | Strategic Planning & Analytics | Client Relations | Decision Making | Communication

Time Management | Business Operations | Supervision | Organizational Skills | Problem Solving | Process Improvement | Vendor Relations

Relationship Building | Microsoft Office | SharePoint | Facets | Cactus | Diamond | The Enterprise System | Business Objects

Care Planner | Altruista | PeopleSoft | Crystal Reports | Macess | Footprints | Siebel



Professional Experience


COGNIZANT TECHNOLOGY SOLUTIONS/EMBLEM HEALTH PLAN | Senior Manager, Provider File Operations (2015-2017)

         Led maintenance functions for over 70 delegated accounts; supervised a 13-prson team of Data Analysts in assisting with operations

         Created and implemented daily workloads, including production and deliverables for all Data Analysts

         Developed and enforced business guidelines that fuel steadiness among staff members performing database modifications

         Liaised with internal customers to ensure streamlined processes; delivered direction to personnel to ensure workflow adherence

         Referred to daily inventory receipts to compare against production outcomes and optimally control inventory levels

         Assessed procedures to note axxxxxx present potential for process improvements

         Audited providers chosen at random to drive accuracy within demographic data

         Validated incoming delegated datasets monthly and weekly to guarantee an 85% accuracy rate or higher prior to data entry

         Actively engage as a key member of multiple committees and work groups to assess existing protocols and devise new rules


AFFINITY HEALTH PLAN | Manager, Provider Data Maintenance/Credentialing (2012-2013)

         Coached, mentored and managed a dynamic team of nine Provider Data Specialists; ensured accountability in their daily work processes using routine observation, reporting and counseling

         Completed performance evaluations, as well as launched department processes and business rules that drove the importance of procedural accuracy and excellence

         Confirmed demographic data integrity across more than 22K credentialed providers including 32 delegated accounts

         Prepared monthly statistical summaries on claims related to the setup of data entry issues

         Noted payment errors in agreement schedules, operating certificate updates and capitation cycle configuration; inspected items in conjunction with the Claims Department

         Audited the primary data system to make certain that its set p and design complied with health plan objectives

         Entered, validated and updated data from direct contracts; also delegated rosters through source documents and website resources

         Authored weekly and monthly ad-hoc and standard error reports to identify discrepancies and correct them to best support interfacing systems; also aimed to confirm compliance with numerous regulators, e.g. HPN, Article 44, IPRO and CMS audits

         Oversaw seven Credentialing Specialists in handling primary source verification, along with online methods of provider validation via ABMS, AMA, CAQH, Joint Commission, NPDB, OPMC, OIG, OMIG and SAM while working as the team s Interim Manager

         Developed and set into motion work plans that detailed key objectives, specific deliverables and detailed timelines

         Supervised daily credentialing team duties e.g. preparation and assignment of schedules and leadership over departmental and workflows

         Screened credentialing documentation from providers prior to database entry; included Licensure, DEA, Malpractice, Curriculum Vitae, Education, Training, Work History, Application and Attestation Content, Medical Board Sanctions and Medicaid/Medicare Sanctions

         Produced monthly standard reports to confirm credential files status

o    Made note of lapsed credentials and certifications, along with other essential missing data in need of correction

o    Effectively re-credentialed 1.6K outdated files within one year in order to rectify regulatory deficiencies

         Also compiled and maintained data within departmental activity reports


DENTAL BENEFIT PROVIDERS | Senior Provider Analyst/Provider Relations (2010)

         Assessed network deficiencies carefully to note geo-access requirements; targeted additional networks to fill projected gaps

         Persuasively negotiated contracts to secure competitive rates; increased network capacity and upheld budgetary restraints as a result

         Coordinated and discussed the terms of settlement agreements that stabilized provider networks, thus yielding a 97% retention rate

         Evaluated new networks through acquisition and executed negotiation strategies to improve capacity

            Yyyyyy x. yyyyyy


Senior Provider Analyst/Provider Relations (Continued)

         Led intricate claims analyses and audits to drive accuracy in developing fee schedules and processing claims

         Restructured the tracking system to improve the reimbursement rate validation while, at the same time, taking note of abusive billing practices; worked to identify and resolve repetitive patterns and erroneous payment processes

         Monitored billing trends, which generated an impressive 32% error reduction rate

         Introduced provider survey processes that were in accordance with all applicable compliance guidelines

         Developed the first dental provider manual in the compaxxxxxx s 14-year history, which included an all-inclusive reference guide for all New Jersey providers


AMERICHOICE | Senior Business Analyst/National Dental Analyst, National (2008-2009)

         Acted as an Internal Auditor for establishment of a provider network, contract compliance measures and a related fee schedule

         Led multifaceted claims analyses and audits to note trends, decide on the root cause of payment inaccuracies, as well as suggest valued process improvements

         Proved crucial in completing analysis and interpretation of UM practice patterns

         Confirmed high levels of data integrity across the claims processing system; updated databases and spreadsheets for analysis and reporting purposes

         Developed and upheld positive working relationships with internal and external clients

         Supported all elements of the National Contract Administration Oversight Audit process

         Helped the Chief Dental Officer prepare annual budgets and fulfill special projects

         Regarded as a Provider Relations subject matter expert (SME) while partaking in work groups dedicated to EDI Transmission and ASO to Risk Conversions, among other essential functions


Dental Provider Network Administrator, NJ/XXXXXX (1999-2007)

         Directed work with internal and external clients in crafting effective strategies that led to HEDIS scores increases of 9%

         Negotiated non-contracted specialist provider fees in order to adhere to state-level requirements

         Led a comprehensive benefits review for services offered by competitors in order to further develop in both new and existing markets

         Helped translate rebranding contracts; negotiated with great success to secure the best possible rates, as well as increase network capacity while maintaining budgetary restraints

         Optimized regulatory compliance and operational efficiency by collaboratively developing effective policies and procedures

         Streamlined regulatory reporting; resulted in recognition for three consecutive years as "best practice" by the Peer Review Organization

         Developed and maintained methods for performance reporting; used by personnel to recognize and evaluate claim trends

         Maintained integrity across demographic and fee schedules to drive customer satisfaction for all network providers

         Amassed all required documents needed to complete provider credentialing and re-credentialing per NCQA requirements

         Worked on the Dental Affairs Subcommittee to prepare quarterly and annual regulatory assessments

         Monitored provider concerns, grievances and appeals to make certain that providers complied with contractual requirements


Also worked as a Consultant with United Dental Group (2015) and with Broadpath Healthcare Solutions (2014-2015)


Education & Qualifications


Associate of Science, Ulster County Community College

Diploma, Business Studies, Ulster County Community College

Also engaged in Risk Management classes, completed in March of 2017 but have yet to complete the certification test


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