Relations Representative Credentialing Coordinator
Resume:
Ariel Diaz Jr.
Seffner, FL 33584
*****.****.**@*****.***
SKILL SUMMARY
Sr. Contracting and Network Development Manager
Provider Solution Advisor III
Provider Network Manager I
●Contracting/ Provider Relations Specialist
●Practice Transformation Specialist
●Senior Configuration Specialist
●Senior Credentialing Specialist
●Computers (Microsoft Office, Excel, OmniFlow, Xcelys, Emptoris, Cactus, Facets)
EMPLOYMENT
HISTORY
Friday Health Plans (Remote) Seffner, FL 33584
Sr. Contracting and Network Development Manager 05/22-Present
Contact Providers and Provider Groups in Multi States ( CO,TX,OK, GA. NC, NM NV), with goals to expand and develop the Friday Health Plan, Network
Assist with the development and growth of new state expansions
Educate providers/Groups on the Friday Health Plans ACA In/ Out of Exchange of the Market Place Plans and its various products
Close Geo Access Network Gaps in assigned In Network Markets and surrounding Counties
Negotiate and Drafting of Provider (Professional, Ancillary, Facility, Hospital) Agreements
Provide and collect all required documents from provider group for submission in order to initiate the Credentialing and Loading Process.
Educate participating Provider Groups of Friday Health Plan, Provider Manual and Portal
Act as liaison between In Network Provider Groups and internal Friday Health Care Departments
Florida Blue/ Guide Well Health Plans Lake Mary, FL 32746
Provider Solution Advisor III, Region 7 04/21-05/22
Leverage business relationships with executives of integrated hospital systems and acute hospital and facilities
Oversee all In Network Provider groups in Sumter and Lake County
Conducts and facilitate JOC for Orlando Health Group, Veterans Hospital Administration for entire State of Florida, and Health First Hospital and all affiliates.
Conduct New Provider Onboarding, Provider Servicing, and Escalation of any In Network Provider Group concerns
Serves as an advisor and educator to providers as the Healthcare industry transforms in order to impact performance outcomes
Coordinate Solutions of critical non-resolved Provider Issue within internal business partners
Experience developing and implementing strategic plans
Experience in preparing and presenting training material
Experience with managing a territory and associated priorities, actions plans and task
Experience with collaborating and building relationships with multiple internal and external partners such as Vendors and Providers
Create action plans, task, scoreboards and/or management plans
Escalate Provider Claim issues, to internal Provider Issue Department.
Simply Healthcare Plans ( an Anthem Company) Maitland, FL 32751
Provider Network Manager I, Region 7 05/19- 04/21
●Manage Provider Medicare, Medicaid and Florida Healthy Kids, (FHK) Product Lines of Business. Verify and submit Provider Credentialing Applications with all required documents ( Medical License, DEA Certificate, Certificate of Liability, CV and Board/Speciality Certificates)
●Manage individual provider practices, groups and IPA/MSO, to include demographic changes, updates, additions and terminations of Providers
●Coordinate monthly IPA/Value Base Provider JOC Meetings, between all internal Simply Departments and Provider Group to discuss, In Patient/ ER Utilization, Pharmacy Expense,Quality, Hedis, MLR, Financial Risk/ Service Funds recorded data
●Provide In-Service Training and Materials to new and established provider practice and/or groups in assigned Geographical Territory, in regards to the Health Plans Policies, Procedures, Incentives,and Benefits
●Coordinate with Value Base Providers in to maximize coding potential, and documenting of patient records
●Fill all Potential Geographical Provider Speciality Gaps within assigned territory
●Develop and maintain strong positive relationships with Internal Simply Departments ( In House Reps, Sales/ Marketing, Finance, Authorization and Claims) Provider Groups, IPA/MSO, Value Based providers and other contracted In Network Providers Groups
●Conduct Network Field Visits, and maintain logs for all contracted Providers of all applicable Lines of Business ( PCP, Specialist and Ancillary) hold discussions based on information provided on reports to impact performance and Identify provider solutions and overall practice improvement
●Provide Claims Support and assist facilitate resolution
●Project Management Initiatives, Hedis 5 Star Performance, Compliance, Medical Record Retrieval and review for Star rating
●Conduct, Complete and Reconcile Provider Directory audits for all In Network Providers, to assure the Simply Provider Directory remains updated and accurate for member use
● Work Independently, self motivated with minimal guidance and supervision,
Provider Network Solution (PNS) Miami, FL 33126
North/Central Florida’s Provider Servicing and Contracting Specialist 08/16-05/19
●Develop provider networks for initial and/or expansion review and approval satisfying or
exceeding the minimum network standards according to membership needs for the health plan partners
●Obtain leads for prospective physicians, manages all incoming new provider leads and follow-up with the providers on the status of their new contractual agreements
●Ensure that the provider network consists of Board Certified/ Board Eligible Dermatologist, Podiatrist, and Orthopedic, providers and all other specialties as contracted by the network
●Identify network gaps and conduct recruitment efforts to address the deficiencies
●Strategize to maintain an adequate network during monthly Geo Access reviews
●Completes new provider orientations within 30 days of health plan effective date for all applicable health plans partners product lines
●Conduct Monthly site visit to resolve issues, educate new staff/ provider on policies, collect new/updated credentialing information and review any changes/updates to the Provider Manual or Network guideline
●During initial onboarding, meet with the appropriate Network Provider personnel and fully explain the company’s protocols. The company’s protocol will include all requirements necessary to comply standard identified in the Provider Manual
●Achieve quarterly servicing goals to establish consistent and strong relationships with the network provider and offices
●Strategizes to maintain network provider/health plan retentions
Primary Partners LLC /Aledade ACO Clermont, FL 34711
Practice Transformation Specialist/Provider Relations Rep 01/16- 07/16
●Audit Patient Medical Charts, In preparation of Medicare Quality Measure Reporting
●Streamline 11 provider office’s policy and procedures
●Educate and monitor all TCM opportunities are captured, once a patient has been discharge from the hospital
●Increase practice revenue by capturing all TCM opportunities
●Run reports on HCC patients, pin pointing which specialist are over utilizing the network, or conducting unnecessary procedure without consent of patients PCP
●Identify if patient is considered for an Active Care Management candidate
● Educate, Physicians and staff on the Cost Saving Module
●Assure office has completed all AWV and charts are properly documented, to include BMI, BP reading, and Colonoscopy and Mammogram readings.
●Educate patients, and office staff of the importance of seeing your PCP or Urgent Care Centers, before choosing to visit the ER.
●Coordinate with Value Base Providers in to maximize coding potential, and documenting of patient records
●Run QRUR Reports and educating providers with information associated to such reports
●Review Cigna Care Gap Reports with Office Managers and develop plans on how to close such gaps
WellCare Health Plans, Inc. Maitland, FL 32751
Provider Relations Representative 07/2013-10/2015
●Manage physician network in Orange, Osceola, Lake and Sumter counties
●Educate new PAR providers by conducting Web Portal Provider In-Services
●Educate and inform providers office of MMA requirements and expectations
●Conduct New/Re- credentialing site visit for new on boarding PCP offices or Re-Credentialing provider offices
●Support Par providers on Claims, Authorization and credentialing related issues
●Coordinate with Value Base Providers in to maximize coding potential, and documenting of patient records
●Educate staff/providers on Wellcare Corporate policies by reviewing their Wellcare Group Agreements
●Review and educate Providers/ Practice Administrator on Hedis, Utilization, Pharmacy Over Usage, ER Contingencies Frequent Fliers Reports, and other analytics to improve practice workflow
●Act as liaison between Health Care Plan and Providers Office
●Constantly looking for cost effective methods by enrolling providers in EFT and Electronic EOP by using PaySpan
Sr. Configuration Specialist Tampa, FL 33634
●Monitor Data Correction Review (DCR) and Critical Error (CE) Rates and Reports
●Work with Configurations Managers to ensure proper Provider/Vendor loads within Peradigm
●Strong working knowledge of the Provider Contract Adjudication system
●Run queries using MS Access or TOAD to analyze DCR, Reject and CE reports
●Ensure accurate provider and vendor pick through Legacy Business Rule Maintenance
●Develop and maintain interdepartmental relationships to ensure proper involvement, cooperation and communication of changes
●Load and correct Fee Schedules
●Update NPI Xwalk databases
●Update Peradigm Provider and Vendor Records
●Responsible for special projects that require analytical skills, open-thinking whereby data is analyzed from different angles.
●Occasional Presentations and Learning and Development Seminars
●Performs updates to Omni Flow as well UAT updates and testing with IBM
●Applies a comprehensive knowledge of claims processing, provider contracts and contract configuration to escalated provider inquiries
●Thoroughly researches escalated issues and takes appropriate action to resolve them within established service level agreements, WellCare best practice and quality standards
●Ensures satisfaction of providers and regional partners through timely status updates and completion of projects
●Complies with all corporate and Provider Solutions policies, procedures and workflows
●Serves as primary contact for Provider Relations, VP’s and managers for escalated provider issues
●Performs Regulatory reporting for all Operations
●Performs other projects as assigned
Parallon Workforce Management Solution St. Petersburg, FL 33716
Credentialing Specialist 11/2012-06/2013
●Audit local staffing agencies employee credentialing profiles
●Approve and clear vendor employee profiles and assure they are compliant with HCA requirements and policies before extending employment offers
●Advise vendors regarding nurses credentials that have or are about expired
●Terminate nurses for compliance or inactivity issues
●Rehire and verify rehire eligibility status with HCA and Parallon Workforce Management
●Conduct Drug Screening and Respiratory Mask Fit Test
●Process Payroll for both vendor billing and Parallon Employees
●Forward complaint from CNO to local vendor regarding corrective action complaints and resolutions against their employees
●Liaison between various Local Staffing Agency, Parallon Workforce Management Solution and HCA Hospital West Florida Division
● Inform all local staffing agencies with changes and updates requirements in credentialing nurses to any of the 16 HCA Facilities for the West Florida Division
●Run Reports on new hires, determine what newly credentialed and approve employee is working continuously
●Run 30 day inactive employee report, verify nursing license, AHCA fingerprint background results online
FWC Management Company, LLC Boca Raton, FL 33445
Credentialing Coordinator 11/2010-11/2012
●Complete credentialing application for various health plan, and submit with all required supporting documentation to initiate credentialing
●Correspond with designated health plans representative to obtain credentialing and affiliation updates
●Correspond with office managers to obtain required attachments/Create and update CAQH profiles.
●Audit physician’s Managed Care files, and ensure that all supporting documentations is current and complete
●Comply with specific health plan re-credentialing requirements
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