Rhea Y. Carrington

*** ******* ****

Bloomingburg, New York 12721

845-***-****

abl62e@r.postjobfree.com

Objective:

To secure a position with an organization that will be mutually beneficial

and allows for professional and personal growth.

Qualifications:

Strong self motivated individual capable of initiating and implementing

major decisions. Highly productive achiever who works as a team member or

independently. Proven leadership, communication and organizational skills.

Organized person with ability to restructure planned objectives and goals.

Employment:

Network Management Rep 2009 to present

WellCare Health Plans

. Services, contracts and negotiates with physicians, facilities and

vendors for Medicare Advantage Plan.

. Identifies network gaps and completes contracts.

. Manages physician network by developing and maintaining relationships

to drive business results within Syracuse market.

. Conducts site surveys, resolve issues, educate staff/providers on

policies, collect credentialing information and reviews HEDIS

information.

. Strategizes for membership growth and retention.

. Implements Network Improvement Plan targets by providing utilization

reports, pharmacy profiles, ER contingencies and analytics available

to improve region.

Contract Data Analyst 2009

Emblem Health/Sharp Decisions

. Performed administrative review and analysis of contracts to ensure

compliance with contract specifications, company policies and state

and federal regulations.

. Created and updated contracts based on fee schedule models.

. Identified contracting error for financial impact reporting.

. Provided reporting of contract integration.

. Entered contracts into internal mainframe and maintain customer

pricing information, and contract language.

. Corresponded and communicated with company managers regarding the

terms of the contract as necessary.

Sr. Network Account Manager 2000-2008

United Healthcare

. Developed and monitored geography specific unit cost improvement plans

and improves market competitiveness.

. Developed and executed negotiation strategies that directly impacted

financial performance of company.

. Accountable for relevant components of provider relationship

management, including leading Joint Operation Committee meetings as

necessary and provider outreach and communications.

. Worked with and involved relevant stakeholders (Regional & Corporate

Network Management, internal customers and network pricing) in

negotiation decisions impacting legal and regulatory requirements,

contract standards, and cost targets.

. Investigated and facilitated service issue resolution through action

planning with appropriate areas and communicated the resolution to the

physicians and groups.

. Created reimbursement schedules utilizing several methodologies.

. Performed financial analysis of all reimbursement rate proposals to

determine cost savings and negotiation strategies.

. Provided advice, guidance, and recommendations to senior management

regarding healthcare costs, cost saving opportunities, best practices,

provider performance issues as well as network expansion.

. Mentored and trained new Network Account Managers on systems and

policies and procedures.

Customer Service Manager 1999-2000

Macys*(Federated Stores Inc.)

. Senior Executive Manager for entire store.

. Facilitated daily meetings to communicate team/store performance goals

and results, share corporate communications, and provided a for

surfacing opportunities and/or issues

. Realigned staff based on business needs.

. Worked closed with security to monitor internal and external theft.

Assisted with apprehension of shoplifters.

. Conducted nightly audit of sales for store by department and prepared

comparison reports to other regions.

. Handled customer complaints and determined resolution.

. Assisted on selling floor with merchandising and placement of products

according to store plan.

Provider Services Supervisor 1999-2000

Group Heath Incorporated

. Administered the ACD system to evaluate speed to answer and

availability of provider services representatives.

. Direct supervisor of 30+ provider services representatives.

. Identified claim processing errors and made proposals for corrective

action.

. Prepared daily and monthly attendance reports for entire

customer/provider service staff.

. Coached and counsel union staff.

. Prepared statistical information, e.g. (manned phone times, speed to

answer and daily number of calls taken) per provider/customer service

representative in comparison to entire department.

. Facilitated training sessions on new products and changes in existing

physician contracts.

. Prepared payroll for all union employees.

Senior Provider Relations Specialist 1997-1999

Magellan Health Group

. Education of physicians and medical billing personnel for correct

usage of ICD-9, CPT-4 and HCPCS coding.

. Identified internal human error and proposed corrections to upper

management.

. Trained new department members as necessary on policies and

procedures.

. Fielded 10-25 irate calls per day.

. Direct Supervisor to 5-10 customer service representatives.

. Resolved long term claims due to system errors.

. Coordinated with Medical Affair for authorization approval.

. Acted as a single point of contact for subset of physicians and

vendors.

Team Developer 1995-1997

Oxford Health Plans

. Processed medical claims for commercial, Medicare and Medicaid

members.

. Extensive interaction with internal and external customers and clients

to identify, research, and analyze situations in a problem solving

capacity.

. Coached, counseled and motivated customer service team.

. Direct supervisor of 20-30 crossed trained customer service

representatives.

. Set performance goals, analyzed team performance and identified ways

to increase productivity.

. Administrated ACD system to ensure productivity measures were met.

. Worked closely with Quality Assurance and training department to

assist employees in development.

Education:

Business Sciences 1986-1989

Hampton University

Business Management 1984-1985

Bronx Community College

Skills:

. Microsoft Word, Excel, PowerPoint, Access, Sharepoint,

. Amysis, Emptoris, Salesforce, Facets and Peradigm.

. In depth knowledge of Medicare reimbursement methodologies (i.e.

Resource Based Relative Value System, DRG and Ambulatory Surgery

Center Groupers)

. Experienced in fee schedule development using actuarial models.

. Six Sigma Green Belt

Contact this candidate