Glee L. Anderson

***** *. ****** *****

Aurora, CO 80013

720-***-****

OBJECTIVE:

Obtain a professional, challenging position utilizing my personal and

professional skills. My experience and education have provided me with the

necessary skills to be an organized, outgoing and goal-attaining employee.

I am team-oriented, a quick learner and have the potential to be an asset

to any organization.

EMPLOYMENT EXPERIENCE

Provider Relations

> Develops and maintains relationships with providers, to include serving

as a provider advocate in external community.

> Proactively manages the maintenance of the Provider Network.

> Serves as a consultative resource to facilitate education and discussion

on products, quality initiatives, disease management programs, joint

ventures, etc.

Contracting

> Negotiate contracts including financial terms, reimbursement

methodologies and language with medical groups, IPA's, ambulatory surgery

centers, and other ancillary providers.

> Identify and resolve network needs for expansion in both existing and

additional service areas.

> Maintain close working relationships with sales, medical outreach, claims

and customer service departments.

Management

> Developed and Administered the centralized credentialing/recredentialing

process for 42 states. Provider population = 200,000+ practitioners,

5,000+ facilities.

> Managed profiling of data related to clinical competency and adherence to

regulatory standard requirements (NCQA, URAC and JCAHO), for review by

the medical director and committee

> Management of Sanction Monitoring System, ensuring providers with

sanctions are reviewed according to company policy and timeliness

standards. This involved oversight of contractual terminations and

review of all appeals/hearing requests.

> Hired, trained, and conducted weekly staff meetings and resolved human

resource issues.

> Created/maintained credentialing processes consistent with regulatory

agencies and maintains a working knowledge of standards and continuous

compliance with all authorities pertaining to credentialing (42 states).

> Responded to sensitive and contractual provider inquiries and issues both

verbally and in writing.

> Develop/maintain departmental policies and procedures as well as maintain

a centralized tracking system to ensure regular review and maintenance of

policies.

> Management and oversight of systems data entry functionality (i.e.

provider enrollment systems, provider information management databases,

CACTUS, and PCMS).

> Perform oversight audits of delegated entities credentialing process(es).

Audit ensures that entity complies with Health Plan standards, policies

and procedures.

> Coordinate facility credentialing and recredentialing ensuring files are

accurate and

completed in a timely manner.

Auditor/Audit Analysis

> Performed audits of all Pricing functions to include claims, software and

tracking database.

> Daily, weekly and quarterly reports compiled and analyzed and provided to

senior management with recommendations. .

> Developed and maintained audit forms.

> Maintained pricing data such as adding and deleting information.

> Developed and maintained policies and procedures in accordance with

changes in regulatory, client specific or organizational requirements.

> Responsible for monitoring, auditing and reporting performance related to

audits of member calls taken in market level Benefit Payment Offices and

the Member/Provider Services Unit(s). Department representative for the

Corporate Field Trainers and Technical Writing Unit; helped to create

updated materials and provided research for reference materials

> Researched and responded to complaint calls from members, providers,

group offices, and State insurance departments in a timely manner.

> Audited all documentation related to telephone calls as well as all

claims processed.

> Trained all staff members by keeping them informed of new and upcoming

procedures.

> Audited large checks.

Benefit Analyst/Disability Consultant

> Reviewed and evaluated complex claim issues.

> Determined specific contract and/or applicable legislation.

> Responded to Insurance Commissioner complaints, to include gathering the

necessary

information and investigating the claim for validity.

> Responded to attorney inquiries, complaints and lawsuits, to include

gathering the

necessary information and investigation.

> Reviewed and evaluated medical, surgical, dental, vision, and

chiropractic claims according to plan provisions.

> Responded to inquiries, both written and verbal, from the benefit

payment offices, group offices, plan administrators, members, providers,

> Determined contractual obligations, and gathered information from various

departments to assist members, plan holders and providers with questions.

WORK HISTORY

Manager, Provider Network Management & 8/2007 to Present

Contracting (Great-West Healthcare now part of CIGNA)

Manager, Credentialing Operations 1999 to 8/2007

(Great-West Healthcare)

Manager, Facility Pricing Department 1997 to 1999

Audit Analyst 1995 to

1997

Assistant Manager, Benefit Payment Review 1993 to 1995

Disability Consultant 1991 to

1993

Benefit Analyst 1989 to

1991

Connecticut General Life Insurance 1985 to 1989

Buckingham Chiropractic 1981 to 1985

R.F. Warner, MD 1980 to

1981

EDUCATION

United Health Careers Institute Certified Medical Assistant

Delta-Montrose Vocational School Accounting and Bookkeeping

AFFILIATIONS

Member of Colorado Association of Medical Staff Services and National

Association of Medical Staff Services, Member of the Board for Colorado

Managed Care Contractors Association

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