Customer Service Network Consultant

CYNTHIA D. THOMPSON

***** *. ****** *** *****: 602-***-****

Maricopa, AZ 85138

SUMMARY

Extensive and diversified experience in Provider Relations, Management, and customer service within multiple service fields. Experienced in managing and motivating staff in providing exceptional customer service and positive communications. Strong decision-making skills and ability to empathize with providers.

Dedicated Detailed Oriented Professional

Adaptable Team Player Decisive

PROFESSIONAL EXPERIENCE

GLOBAL HEALTH HOLDINGS 2022 - current

Manager, Provider Relations

Provider Relations

Educates and engages providers in value-based agreements which serve as healthcare networks and fosters growth of managed care products.

Manages provider relationships to achieve performance in various types of financial arrangements including fee for service, capitation, value based and shared savings.

Monitor provider performance utilizing both claims utilization and cost-per-unit trends and develops action plans to achieve shared goals.

Leads provider engagement, cultivates relationships, and executes network strategies.

Evaluates provider performance ensuring accurate provider level reporting.

Leads and manages Joint Operating Committee (JOC) meetings with providers and facilities.

Works with Leadership to meet network adequacy including service area expansions.

Evaluates the provider network to ensure appropriate access and availability for provider panels.

Educates providers including initial and ongoing training in the managed care program including applicable CMS updates and quality standards.

Respond timely to internal and external provider related inquires via Jira, Provider Relations email, CRMs and surveys.

Responds to second level claims appeals and reconsiderations to achieve resolution.

Assists in the maintenance of accurate Provider/Vendor records and Provider Directory.

Adheres to provider network policies meeting applicable CMS and company guidelines.

Maintains confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.

MERCY CARE RBHA/AETNA 2017-2022

Network Relations Manager

Provider Relations

Responsible for developing and maintaining relationships with physician 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 resolve disputes and find solutions that are mutually beneficial for both providers and the organization.

Builds strong relationships with providers and key contacts to support on-going negotiating efforts Finalize routine contracts and recruitment arrangements with providers Understands medical cost drivers and executes specific medical cost initiatives to support operational objectives. Proactively identifies new trends within the industry and works to raise awareness throughout the organization in order to gain consensus on a course of action and ultimately drive to implementation Identifies opportunities for process improvement and works cross-functionally within the organization to gain desired outcomes regarding provider service issues Accesses and coordinates highly sensitive member medical records Monitors the ever-changing and competitive landscape of health care delivery and evaluates the potential to adopt and implement policies and procedures to keep Aetna at the lead or ahead of industry movements Executes organizational strategy at the market level to meet and exceed company goals and objectives Exhibits the following employee behaviors; honor commitments; keep our promises, communicate with candor, behave ethically and act with integrity, coach, mentor and continuously learn, be supportive, caring and optimistic

MERCY CARE PLAN/AETNA 2014-2017

Network Consultant

Provider Relations

Experienced in contract management, reimbursement methodologies, provider data management, credentialing, claims reconciliation processes and compliance.

Direct communications with providers, Managers, Directors and Medical Directors to maintain and foster strong, positive relationships

Build positive relationships between health plans, providers and practice managers

Strong experience and knowledge working with AHCCCS, CMS, managed care contracts and all provider types

Assist providers in setting up and utilizing provider portals and networks

Working knowledge of healthcare business operations

Managed working with all provider types: Skilled Nursing Facilities, Ancillaries and Physicians

Review contracts for correct rates and accuracies

Assist with claims resolution, review provider records set up and reporting

Identify and remediate claims to ensure early resolution of claims problems

Strong interpersonal, clear and concise written and oral communication skills

Investigate a provider problem resulting in increased customer satisfaction

VALASSIS 2007–2014

Client Program Coordinator

Advertising and Marketing

Client contact on day-to-day fulfillment regarding orders/schedules, copy shortages, profile

changes,

Communication with production and printers

Build/maintain thorough Valassis knowledge; expand knowledge to include general information

regarding the direct mail industry.

Maintain base of knowledge on Valassis products, services, promotions Working knowledge of all

Valassis programs and delivery methods Determine process steps required to execute client programs

efficiently

Communicate changes in client profiles (including geography changes to Sales or client)

Preparation of the Valassis order form for specified accounts

Request mapping and targeting reports from the Valassis Targeting Center

Maintain knowledge/understanding of geography's (creation of, calculation of up charge, etc.)

Request financial data in order to analyze and track incorrectly coded decentralized business;

contact team leader to resolve disputes as appropriate

Track and analyze sold team business for quarterly account reviews Coordinate materials for trade

shows

CIGNA Health Care 1996-2006

Client Service Specialist (2005-2006)

Healthcare Industry

Assist Client Managers with developing a customer service strategic plan and execution to achieve

desired results. Act as primary contact for assigned book of business in coordinating support for

customer's enrollment needs. Prepare and deliver customer reports for established performance

guarantees, in partnership with account team. Demonstrate excellent customer service skills,

including negotiation and resolution of service issues directly with customers.

Attend on-site employee and member meetings for enrollment purposes or to increase member wellness

and awareness throughout the year. Make on-site presentations to existing and prospective clients

to educate and inform. Responsible for responding to complex inquires, solving non-routine problems

using independent judgment and discretion, and ensuring client satisfaction with products and

service.

Internal Provider Relations Representative (2004-2005)

Developed and maintain positive relationships with physicians and providers within the networks to

ensure proper communication and complete understandings.

Specified policies and procedure to providers; educated providers on compliance issues and

disputes.

Compile fee schedules, assist providers with tax identification and address changes; thorough

knowledge of medical terminology and various reimbursement methodologies.

Communicated changes with product lines of business, Explanation of Payments and Appeals process to

ensure accuracy. Answer over 50 incoming calls per day for provider inquiries and resolutions to

fulfill desired request.

National Accounts Representative (1996-2004)

Personally, selected to have full accessibility to view utilization review notes from nurse

reviewer, confirms correspondence letters issued to providers and receipt.

Reviewed provider contracts with CIGNA, PHCS, Healthsource and other network providers for proper

assessment of contracts.

Ensure customer satisfaction by prompt and proper resolution of questions, issues, and customer

complaints. Provided information and education to providers and prospective clients.

Provided members/providers with a single point of contact with CIGNA and act as a customer

advocate. Assisted contracted providers with claims issues and view contracts for correct fee

schedule process.

Managed escalated and most complex customer complaints. Knowledgeable of CPT 4, ICD -9 codes and

claims processing through claim check.

Handled and assisted supervisors with elevated and complex supervisory issues. Assisted with

inquiries pertaining to overflow of calls from affiliated call centers.

Appointed to support the claims correspondence project by reviewing and updating coordination of

benefits, re-direct electronically submitted claims to their designated field claims offices and

generate claim status letters to providers that has been either paid, denied, pended, or rejected.

BANK OF AMERICA 1991-1994

Fraud Analyst/Collector

Financial Institution and Credit Card Company

Contacted card members regarding possible fraud, verified fraudulent activity, mail order requests,

and transfer f inance charges that applied.

Resolved customer inquiries and recommendations to ensure customer satisfaction. Research f

raudulent activity on credit card accounts to determine unauthorized access. Assist Corporate

Security with fraud information, which lead to apprehension of suspects. Thorough knowledge of

bankcard operations and collections procedures.

Diplomatically handled customer negotiations for financial recovery of bad debt.

METAGRAM AMERICA, INC. 1990-1992

Customer Service Supervisor

Alpha Numeric Paging Company

Direct supervision of 15-30 customer service associates.

Led the associates to determine and monitor work distribution.

Reviewed customer complaints and status for recommendation; research, analyze and make

recommendations for improvement efficiency of statistical reports.

Responsible for accounting summaries for bonus reports for the over 500 employee Western Region.

Led in the day-to-day operation by managing call volume in a Call Center environment.

References are available upon request

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