Manager Customer Service

CARLO DELLA RAGIONE

*** ******** ****** ****** ******, N.Y. 10306 917-***-**** 718-***-**** *************.***@*****.***

EXPERIENCE

QualCare/Cigna Company. Piscataway, NJ 8/15 – 3/17 Provider Relations Manager

Oversee Provider Relations Representatives assigned to territories in NJ, Del,PA & NY

Develop and oversee provider education, recruitment and intervention efforts

Experienced in handling escalated issues (i.e. recruitment request, enhanced fee negotiations request, provider complaints, appeals)

Identify and resolve provider billing dilemmas and implement appropriate corrective methods

Strong leadership and interpersonal communication skills at all level within organization

Provided timely status updates to all stakeholders, including senior management. Reported on key accomplishments, upcoming deliverables, key projects risks (Schedule, scope, budget, resources) and overall health of assigned projects

Developed financial forecasting and budget and analyzed financial processes and its impact on financial results

Create and oversee training needs and develop plans to ensure all direct reports are trained on policies and procedures, new programs and incentives

Perform additional duties and projects a s assigned by management New York Network IPA, Brooklyn, NY 3/14-7/14

Data Compliance Manager (Consultant)

Implemented programs, policies and practices to ensure that all departments are in compliance with HIPPA, NCQA accreditation standards

Experienced in creating and leading cross functional teams and creating vision strategies and plans from requirements gathering through implementation and support

Maintained compliance with federal, state and local regulatory requirements

Developed and implemented policies and procedures changes to day to day provider data operation

Responsible for state/delegation audit preparation and oversight

Coordinated monthly reports for submission to delegated vendors of critical provider demographical changes to profile

Responsible for monthly monitoring of delegated report from vendors to ensure the accuracy of changes made as well in compliance with all state and regulatory requirements Emblem Health, New York, NY 6/06–7/13

Provider Operations Manager

Supervised and trained the provider operation staff to meet departmental goal/production needs

Oversaw provider demographic, addition and deletion and terminated information were accurately recorded according to department standards

Monitored changes made to the system through random checks of the daily, weekly, and monthly reports

Oversaw maintenance of electronic filing systems/and monitoring execution of provider contracts

Monitored directory data accuracy according to company standards publication

Prepared weekly inventory reports which detail the activity of the staff

Acted as the primary liaison between network management, MIS, Customer service, credentialing, and claims to assure continuity of provider network changes and application processing

Oversaw 15 union claim staff to ensure policy and billing procedures were in compliance with federal and state regulations

Monitored the timely processes of par, non-par, clean claims, reviews, denial, corrected and rebill claims along with return checks ensuring timely turnarounds are meet according to department standard

Maintain metrics on clean claims, denial, re-submissions and other measurement standards for senior management review

Developed and implemented provider operation workflow procedures Center Care, New York, NY 12/02–2/06

Providers Credentialing/Re-credentialing and Data Maintenance Manager

Managed the NY credentialing/re-credentialing staff to ensure that all physicians and facilities were in accordance with Center Care and NCQA/JCAHO standards

Audited credentialing committee provider presentation ensuring information accuracy

Developed and implemented credentialing policies and procedures

Investigated providers sanctioned by regulatory agencies

Monitored activities related to the credentialing/re-credentialing processes and other provider service issues and providers’ denial/termination appeals

Responsible for Article 44 state audit preparation as well as Coordinated delegation audits and oversight

Assisted with contracting implementation and oversight

Compiled ad hoc reports with statistical data for monthly reports

Created a high-performance work culture and tracking mechanism SKILLS

MS Office Suite, Visual Cactus, Facets, Provider Work Bench, Central Provider File, Access, Uniflow HSP system

Fluent in Italian

EDUCATION

Kingsborough Community College, Brooklyn, NY

A.A.S. Buying and Merchandising

College of Staten Island, Staten Island, NY

Coursework in Business Management Degree in Progress

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