Service Representative Relations Manager
Resume:
Rhonda Small
***********@*****.***
TECHNICAL SKILLS:
QXNT, Infoweb, PAT, Webfocus, Oracle, SQL Navigator, Access, WordPerfect, PowerPoint, Excel, Amisys, Lotus Notes, Reflections, SAS, NEHEN, and Knowledge of HIPPA regulations and guidelines, Sales Force, ATHENA, Citrix, Kronos
PROFESSIONAL EXPERIENCE:
Delta Dental, Charlestown, MA
Claims Analyst Remote 2016-2021
•Providing thorough claims assessment and coverage analysis.
•Proficient at processing and Identifing to and resolve claims issues with HMO, PPO and Medicare claims.
•Collaborated with all internal departments for analytical needs and claims processing.
•Created a monthly report for management on the financial status of outstanding and paid claim
•Received and processed goverment medical claims to insure payment is issued as soon as possible
Medicare Authorization Coordinator 2015-2016
•Primary Liason to provider offices for approvals of access request to grants the access of a User ID and Password to access all Delta Dental websites on Provider portal.
•Training providers on their specific access on portal for review of Auth, Elig, paymnt and claims status
•Review and approve Auth request from provider offices
•Weekly meeting with Medical Directors on Auth request
Steward Health Care Network Boston, MA
The Provider Onboarding Specialist (2013-2015)
•Rresponsible for coordinating the onboarding activities for all new providers
• Supporti the Director of Physician Services and hospital Medical Staff Offices with the processing of medical staff applications and verification Review CVs/applications and phone screen all candidates to determine quality and fit for the organization.
•Present physician opportunities with detail and clarity, providing information about compensation plan, benefits, and specific elements of the position
•Contact prospective candidates and conduct preliminary screening for recruiting Directors
•Place/maintain all Contingency and Locum physician recruitment ads
•Create comprehensive practice descriptions for each opportunity with job specifics from the Identified department leadership
•Prepare job descriptions and develop job postings for company web site
•Identify and search candidate database(s) for potential candidates
•Develop hiring campaigns for physicians and place follow-up calls to proactive source
•Maintain a candidate tracking worksheet/database reflecting documentation of open positions
•Schedule interviews, document conversations, offers, acceptances/ non acceptance.
•Communicate Credentialing requirements and documents to agencies
•Manage the relationship between the agency Credentialing Department and Steward Medical Staff office ensuring all documentation is received in a timely manner to assist the selected provider with privileges at set facility.
•Track and verify all invoices and funds spent on external recruitment resources; including job postings, ad placements, third party placement fees, etc.
•Direct, organize and coordinates all aspects of Locum candidate itineraries, agendas and site visits
•Participate in other duties and responsibilities as assigned
Provider Relations Manager
NEIGHBORHOOD HEALTH PLAN - Boston, MA
January 2010 to March 2013
•Leveraged provider relationships to help advance the company vision
•Support leadership with the design, development, and implementation of provider network communication strategies
•Facilitated and lead in person, telephonic, and online meetings and communication sessions with key providers
•Responsibilities included understanding the complexity of assigned territories and how provider sites and administrative staff are interrelated
•Met with territory providers regularly and proactively identified education and performance improvement opportunities through these interactions and/or feedback from NHP staff
•Adequately documented and maintained records relative to communications with assigned providers to ensure a mutual understanding of expectations
•Framed difficult messages to providers while maintaining relationship
•Managed high volume of provider inquiry and ensured consistent follow through on resolution of provider issues
•Ensured professional growth through management and self-directed learning opportunities
•Primary Liaison with BIDMC, BIDPO
•Correct spelling to BID?
•, BMC, DFCI and a host of providers in the Greater Boston area for ongoing customer servicing.
•Identified and resolved operational issues
•Collaborated with internal departments on analytical, credentialing and claims processing
•Assist in developing training materials to conduct provider and office staff training
•Assigned to the outreach of new providers and set up on the NHPNet portal
•Extract specific Fee Schedules from the current PNM Reimbursement Management section of PNM SharePoint and transfer provider data onto NHPNet for provider viewing when requested
Data Quality Analyst
HARVARD PILGRIM HEALTHCARE - Quincy, MA
February 2000 to June 2010
•Primary contact for Hedis and Data downloads on the secure FTP server for external users
•Ensure that HEDIS reports were created, provide quality assurance on HEDIS reporting
•Created task orders providing instructions on where pharmacy and claims data is to be pulled from Data Warehouse
•Primary vendor contact with Medimpact client ensuring validation of Pharmacy data requirements and reports
•Managed shut down migration of all Provider reporting
•Provided end user training on claims processing and technical support
•Oversaw timeliness of reports to avoid contractual financial penalties
•Ensured quality analysis over data downloads on a monthly basis
•Supervised access of Internal and External users for provider reports
•Liaison for data issues with the transmission of files to the HPHC Connect web site for provider reports
•Worked in collaboration with Stakeholders to identify needs and establish priority for Data quality projects
•Assisted with Oracle sales reporting effort in testing and launching new report scripts
•Provided analytical support to Internal and External users of provider reports and downloads
•Quality checked the MA, ME, NH extracts and transferred data to State portal monthly
•Primary Liaison
•Beth Israel Deaconess Medical Center - Waltham, MA
•May 1998 to February 2000
•providers for ongoing customer servicing
•Identified and resolve operational issues with Beth Israel Deaconess Physician Organization
•Collaborated with all internal departments for analytical needs and claims processing
•Participated in internal and external cross-functional teams charged with problem solving, operational planning, and implementation
Provider Relations Consultant, Waltham, MA (1998 – 2000)
•Primary Liaison with Beth Israel Deaconess Medical Center providers for ongoing customer servicing.
•Identified and resolve operational issues with Beth Israel Deaconess Physician Organization
•Participated in internal and external cross-functional teams charged with problem solving, operational planning, and implementation
•Assisted in developing training materials and programs to conduct provider and office staff training
•Managed a variety of projects, specifically claims and credentialing issues
Specialized Customer Service Representative
HARVARD COMMUNITY HEALTH PLAN - Boston, MA
Boston, MA
1995 to 1998
•Assigned to vacant positions until the position was filled. Once filled, the assignment became a training assignment of the new candidate for the position.
•Assigned special projects throughout Account Services during quality improvement task.
•First Seniority, Account Representative
•First Seniority and the Plan65 Programs
•1995 to 1997
•Administered enrollment, disenrollment, and billing collection for the First Seniority and the Plan65 Programs.
Claims Service Representative
HARVARD COMMUNITY HEALTH PLAN - Boston, MA
1994 to 1995
•Researched, reprocessed and resolved claims and complaint issues as presented by phone, in person or mail.
First Seniority, Account Representative (1995 - 1997)
Administered enrollment, disenrollment, and billing collection for the First Seniority and the Plan65 Programs.
EDUCATION:
NORTHEASTERN UNIVERSITY
Criminal Justice/Speech Communication, Boston, MA (1985 – 1990)
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