Manager Customer Service

Stephen M. Herring

**** ******** ****** ****** ****, FL 34609 352-***-**** *********@*****.***

OBJECTIVE

I am looking for a position within a company that offers me the opportunity to use my experience in Provider Relations and

Network Development.

EXPERIENCE

HealthSouth Rehabilitation Hospital – Brooksville, FL

Guardian Angel / Spinal Cord Injury Peer Mentor, 11/10 – Current (Volunteer)

Visit with assigned patients as well as referred patients to ensure they are happy with any and all services they are receiving within the

rehab and assist on correcting any issues or concerns that occur or answer any questions they may not be getting answers to from any of

the staff or physicians. Be an advocate for the patients and help emotional adjustment to newly injured spinal cord injury survivors by

listening and offering empathy and support, and providing the opportunities for the injured to be listened to and taken seriously. Teach

problem solving skills by example and appropriate assertivness. Notate the injureds medical records or files for progress. Work on

setting goals with the injured for short term and long term. Work with family members to understand the injury and lend support and

direction as to how to care for the injured.

Florida Spinal Cord Injury Resource Center - Tampa, FL

Spinal Cord Injury Peer Mentor, 3/09 – Current (Volunteer)

Help emotional adjustment to newly injured spinal cord injury survivors by listening and offering empathy and support, and providing

the opportunities for the injured to be listened to and taken seriously. Teach problem solving skills by example and appropriate

assertivness. Notate the injureds medical records or files for progress. Work on setting goals with the injured for short term and long

term. Work with family members to understand the injury and lend support and direction as to how to care for the injured.

Value Options, Inc. - Brandon, FL

Director, Provider Relations, 2/10 - 6/10

Manages the operations of provider relations office based in a service center. Including carrying out strategic plans designed to establish

consistency within and across regional operations and effective collaboration with national network operations. Manages relationships

with providers in the geographic area of responsibility and advocates for information and resolution of issues. Responsible for the

oversight of day-to-day Proivider Relaations, Network Developement, Claims Research and Analysis. Responsible for development,

implementation and maintenance of business rules for account operations including provider maintenance, benefits and claims payment

rules. Conducts Geo Access and Single Case Ageement data analysis to identify gaps in the provider network, opportunities for

recruitment and forwards contact opportunities to field representatives.

WellCare Health Plans - Tampa, FL

Manager of Provider Relations, 2/07 - 12/08

Led and developed a team of 6 Provider Relations Reps and Claims Resolution Specialists. Assisted with prioritizing corporate functions

and focuses on producing revenue for the corporation through the effective coaching and developing of Representatives to build

relationships and manage the accounts of their Providers. Performed data analysis and developed specific actions to manage medical cost

trend. Assists in developing practices to assist risk partners in managing financial risk. Identified areas to improve provider service

levels. Educated/enhanced relationships within the provider community. Assisted in developing provider contracting and service.

Strategized for membership growth and retention.

Senior Provider Relations/Network Development, 4/06 – 2/07

A Liason between Management and Provider Relations / Network Development. Would see to all tasks as a Provider Relations

Rep/Network Development Rep along with report to management. Point person for the team and all projects. Train all new and

existing associates.

Provider Relations/Network Development, 8/02 – 4/06

Managed physician network by developing and maintaining a specific geographic area. Achieved company targets through contracting

of primary care, specialty and ancillary providers. Monitored primary care and specialty risk arrangements for Medicaid, and Medicare

product lines. Worked closely with the In-house Network Development staff regarding contracting questions. Assisted in the analysis

of claim trend data and/or market information to derive conclusions to support positive risk arrangements. Completed new provider

orientation for all newly contracted providers. Maintained relationships with Provider administrators and conducted on-site educational

meetings to ensure providers and staff understands companies’ policies and procedures. Service providers, resolve issues, collect

credentialing information, and review HEDIS information. Performed contract administration including working with corporate on

market specific templates, maintaining local files and documentation, ensuring LOA's are converted to contracts, and meeting

GEOACCESS requirements for LOB's. Provided oversight on inquiries and claims issues and follows up with providers to ensure

problems have been resolved. Strategizes for membership growth and retention.

Claims processor, 1/01 – 8/02

Analyzed claims to determine extent of company's liability, make approval or denial decisions in accordance with policy provisions.

Processed professional, hospital, ancillary and secondary claims using the appropriate ICD-9 and CPT codes. Supported business

definition and testing efforts, attended project meetings, maintained project plans and provided internal and external status reports.

Worked with management and associates to document current business and workflow processes and collaborated in identifying, defining

and documenting process improvement options and alternatives. Researched complex claims issues and worked with other departments

to resolve. Served as primary liaison to Configuration department on claims issues. Prepared detail and summary level reports

including written interpretation of analytic results for senior management. Analyzed trends claims issues performed true root cause

analysis and determined next step for resolution and process improvement. Researched issues, compiles feedback and drafts

corresponding business requirements documents and business decision documents as needed. Communicated changes in processes,

project status and issue resolutions through email, memos, group presentations, and / or one on one meetings. Assisted manager and

director with projects and problem resolution as required. Ran and analyzes ad-hoc reports. Processes claims and adjustments.

Mentored and trained new and existing associates. Researches and responds to elevated e-mail requests from Provider Representatives,

taking action when necessary. Recommended and implemented process improvement.

Claims Customer Service, 8/00 – 1/01

Responded to member, provider and other inquiries via telephone, correspondence or lobby walk-in while meeting all corporate

guidelines and performance standards. Demonstrated appropriate customer-care skills such as empathy, active listening, courtesy,

politeness, helpfulness and other skills. Investigated and resolves member complaints as detailed in Grievance Procedure narratives.

Assisted in education of new members and in re-education of existing members regarding health plan procedures. Logged, tracked and

appropriately documented all issues utilizing on-line systems and procedures in accordance with all applicable guidelines and

requirements. Made decisions that are consistent with the concept of a win-win-win for members, associates and company.

Demonstrated based behaviors such as initiative, accountability and value. Performed skills necessary to create a high-quality customer

experience, as reflected through acceptable C-Sat scores, quality monitors and member feedback

Evolutions HealthCare Systems - New Port Richey, FL

Network Development Coordinator, 3/98 - 8/00

Developed the PPO Network's in 3 states negotiating contractual agreements with providers and networks of providers to secure

arrangements for payor clients using RBRVS payment methodology. Renegotiated agreements after original terms were expired.

Reviewed all contract language changes in the agreements. Reviewed and processed all credentialing packets received by providers.

Retained network with little turn around. Facilitates the continuous provider education program on all new policies and procedures.

Assisted in the training of new Network Development Representatives.

Consolidated Physicians Services, New Port Richey, FL

Manager of Operations, 9/96 - 3-98

Managed a team of 10 Medical Coders/Billers and Collectors for a physicians billing service. Used Med Master and Visionary software

in processing physicians claims using the most recent CPT-IV codes and modifiers and ICD-9 diagnosis codes. Posting all the

payments, discounts, write-offs and copayments into the systems. Follow up with the insurance companies for collections on unpaid or

in corrected claims processed. Transmitted claims electronically as well as printed CMS 1500 forms for original submissions and

secondary submissions. Assisted physicians patients with billing inquires. Trained all new and existing employees on new policies.

Picked up and delivered all medical documentation and reports from physicians office. Met with physicians on there Accounts

Receivable reports monthly outcomes.

EDUCATION

1993 Abilities of Florida, Clearwater, FL Certificate for Data Entry/Clerical

1988 John Adams High School, Queens, NY Academics

*References available upon request*

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