Customer Service Quality Assurance
Resume:
EDWARD S. VARGAS
Cell: 210-***-****
San Antonio, Texas 78254
**********@***.***
HEALTHCARE ADMINISTRATIVE PROFESSIONAL
QUALIFICATION HIGHLIGHTS
I am a senior-level healthcare professional offering over 20 years of
experience working in hospital, managed care, and nursing home
administration. I have consistently established excellent professional
relationships with the medical community throughout my career. I am an
administrative professional experienced in working in a fast -paced
environment. I work well with people of diverse cultures, professional and
educational levels. I understand the importance of relationship building
with the community, colleagues, clients and staff. I possess excellent
management, leadership, communication, organization, customer service and
public relations skills. Detail-oriented and resourceful in completing
projects with the ability to multi-task effectively. I am highly
trustworthy, discreet and ethical.
KEY STRENGTHS
Physician Relations Managed Care Contract Negotiations
HMO's
Physician Recruitment Independent Physician Associations
Marketing
Business Development Nursing Home Administration
Strategic Planning
PROFESSIONAL EXPERIENCE
CALLIDUS CONSULTING
April 2009 - Present
Consultant - Owner
> Provide consulting services for clients seeking to develop a network of
providers
> Responsible for negotiating rates and contract language with hospitals,
physician groups (i.e. large groups, IPA's, PHO's, etc.) physicians and
ancillary providers
> Provide assessment, strategy and advice on various contracting and
network development efforts for clients
HEALTHSMART PREFERRED CARE, INC. March
2007 - March 2009
Regional Vice President of Network Development
> Responsible for the South Texas market which begins in San Antonio down
to the RGV
> Negotiate hospital contracts, at market competitive pricing. Initiate
and maintain successful relationships with including but not limited to
key hospital and group practice administrators
> Direct and provide assistance to physician and ancillary contractors on
contracting needs and strategies
> Negotiate complex contract negotiations with hospitals, integrated
delivery systems and ancillary groups
> Analyze network adequacy and recruitment needs
> Utilize extensive provider contracting technical skills; contract
preparation and implementation, financial analysis and rate proposal
development to meet the organizations needs
> Utilize an in-depth knowledge of the various reimbursement
methodologies
EDWARD S. VARGAS
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> Utilize knowledge of the distinct market areas for the development of
provider network strategies while utilizing a level of problem-solving
skills
HUMANA, INC.
September 2004 - March 2007
Large Group and Ancillary Contracting Executive
> Negotiate hospital, physician and ancillary contracts, at market
competitive pricing. Initiate and maintain successful relationships
with including but not limited to key hospital and group practice
administrators
> Develop and manage provider network, including complex contract
negotiations with hospitals, integrated delivery systems and ancillary
groups. Analyze network adequacy and recruitment needs
> Utilize extensive provider contracting technical skills; contract
preparation and implementation, financial analysis and rate proposal
development
> Utilize an in-depth knowledge of the various reimbursement
methodologies
> Contracted within required guidelines and financial parameters to
ensure cost-effective administration of provider contracts
> Demonstrated a high level of problem-solving skills
SKILLED HEALTHCARE, LLP, MCALLEN, TEXAS December
2002 - September 2004
Assistant Administrator
> Direct the daily operations of a 194-bed nursing and rehabilitation
facility with yearly net revenues of approximately $11,000,000
> Supervise six departments with 52 employees
> Negotiated and/or re-negotiated contracts required by the Texas
Department of Human Services (i.e., laboratory, x-ray, and dialysis
providers)
> Coordinated with marketing staff to help identify physicians with a
high Medicare patient base, resulting in a 17% increase in admissions
to the facility
> Coordinated with department heads to identify areas of overrun in Per
Patient Day (PPD) labor and supply costs. Within the first quarter of
2003 overruns were within budget
> Established excellent relationships with Medical Directors, as well as
other physicians who admit to the facility
> Gained the trust of the residents and their families
SKILLED HEALTHCARE, LLP, FLATONIA, TEXAS July
2002 - November 2002
Administrator
> Oversaw the daily operations of a 90-bed nursing & rehabilitation
facility with yearly net revenues of approximately $2,500,000
> Operated within budget
> Established new, and strengthened existing physician relationships
within the community and surrounding areas
> Coordinated with area business leaders to develop outpatient
rehabilitation line of business
> Coordinated with Department Heads to keep PPD costs for labor and
supplies within budget
> Encouraged managerial staff to attend self-development classes and or
seminars
> Established excellent relationships with residents and their families
EDWARD S. VARGAS
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SUPERIOR HEALTH PLANS OF TEXAS
May 2000 - July 2002
Senior Provider Relations/Contract Specialist
> Lead the negotiating and obtaining signed provider contracts
(hospital, physician, and ancillary) needed to receive an expansion
license from the State of Texas for the Bexar and Travis service areas
> Established procedures and systems to manage provider contracts that
were either assigned or contracted with directly
> Developed provider database in order to produce directories and aid in
mapping of provider network to ensure coverage and appropriate access
to the plan members
> Audited provider files to ensure the accurate loading of contract
terms in claims payment software
> Provided orientations to network providers on requirements of the
health plan, i.e., submission of claims, pre-certification and pre-
authorization procedures
> Establish professional relationships with network providers, and
became a resource to them concerning managed care issues
BROWNSVILLE MEDICAL CENTER
May 1997 - May 2000
Business Development Specialist
> Developed Centers of Excellence for OB/GYN and Heart Services.
> Performed the business development, physician relations and managed
care activities for a 220- bed Hospital with net revenues of
approximately $42,000,000.
> Re-established the PHO, which had become dormant and inactive.
> Grew the PHO membership from a stagnant 53 members to a dynamic 103-
member network.
> Re-negotiated existing PHO and Hospital contracts. Average increase
in fee schedules was approximately 18%.
> Recruited much-needed primary care and specialty physicians to the
area by working with internal and external recruiters as well as
attending medical conferences.
> Negotiated relocation, directorship, and lease agreements with medical
staff.
> Identified, established and maintained professional relationships with
the medical community to help meet the goals and objectives of
increasing referrals and admissions to the facility.
> Provided managed care seminars to the community.
> Coordinated with area politicians and their staffs to provide campaign
funds on behalf of the hospital and provided tours for local
dignitaries.
PCA HEALTH PLANS OF TEXAS
February 1994 to May 1997
Provider Relations Representative/Supervisor
> Managed a staff of five provider relation representatives.
> Negotiated contracts with IPA's and hospitals. IPA contracts were of
a complex nature involving either shared or global risk.
> Visited with network physicians on a scheduled basis, and provided
information about plan policies and procedures.
> Addressed and resolved discrepancies in the adjudication of claims.
> Participated in the Quality Assurance Committee.
EDWARD S. VARGAS
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Other - Managed Care customer service and
November 1988 - January 1994
claims processing positions
EDUCATION
Master of Healthcare Administration
Webster University, San Antonio, Texas
Graduation Date - May 2008
BSOE, Healthcare Administration
Wayland Baptist University, San Antonio, Texas
Graduation Date - May 2002
PROFESSIONAL AFFILIATIONS
American College of Healthcare Executives
OTHER
Read, write and speak Spanish
Contact this candidate