Tongela Robinson

**** ********* ******, ********, **, 23234

Phone 804-***-****

ad3l18@r.postjobfree.com

Objective

I am a workforce professional with 20+ years in the health care industry working in fast-paced environments, demanding strong organizational, technical, and interpersonal skills. Knowledge of medical terminology and standard contract terms and reimbursement methodology. I am seeking a position that will provide me with the opportunity to utilize my skills and experience obtained in the field of healthcare. Subject Matter Expert

PPO, HMO, Medicaid Customer Service Provider Relations Problem Resolution Process Management Behavioral Health and Medical Professional Experience

Molina Healthcare Richmond, VA

Provider Relations Manager February 2022-Current

• Educate and train providers on issue resolution and provide updates on managed care policies and procedures.

• Work with internal departments to resolve COB, EAPG, DRG pricing, and non-routine claim issues.

• Maintain positive relationships with providers all while ensuring their issues are resolved in a timely accurate manner.

• Communicate to providers updates to medical policy, administrative and programmatic changes, and reimbursement policies.

• Assist with contract negotiations as needed.

• Work cross-functionally with multiple departments to resolve ongoing provider issues.

• Support the Medicaid and Medicare provider (DSNP) community. Aetna Better Health of Virginia Work From Home-VA

Network Relations Consultant June 2019-February 2022

• Educate and train providers on issue resolution and provide updates on managed care policies and procedures.

• Work with internal departments to resolve COB, EAPG, DRG pricing, and non-routine claim issues.

• Maintain positive relationships with providers all while ensuring their issues are resolved in a timely accurate manner.

• Communicate to providers updates to medical policy, administrative and programmatic changes, and reimbursement policies.

• Assist with contract negotiations as needed.

• Work cross-functionally with multiple departments to resolve ongoing provider issues.

• Support the Medicaid and Medicare provider (DSNP) community. Magellan Health Services Glen Allen, Virginia

Claims Resolution Specialist February 2017- June 2019

• Continuously identifies process improvements that impact quality and service results.

• Effectively communicates both verbally and in writing with providers, stake holders, the Governor, and the client (Commonwealth of Virginia).

• Completes special projects as assigned by upper management to include General Manager, Director, or Supervisors.

• Prepares feedback and review to Supervisors and Managers.

• Research adjustment request to include tracking and trending performance of root cause analysis.

• Handle all types of high complexity behavioral health claims request, inquiries and complaints accurately and timely.

• Seek, gather and analyze relevant data to address problems effectively.

• Research and resolve all COB issues.

• Operates as a liaison between multiple teams to include Claims, Customer Service, Care Managers, Provider Network, and Grievance departments.

• Handle all expedited claims concerns from DMAS and the Grievance team in a timely manner.

• Works directly with providers to resolve claim and care management concerns

• Actively participates on the weekly calls to include provider concerns, eligibility file feed concerns, internal and external issue calls.

• Train both customer service and clinical teams on accurately entering authorizations to decrease claims abrasion.

Magellan Behavioral Health Service Richmond, Virginia Outpatient Support Specialist July 2015- February 2017

• Responsible for researching escalated claims inquiries from customer service associates and providers.

• Process registrations for crisis stabilization H2019, crisis intervention, H2012, skill building H0046. Therapeutic Day Treatment (TDT) H0035 and case management services.

• Partner with internal departments to resolve complex claim and customer services issues.

• Resolve auth issues.

• Go out in the field and go to providers meeting with our provider network department to assist on claims issues.

Virginia Premier Health Plans Richmond, Virginia

Claims Customer Service Representative II and III February 2004- February 2014

• Responsible for managing and working appeals submitted by providers.

• Monitored calls and handle escalated provider claims issues referred by customer service representative.

• Worked closely with internal partners, vendors, providers, and billing representatives to resolve provider concerns.

• Provided education and feedback to staff concerning claim and call audit results to reduce errors and improve processes and performance.

• Provided the training to new hires and frontline staff surrounding call handling and claims processing as needed.

• Submitted change gear request for system updates (benefit review, provider contracts, DRG calculator updates).

• Manually process complex claims to include: DRG, Inpatient (transfer cases, readmissions, newborns), Home Infusion Therapy, Transportation (ambulance, wheelchair, taxi), COB, DME, etc.

• Pulled and provide provider remittance upon request.

• Assisted with the creation of SOPs to document unique processes for client.

• Responsible for internal auditing of claims processed according to the benefit structure, fee schedule, provider contract terms, SOP processing guidelines, and DMAS/DHHS guidelines.

• Reported any inconsistencies that are identified during audit process in regard to internal department policies and procedures to management.

• Worked on special projects as needed.

Anthem Blue Cross and Blue Shield Richmond, Virginia Customer Service Representative II January 2000- February 2004

• Provided full service to members, providers, and group administrators by processing health care claims, handling inquiries, receiving inbound telephone calls, and reconciling accounts.

• Responsible for handling recovery of monies paid incorrectly to providers and members.

• Researched overpayment errors and made necessary adjustments. Communicate electronically with other Blue Cross and Blue Shield Plans to correct any errors.

• Interacted with group administrators and human resource representatives to ensure members are loaded to policies in a timely manner and handle any issues the group may have.

• Handled escalated member and provider issues referred by customer service representatives.

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