Provider Relations Customer Service

ReTonya Ulmer

Highly motivated Healthcare Professional with extensive experience in the Medicaid/Medicare industry. Possess a thorough knowledge of NCQA and HFS guidelines, policies and procedures. Accomplished in collecting, analyzing, researching and compiling data using current technology to ensure a high-quality physician network. Keen problem-solving ability and memory for detail.

Work Experience

Dec. 2019 to July 2023 Blue Cross and Blue Shield of Illinois Chicago Il. Provider Network Consultant – Provider Relations

Responsible for developing managing and maintaining excellent cooperative working relationships with the contracting provider community; and educating training, researching problems, identifying trends and evaluating problems to ensure contractual and financial requirements are adhered to and performed.

Experienced professional experience in claims, customer service, physical office or hospital, or healthcare related experience in a leadership role.

In-dept physician/provider relations, including but not limited to contracting and reimbursement issues. Knowledge of the healthcare industry and private business. Knowledge of contracts applications and products. Knowledge of claims processing systems and proficiency in provider reimbursement methods. Interpersonal, analytical, verbal and written communication skills.

Organizational and planning skills. Ability to take initiative, work independently, meet deadlines and work well under pressure.

Feb. 20 to Dec. 2019 Evolent Health Chicago, IL.

Provider Relations Representative – Provider Relations

Coordinates with constituents on medical cost and membership growth and network fortification initiatives. Communicates with external constituents and effectively engages the provider community, manages medical cost drivers, executes specific medical cost initiatives to support financial and medical cost objectives. Proactively identifies new trends and products within County Care and the industry and works to raise awareness throughout the organization to gain consensus on action and drive to implementation. Consistently monitors County Care service capabilities to collaboratively ensure that provider constituents needs are met. Seeks to optimize provider interaction, provides recommendations based on provider needs. Responsible for developing and maintaining relationships with physicians and business leadership of key physician groups, ancillary providers, and delivery systems. Interacts with large, high profile physician groups, IPAs, PHOs and hospital systems to facilitate solutions that are mutually beneficial for both providers and the organization. Collaborates cross-functionally on more complex issues to ensure provider needs are met and outstanding issues are resolved. Collaborates with internal team members on the implementation of large, high profile physician groups, IPAs, PHOs and hospital systems to ensure a positive business relationship

Nov. 2016 – Jan 2018 Aetna Better Health Chicago, IL.

Supervisor - Business Information Management and Analysis II

Supervises all activities associated with the establishment and continuous updating of provider databases and provider documentation; ensures the provider data entered the database is accurate and that the provider documentation is complete.

Oversees the resolution of administrative problems affecting network providers, patients, and Plans within contracted guidelines; resolves problems and advises providers of new protocols, policies, and procedures

Provides oversight of provider claims issues; coordinates and communicates resolution.

Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices.

Assesses departmental and provider training needs; develops and implements appropriate training programs.

Coordinates provider status information with member services and other internal departments.

Oct .2015 – Nov. 2016 Aetna Better Health Chicago, IL.

Network Account Manager – Provider Services

Executes strategic components of the HCD business plan for the market. Coordinates with constituents on medical cost and membership growth and network fortification initiatives. Communicates with external constituents and effectively engages the provider community, demonstrating the Aetna value proposition Negotiate contracts on behalf of the company. Manages medical cost drivers, executes specific medical cost initiatives to support financial and medical cost objectives. Proactively identifies new trends and products within Aetna and the industry and works to raise awareness throughout the organization to gain consensus on action and drive to implementation. Consistently monitors Aetna service capabilities to collaboratively ensure that provider constituents needs are met. Seeks to optimize provider interaction, provides recommendations based on provider needs and Aetna’s objectives. Responsible for developing and maintaining relationships with physicians and business leadership of key physician groups, ancillary providers, and delivery systems. Interacts with large, high profile physician groups, IPAs, PHOs and hospital systems to facilitate solutions that are mutually beneficial for both providers and the organization. Collaborates cross-functionally on more complex issues to ensure provider needs are met and outstanding issues are resolved. Collaborates with internal team members on the implementation of large, high profile physician groups, IPAs, PHOs and hospital systems to ensure a positive business relationship

Nov. 2013 – Oct. 2015 Aetna Better Health Chicago, IL.

Senior Credentialing Analyst – Provider Services

Participate in Readiness Reviews for Credentialing in Illinois, New Jersey,

Ohio and the New York Medicaid Plan with successful results.

Maintains highest performance of Credentialing Analyst functions

Provides education and training to providers/producers and/or internal customers on credentialing policy and procedures.

Work collaboratively with network staff (local and regional) in issue/problem identification and resolution.

Conducts ongoing process audit to evaluate compliance with standards and outcomes (e.g. quality, accuracy, timeliness).

Audits timeliness and maintains resource material and/or library of available resources such as updated disks, paper references, internet, state license sources, etc.

Provides coaching/mentoring to peers and co-workers.

Assists with training staff members.

May provide functional leadership within unit (i.e. team lead.

Responsible for developing and maintaining relationships with the business leads of participating hospitals, physicians, facilities, and ancillary providers

Coordinates receipt of provider/producer data with outside vendors and other entities.

Assists and maintains collections of data, tracking and reporting.

Coordinate and oversee provider change requests (e.g. practice affiliation changes, hospital-based provider enrollments, network terminations, etc.) to ensure the timely processing in the company’s provider database and contract system

Interprets and handles highly sensitive investigative activity in preparation for CPC / ongoing sanction activity of at-risk providers.

Apr. 2012 - Nov. 2013 Aetna Better Health Chicago, IL.

Credentialing Analyst – Provider Services

Provides education and training to providers/producers and/or internal customers on credentialing policy and procedures.

Works collaboratively with network staff (local and regional) in issue/problem identification and resolution.

Conducts ongoing process audit to evaluate compliance with standards and outcomes (e.g. quality, accuracy, timeliness).

Audits timeliness and maintains resource material and/or library of available resources such as updated disks, paper references, internet, state license sources, etc.

Creates and manages action plans for assigned projects relative to special network initiatives, workflow or quality improvements.

Coordinates receipt of provider/producer data with outside vendors and other entities.

Assists and maintains collections of data, tracking and reporting.

Assesses business benefit and cost of existing technology-based service or product for competitive advantage.

Monitors exception processes and outcomes and recommends process improvements based on trend analysis.

Interprets and handles highly sensitive investigative activity in preparation for CPC / ongoing sanction activity of at-risk providers

Oct. 2008 – Apr. 2012 Aetna Commercial Medicare Chicago, IL.

Network Representative -

Responsible for Markets in St. Louis, Kansas City, Michigan & Indianapolis

Problem – Solves complex and atypical situations with constituents

Able to explain the plan, contract, and policy parameters.

Multi-task to accomplish workload efficiently.

Articulate features and benefits of Aetna products and services.

Adapt project plans and/or work tasks to create alignment with overall goals.

Actively participate in the change process.

Understand the financial metrics that drive Aetna’s business.

Managed the recredentialing application Management reports (90-day recredentialing.

Met contract TAT score 98.2% and loaded by effective date

Maintained an Echo-Sign database for all provider contracts.

Send out Medicare Amendments through the Echo sign Process.

Maintain an Iron Mountain log for network provider contracts.

Before October 2008 - Blue Cross and Blue Shield of Illinois

Credentialing Coordinator - Rifted in 1999

Education:

1980–1983 Lemoyne Owen College Memphis, Tennessee

• Area of concentration: Business Administration

Interests

National Association of Medical Staff Services (NAMSS)

Computer Skills

QNXT, Echo Sign, Paradox, Sweet Q, Excel, PowerPoint, Microsoft Word, Med Staff, Crystal Reporting, MSO, Aetna Credentialing Recredentialing Application Managements Reports (RAM), CAQH, Aledra Claims, Salesforce Reporting.

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