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Yyyyyy x. yyyyyy
1356 East 87th St. | Xxxxxx, XXXXXX xxxxxx xxx-xxx-xxxx | abc@xyz.com
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
Continued
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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