Managed Care Professional
Resume:
Renee F. Monts
610-***-**** ***********@*****.***
Managed Care Professional, with extensive years’ experience relating to Provider Data Base Management. Knowledge of provider claims setups and Pennsylvania’s Medicaid and Medicare Regulations. Expertise in problem solving and documenting procedures in an effective manner. An efficient team player, assist specialist with problem resolution. Resourceful and detailed-oriented, skilled problem-solver and multi-tasking, result driven, customer oriented, all which authenticates me as a valuable asset to my team.
Technical Skills
• MHS • Macess • SAS Enterprise Guide-5.1 • IntelliCred • IntelliContract • CCMS • Microsoft Office Suite 2011 • Cactus
Professional Experience
Health Partners Plans, Philadelphia, PA Senior Provider Database Coordinator 10/2014-02/2018
Increased productivity; took initiative to learn SAS Enterprise Guide to improve department’s ability to perform query and data mining for various reports for Network Management. Functioned as SAS subject matter expert and the only member of team with ability to run reports.
Mentored and trained 13 new Provider Database Coordinators; created training documents, system handbooks and provided hands on chair side instruction to increase productivity and retention.
Demonstrated analytical and problem solving ability by designing and implementing streamlined work processes to address barriers to receiving and validating accurate provider information.
oPioneered process for creating and utilizing 5 digit dummy numbers when registering new Urgent Care Centers which increased efficiency.
oIntroduced audit spreadsheet and checks/ balance system to validate and process provider updates, W9’s and non-par letter distribution. Eliminated duplicate work and aided claims department in submitting payment quicker.
Handled EDI claim request for non-participating and hospital based providers
Provider Database Coordinator 10/2009-10/2014
Hired to support newly created three member provider data department. Gained recognition for proactively taking on senior level coordinator responsibilities including learning new systems, training new employees and building collaborative cross-functional relationships.
Accurately entered demographic data of new providers into MHS; assigned fee schedules, pricing and contract information.
Completed Macess Service Forms within required turnaround time demonstrating prioritization skills and ability to work independently with minimal supervision.
Reviewed and updated provider sanctions according to OIG and EPPLS websites.
Health Partners (via Hobart West Solutions), Philadelphia, PA Credentialing Services (Temporary Assignment) 05/2008-10/2009
Utilized knowledge of MHS, Cactus and Macess to completed, reviewed and updated all credentialing and re-credentialing applications.
Maintained compliance with all Federal, State regulations, NCQA standards, and managed care criterion related to the credentialing and re-credentialing of practitioners, organizational providers and LTSS providers.
Confirmed physician’s licensing using the State License website; updated physician’s medical license in Cactus and MHS based on mismatch error report.
Updated over 100 physician’s Medicaid and NPI numbers.
Sky Resort Management, Orlando, FL Reservation Agent 11/2007-03/2008
Handled all telephone inquiries with prompt courtesy, while applying the resorts selling strategy and selling technique, in order to achieve budgeted goals and maximize revenue.
Responded to telephone, email and fax inquiries from customers and staff in a professional and courteous manner.
Precedent Management LLC, Kissimmee, FL Customer Service Representative 02/2006-10/2007
Delivered outstanding service; answered over 75 daily inbound and outbound calls within online pharmacy call center.
Utilized multiple screens of information to address customer needs
Validated and entered customer payment into system database with 100% accuracy.
Education
Murrell Dobbins Vocational High School, Philadelphia, PA School Diploma 10/1991-06/1995
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