Las vegas NV ***17
I have seventeen (17) years experience in the healthcare and insurance field. I have a diverse knowledge of the Managed Care Organization (MCO), Medicare, Medicaid, Centers for Medicare & Medicaid Services (CMS) guidelines, Health Maintenance Organization (HMO) both commercial and state programs, Preferred Provider Organization (PPO), capitated agreements and third party payor agreements both contracting new and maintaining already contracted groups. I have modeled fee schedules, reimbursements, and comparisons for new, and existing provider contract, and or reimbursement increase requests. I have nine (9) years experience in clinic, and hospital settings with both front and back office duties. I am familiar with and have credentialed, and re-credentialed providers with knowledge of CAQH, and the credentialing process. I have experience in billing and coding using the CPT and ICD10 (medical) and CDT (dental) coding systems using the HCFA (medical) and Dental Claim forms.
2015 - Current Health Plan of Nevada, Inc./Sierra Health & Life Ins. company, Inc.
Senior Provider Advocate
Network Development & Contracting / Network Contractor
Tricia Schares Manager
Negotiate, draft and execute contracts for new providers, hospitals and facilities. Credentialing and re-credentialing providers, and facilities via paper applications and CAQH. Establishing professional relationships via site visits with providers educating and resolving issues. Researching and resolving claims issues. Educate providers regarding the Health Plan of Nevada, Inc. (HPN) and Sierra Health & Life Ins. Company, Inc. website for access and navigation. Meetings and presentations to providers to deliver updated information and education regarding up and coming changes. Data entry for new providers, groups, hospitals and facilities, and any changes for the existing contracted providers. Created spreadsheets, and letters for providers and internal staff for new contracted providers, and other changes or issues that arise.
2006-2015 Health Plan fo Nevada, Inc., / Sierra Health & Life
Network Development & Contracting (Medical)
Shaun Schoener Associate Director Contracting
Took in new requests for contracted providers, groups, hospitals and facilities. Put together analysis of fee schedules, and reimbursement rates for carve-outs, and drafted agreements to present to providers for possible contracting. Checked and reviewed credentialing applications for new providers. Maintained contracted group rosters, demographic changes, provider additions and terminations, and any other changes. Drafted and negotiated reimbursement rates for amendments to contracted groups agreements. Took any calls from providers to maintain a professional relationships. Data entry maintaining contracted groups regarding demographic changes, provider additions, terminations and any other changes that occur. Heavy phones with provider education and answering and resolving any issues.
2004-2006 Spring Mountain Ranch Pediatrics, Las Vegas NV
Marlon Mendoza MD
Managed a staff of twelve employees in two different locations. Medical Assistant duties in the back office. Conducted regular scheduled staff meetings for updates, changes and any input they may have. Credentialed, maintained, and updated all initial and re-credentialing, certificates and licenses for provider. Managed billing, AR and payroll for the office.
Practice closed 2006.
2001-2004 Women's Specialty Care
Billing Manager / Credentialing specialist
Warrne K Volker MD PhD / Tammy Kelly MD
Credentialed all providers for all insurance companies and kept up the re-credentialing. Kept all license and certificates for all providers updated and current. Managed the billing team to keep all accounts receivable managed. Checked benefits and eligability for patients. Data entry, posting and balancing payments from Explination of Payments (EOP) received. Posted charges to create correct claims to bill to insurance companies using ICD9 (now ICD10) and CPT medical coding system. Negotiated reimbursement for contracts with the insurance companies for increase in revenue. Managed a staff of four (4) in the billing department.
2000-2001 University of Nevada School of Medicine
Front Office Lead / Surgery scheduler
Obstetrics / Gynecology
Scheduled surgeries and procedures and maintained schedules for several providers. Checked that all necessary guidelines (prior authorizations, medical necessity, etc.) for patients insurance prior to scheduling. Oversee all front office duties, checking in patients collecting copayments, coinsurance, and managing the schedule. Entering patient data and Posting payments. Balancing books for that office at the end of the day. Educating patients regarding their pre-operative instructions and orders from the doctor.
1995-2000 St. Alexius Hospital and Medical Center
Medical Assistant / Certified Nursing Assistant (CNA)
Worked in the Intensive Care Unit assisting nursing and physician staff with procedures. Made rounds collecting vital signs, documenting in patient charts and doing EKG's as ordered by the physicians. Performed basic care for all patients in the Intensive Care Unit answering all call light requests and assisting when needed. Answered phones and family questions regarding patients within the confidentiality guidelines. Assisted as part of the Emergency Flight Team.
1999-present Yearly education on Fraud Waste & Abuse (seminars and in house classes)
Highly Effective Criticisim & Discipline Skills for Managers and Supervisors
Rockhurst University, Kansas City MO
The American College of Obstetricians and Gynecologists (ACOG) Coding and
Catalina, CA Billing
How to be a Highly Successful Team Leader
Rockhurst University, Kansas City MO
Yearly classes and seminars on billing, coding and insurance updates
Nevada Association Medical Staff Services (NvAMSS)
Understanding Health Insurance Billing
University of Nevada Medical Center (UMC)
1982 - 1984 Northern State University - Aberdeen South Dakota
Studied General Business & Accounting
1979 - 1982 Aberdeen Central high School - Aberdeen South Dakota
Easily handle and diffuse difficult situations. I am very patient, and great at listening and communication, working with others in person, and on the phone. Attention to detail, very organized and can multitask easily. I am a leader, and self starter who can think and make decisions based on collaboration, and research. Computer literate - Microsoft Word, Excel, Power Point, and Outlook. I can easily navigate programs, facets, Cactus, share drive databases and several others. Easily learn and navigate new computer programs. Detail oriented for data entry. I have been introduces to several UnitedHealth Group computer databases and easily and quickly learn to navigate the new programs.
1. Sue Shell
Independent Credentialing Agent
2. Lynn York - Administrative Assistant HPN SHL/SHO
3. Brenda Ward / manager