Sr. Analyst Network Operations
Resume:
Proprietary
Jacquelyn Q. Luke
*********.******@*****.***
**** ****** **** ** ****** Terrace, FL 33637
Objective: To develop, maintain and enhance relationships with facilities, physicians, and members; to foster growth of managed care products and build a successful and rewarding career in the insurance industry Skills & Abilities: Microsoft Word, Excel, Windows based programs. Medical Terminology, CPT, ICD-9 & HCPCS Coding, Experienced with Managed Care, Medicare and PPO plans. Typing 45 WPM, Data Entry 9,000+ KSPH, Clear Communication, Positive Language, Time Management Skills, Professional Experience
SR ANALYST NETWORK OPS -AETNA, A CVS HEALTH COMPANY Jan 2022-Present
Acts as the primary resource for assigned, high profile providers or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to
complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.
– Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.
– Monitors service capabilities and collaborates cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters,
and accuracy of provider contract or demographic information are resolved.
– Supports or assists with operational activities that may include, but are not limited to, database management, and contract coordination.
– Performs credentialing support activities as needed. Educates providers as needed to ensure compliance with contract policies and parameters, plan design,
compensation process, technology, policies, and procedures.
– Meets with key providers periodically to ensure service levels are meeting expectations.
– Manages the development of agenda, validates materials, and facilitates external provider meetings.
– May collaborate cross functionally on the implementation of large provider systems, to manage cost drivers and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution.
– Conduct standard provider recruitment, contracting, or re-contracting activities and assist with more complex contracting and discussions as needed by business segment.
– May provide guidance and training to less experienced team members. Proprietary
Provider Data Services Consultant- Aetna, Inc
Aug 2018-Dec 31, 2021
Provides support for provider data transactions associated with projects, expansions, and new product implementation. Resolves high volume/high impact systematic problems through proactive and reactive mechanisms (e.g. automation, route audit programs, data reporting, root cause analysis).
Network Relations Specialist-Aetna, Inc
Oct 2017 – Aug 2018
Internally supports and contributes to positive provider relationships by handling routine provider service inquiries and problems regarding policies and procedures, plan design, credentialing process or status, and claims or compensation process or status. Supports the maintenance of contract or demographic data.
Network Representative-Aetna, Inc
Nov 2013 – Aug 2018
Research and review Member and Provider Issues related to claims and contracts
Research and review Workers Comp related issues
Data Maintenance/Special Projects Clean up
Update the Contract database with all incoming documents from contractors as well as mail for tracking purposes
Provider Data Maintenance Coordinator- Coventry Health Care, an Aetna Company Nov 2008 – Nov 2013
Research and review Member and Provider Issues related to claims and contracts
Research and review Workers Comp related issues
Data Maintenance/Special Projects Clean up
Update the Contract database with all incoming documents from contractors as well a as mail for tracking purposes
Responsible for scanning all Contracts and new Credentialing Applications
Assist with scanning of other internal and external documents into provider folder Send Contracts, Welcome Packets and Schedule Provider Orientation. Senior Customer Communications Specialist III-CCN-First Health, a Coventry Healthcare Company
Jul 2000 – Nov 2008
Receive inbound phone calls from payors, members providers and all internal customers regarding Group Health, Workers Compensation and dental claims
Educate callers about CCN products and services
Locate providers
Adhere to quality improvement initiatives
Proprietary
Education
Florida Metropolitan University
Degree -None
Field of Study -Legal Assistant/Paralegal
Dates attended or expected graduation1995 – 1996
Education
HILLSBOROUGH HIGH SCHOOL, FLORIDA
HIGH SCHOOL DIPLOMA
Graduated 5/1995
Communication
Internally supports and contributes to positive provider relationships by handling routine provider service inquiries and problems regarding policies and procedures, plan design, credentialing process or status, and claims or compensation process or status. Supports the maintenance of contract or demographic data. Handle routine provider issues and internal inquiries regarding policies and procedures, credentialing or claims status, orientation activities, and database or portal information or usage. Escalates issues as appropriate. Supports or assists with operational activities that may include, but are not limited to, database management and contract coordination. Performs credentialing support activities as needed.
Educates providers on portals, protocols, policies, procedures, and services to enhance the overall provider experience. May assist with or perform standard provider recruitment or contracting or re-contracting functions and
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