Customer Service Manager
Resume:
Baretta P. Northern
**** *. ******** ******, ************, Tennessee 38017
Mobile: 901-***-****
E-mail:***************@*****.***
Executive Summary
I am an experienced, solution-focused individual with in depth knowledge of
healthcare strategic planning and development. I have 15 years of
healthcare administration experience. In my previous role as Director of
the Provider Services Division, I was responsible for the day to day
operations of network expansion and ongoing development, credentialing,
provider claim appeals as well as provider education & outreach. I
participated in the successful NCQA accreditation efforts for UAHC Health
Plan, assisted the plan in receiving CMS approval for a Medicare Advantage
Special Needs Plan, and participated in a host of other successful health
plan surveys performed annually. I also played an integral role in the
plan receiving a commercial certificate of authority from the Tennessee
Department of Commerce and Insurance. Additional skills include teamwork,
negotiation, project management, client relations, budget development and
maintenance, coaching, mentoring and general supervision and leadership.
Professional Experience
Smith & Nephew Orthopaedics - Memphis, Tennessee 2008 to Present
Professional Affairs Contract Manager, Aug.2008 - Present
Responsibilities include:
o Responsible for overseeing the management of consulting agreements,
including work plan modifications and amendments.
o Communicating with new and existing consultants to familiarize them
with Smith & Nephew (S&N) processes, documentation requirements,
including contract terms, Work Activity Reports and conflict
resolution.
o Primary point of contact with the Office of Ethics & Compliance (OEC)
to ensure all contracts are compliant with internal policies and
procedures, corporate direction and external regulations.
o Responsible for the input, maintenance and accuracy of all information
contained within the Orthopaedic Consultant Management Database
(Lawtrac).
UAHC Health Plan of Tennessee, Inc. - Memphis, Tennessee 1994 to 2008
Director - Provider Services Division, 2005-2008
Responsibilities include:
o Set objectives, planned, staffed, and directed activities related to
the provider services division for the West TN Grand Region.
o Acted as a liaison between the Plan and providers regarding the
development of contractual documents, negotiations, and contract
compliance.
o Worked as a team member across department lines to ensure that
negotiated contractual terms did not conflict with other
operational areas.
Baretta P. Northern Page 2
o Responsible for overseeing the day-to-day operations of regional
network expansion, credentialing, provider claim appeals and provider
relations, which consists of provider education and outreach.
o Responsible for the development of new, the review of existing and
the approval of departmental policies, procedures and business
rules to ensure compliance with CMS, NCQA and TennCare rules and
regulations.
o Developed and implemented departmental strategic plans and goals
for the provider services division.
New Business Development Manager, 2004-2005
o Contracted with physicians, facilities, and ancillary providers at the
most competitive rates possible; in line with the Plan's financial
goals.
o Monitored the adequacy of the plan's provider network and identified
network deficiencies and potential service areas.
o Pursued and developed new customer accounts and relationships to
generate new business.
o Researched and coordinated application efforts for HMO licensure and
expansion into other markets.
Member Outreach and Marketing Manager, 2001-2004
o Managed the promotion and processing of preventive service programs
and outreach activities.
o Responsible for increasing the EPSDT screening ratio by at least 5%
each year.
o Responsible for member retention and acquisition according to
strategic goals and objectives.
o Provided oversight in regard to the continuous quality improvement
process to ensure the development of quality controls for the
department.
Marketing Services Coordinator, 1996-2001
o Developed and expanded marketing service campaigns, member retention
and newborn enrollment programs.
o Coordinated participation and activities for community events.
o Implemented campaign targeting the Hispanic community.
o Conducted training sessions and created training materials for the
Marketing Service Representatives.
o Supervised 15 Marketing Service Representatives, 10 in Memphis and 5
in Nashville.
Customer Service Information Analyst, 1995-1996
o Compiled all statistical information generated and received by the
Customer Service Department.
o Created, implemented and maintained the complaint and grievance
database.
o Assisted in identifying, analyzing and archiving documents of the
department.
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o Processed life insurance claims.
Customer Service Representative, 1994-1995
o Answered in-bound calls from members about benefits, bills
received, complaints, ID cards and member materials.
o Assisted members with locating specialty providers.
o Assigned PCPs to members in the system.
Education
University of St. Francis (Joliet, IL) 2003 (Memphis Campus)
M.S. Health Services Administration
Towson University (Towson, MD) 1993
B.S. Psychology
Health Plan Committees
Quality improvement Committee
Contracts and Credentialing Committee
Delegated Oversight Committee
o Designee for Claims subcontractor Oversight Lead (Included the
responsibility of performing onsite audits)
o Designee for Dental Benefit Manager Oversight Lead
Utilization Management, Pharmacy and Therapeutics Committee
Claims Appeals Subcommittee
RFPs
Georgia Medicaid RFP for Atlanta, Southwest and Central Regions (2005)
o Coordinator for the Georgia RFP process
TennCare RFP for East and West Tennessee Grand Regions (2008)
o Developed responses for the provider agreement, provider
education and network sections
Training and Designations
Team Trek Leadership Training
CMS Conference for Special Needs Plans
CPT and RBRVS 2007 Annual Symposium
NCQA Conferences
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Business Forum for New Products and Business Expansion (by AHIP)
Management and Leadership Training for Managers
Academy for Healthcare Management
Professional, Academy for Healthcare Management (PAHM) Designation
Professional Affiliations
National Association of Health Services Executives (NAHSE)
o Officer of Memphis Chapter - Parliamentarian, 2003-2007
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