Team Lead Provider Relations

********.*.******@**.*** 720-***-**** ***** East Mansfield Circle, Aurora, CO 80013

PROFESSIONAL PROFILE

Offering over 20 years of experience in healthcare claims processing and auditing, contract interpretation, network adequacy, claims consulting, and provider relations. Experience with individual contract agreements, prepayments, overpayments, regulatory requirements, and outsourcing. Ability to maintain strong working relationships with clients and the network community. Brings a positive and energetic approach to addressing concerns and resolving issues.

SKILLS

WORK EXPERIENCE

Epic Tapestry AP Superuser

Advanced Microsoft Office Suite

ICD9 and CPT Coding

Medical Terminology

HIPPA Regulations

Contracts

Training and Education

Process Improvement

Team Lead Experience

Benefit Interpretation

Provider Experience Consultant

CPMG July 2014 - Present

Train all new department hires on claim processing, relevant systems, and department procedures as the Tapestry AP superuser

Identify process and system gaps resulting from system implementations and contract loading

Execute new contract orientation and training to external network physicians and groups

Partner with internal Medical Directors for network adequacy needs and direction

Facilitate communication, implementation, and training for outsourcing initiatives

Manage and support 66 network contracts consisting of 4000 individual physicians and staff

Implemented internal department auditing and reporting of network contracts resulting in negative claims payment

Provider Appeals Analyst

Kaiser Permanente March 2012 – July 2014

Reconcile provider payment disputes subject to CMS independent review processes and guidelines

Analyze and report compliance data to Leadership staff providing a dashboard and projections for trends and resolution

Collaborate with internal departments to establish consistent and systematic processes

Claims Examiner III

Kaiser Permanente May 2009 – March 2012

Research and process claims according the processing guidelines and benefits

Provide independent decision-making skills and demonstrate initiatives to resolve issues for internal and external customers

Lead for claims staff assisting with coaching, training, procedure clarifications, and claims handling

Additional Previous Experience

2003 – 2009

A/R Supervisor/ Facility Data Loader/ Appeal Coordinator

KHALILIAH HUNTER

Claims and Contract Professional

KH

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