Service Customer

MonaLisa S. Webb

**** ******* **** ****** ************, FL 32222

Contact Number: 904-***-**** email: ********.****@*****.***

Profile

An outstanding healthcare professional offering versatile experience within the area of Health Care Administration that will allow me to demonstrate skills, abilities and over 15 years of proven experience with growth and advancement opportunities. My background in Leadership, Account Management, Project Management and Technical Process Management represent a unique combination of disciplines. I’m flexible and adapt well to change to satisfy and meet business needs.

Skills & Abilites

MANAGEMENT

Director level of Management, Operational, Departmental, Team Manager, Field Trainer and Subject Matter Expert (SME)

PROJECT ANALYST/COORDINATOR

Claims and billing issues, HEDIS measurement provider improvement plans, directory audits, overpayment recovery, trend bending, risk adjustment, and cost savings tracking and reporting

PROVIDER RELATIONS

Provider demographic updates/changes, provider visits, site inspections, HEDIS, credentialing, provider training, and in-services

PROVIDER CONTRACTING

Handle new contract request, negotiations, LOA’s, amendments, re-paper, network adequacy, meeting GEO Access requirements

PATIENT CARE

Handled patient care issues, from admissions, to referrals, transportation, provider look up, claims, copay and benefits

CUSTOMER SERVICE & CLAIMS

Audited healthcare claims for accuracy and quality, loaded and updated fee schedules, ran various cost reports and handled escalated calls.

LINES OF BUSNESS

Commercial, Traditional, Indemnity, Medicare, Medicare, Choice Care, Fee for Service, PPO, POS, ASO, and HUM-X

AGENCIES

AHCA, CMS, JACHO, OSHA, AHRQ, HRSA, HHS, HRSA

Professional Experience

Humana Healthcare Plans- Jacksonville, FL September 2015- Present Senior Provider Network Executive

Build strategic and collaborative partnerships with ancillary and physicians providers to negotiate contracts that

are favorable for business needs.

Manage initial and ongoing cost/benefit analysis of contracts to determine cost effectiveness, renegotiating as

appropriate

Facilitate provider education, training them in order to increase their familiarity and satisfaction with systems and

strategies

Ensures networks adequacy and cost effectiveness in accordance with established minimum standards

Interface with market leaders to align contracting needs and business efforts

Set targets and priorities in order to meet national and market-specific network needs

Liaison for all MCCI and Island Doctors facilities

WellCare Health Plans, Inc. -Jacksonville, FL March 2014-Septemeber 2015

Provider Relations/Provider Network Contracting Team Lead

Manages physician network by developing and maintaining relationships to drive business results within a specific

geographic area. Provides service and education to network physicians/providers. Achieves company targets through

implementation of Network Improvement plans

Assists in network development and provider service functions for hospitals and selected ancillary providers within

a state(s). Works with finance, legal, medical management, sales, provider operations and provider service center

personnel in developing actions to meet market growth and medical cost targets and excellent provider customer

service

Conducts site visits to service providers, resolve issues, educate staff/providers on policies, collect credentialing

information, and review HEDIS information.

Provides oversight on inquiries and claims issues and follows up with providers to ensure problems have been

resolved.

Performs contract administration including working with corporate on market specific templates, maintaining local

files and documentation, ensuring LOA's are converted to contracts, and meeting GEOACCESS requirements for LOB's

Assist in preparation and execution of periodic contract escalators/amendments and changes related to all lines of

business, also ensure all contracts/amendments meet regulatory guidelines for all products

Supports Regional Network Improvement Plan targets by providing utilization reports, pharmacy profiles, ER

contingencies, Frequent Flier Reports and other analytics available to improve /maintain regions.

Create and maintain strong relationships with internal and external contracts to support departmental goals

Perform provider education through in-service activities and regularly scheduled follow up with providers

Serve as Group Liaison for big groups such as; St. Vincent’s Medical, Family Care Partners, Nemours and HCA

Subject Matter Expert, trained new employees and provided coaching and feed back

Jones College – Jacksonville, FL March 2012 – March 2014

Director of Operations

Oversee all current students, graduates and alumni’s and departmental staff

Assist in recruiting and interviewing for organizations

Manage and oversee Career Development at two campuses

Implement policies and procedures that update and improve placement services on campus in

accordance with ACICS and College directives

Conduct in-class and outside-class workshops coaching students on resumes and interview skills

Perform quality audits for accuracy

Prepared employee reviews, annual evaluations and departmental training

Provide operational supervision to staffed employee

Emdeon of Flagler Hospital – St. Augustine, FL June 2013-May 2014

Health Care Analyst (weekends)

Providing high quality client focused service by using extensive knowledge of state and federal program requirements

to assist clients in applying for and obtaining government benefits.

Review medical records such as H & P, E. R. reports, admission assessments and most recent progress notes to

determine program eligibility

Interviewing clients in a hospital setting and/or home visits to assist them in obtaining maximum benefit coverage.

Maintain ongoing communications with government agencies regarding the status of benefits eligibility and claims.

Completing applications for state and federal program, communicating with third party insurance companies taking

all actions necessary to expedite benefit approval.

Maintain documentation of status of claims and client contact via various computer systems.

Prioritize, plan, and follow tasks through to completion without direct supervision.

Bank of America – Jacksonville, FL July 2010 – January 2012

Customer Relations Manager

Interviewed customers for modification eligibility options based on their current hardship status

Analyzed customer application and financial documents to determine modification approval

Perform audits on loan files for accuracy according to current guidelines

Perform underwritten procedures on loan files based on signing authority

Created payment options to bring account within good standing

Provided feedback and coaching to internal and external employees and customers

Operate in a call center environment setting

Blue Cross and Blue Shield/Florida Blue – Jacksonville, FL January 2000 – June 2010

Provider Services Operations Team Lead

Analyzed and audited health care claims processed through system automation

Reprocessed claims for payment accuracy that rejected via system automation

Created and preformed audits on cost reports for various lines of business

Updated provider contracts and fee schedules based on the contractual agreement

Contact providers and third parties to discuss overpayment claim and request refund

Review and audit customer account status

Perform credentialing reviews for new and existing providers

Claims Project Manager for top ten health care providers

Contacted providers and suppliers for missing claim information needed to process medical claims

Work closely with home plans on provider projects for out of state providers

Crossed trained existing employees on new policies and procedures and provided feedback

Subject Matter Expert and trained new employees and provided coaching and feed back

Call Center Team Leader

EDUCATION

Rasmussen University Currently Attending

Bachelors of Science Health Care Management

Jones College December 2002

Associate of Science Business Administration

References available upon request

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