Data Entry Relations Specialist
Resume:
Susan
Richards
*******@*****.***
Maplewood, NJ 07040
Experience
Provider Relations Specialist, Maximus Inc
January 2022-current
Function as primary point of contact for IRP/IPP providers as assigned to provide technical assistance,
and function as a conduit for all operational questions and issues. Collaborate with Operation Support Unit to address clinical operational issues and/or concerns as needed. Responsible for making schedule visits remote as assigned to provide training and education on Maximus policy and procedures as necessary, ensuring provider/consumer satisfaction and operational readiness/success. Engage IRP/IPP providers as required to assist monitoring turnaround time to ensure SLA adherence. Recruited Clinicians in assigned territory in collaboration with Human resources and Vendors. Assist Credentialing with maintaining accurate Provider Data Files. Ran various leadership reports to track Provider Relations recruitment efforts. Collaborated with Human Resource and Vendors to develop and implement effective recruitment strategies ensuring robust pipeline of candidates across platforms as needed. Conducted final interview of recruited clinician to ensure they aligned with the program. Collaborate with OSU and IT to address various technical issues and find resolutions to ensure function of the program. Provider Network Relations -Delegated, Emblemhealth March 2021-January 2022
Support the financial analysis and reporting of Somos full risk arrangement. Collaborate with internal business owners and delegated team to effectively manage projects. Maintained necessary records of outstanding provider datasets. Manage relationship with external Somos staff as required. Perform database and computer functions as required to verify providers participation in plan. Assists in ad hoc financial analyses for claims. Work cross functionally to track, identify and drive key deliverables. Monitor, manage and communicate any discrepancies in provider dataset, load, and member move. Led monthly meetings with external staff to discuss contractual issues, claims issues, capitation, provider, and member move. Participated in monthly AOC and JOC with internal and external staff. Collaborated with Provider Operations to resolved issues pertaining to member and provider loads. SR. PROVIDER NETWORK COORDINATOR, EMBLEMHEALTH
January 2011- March 2021
Collaborate with Ancillary and Hospital contractors regarding the receipt and review of Ancillary and Hospital contracts submission, to ensure they remained in compliance with Company, Federal and State standard. Participated in various department projects which relates to contracting. Processed and maintained Ancillary and Hospital contract which includes implementation, scanning, filing, distributing of contracts to various department for loading and archiving contracts. Developed and Managed systems that store, track, and analyzed hospital and ancillary contracts. Consult with various departments including claims, credentialing, grievance and appeals, and Provider Operation to effectively resolve contractual issues in a timely manner. Generate weekly hospital offset reports and submit them to various facilities by mail and by email to financial recovery unit and claims department. Collaborated with Finance in processing and issuing Wire transfers and EFT to various facilities. Partnered with IT to grant and connect external vendors to various internal systems, as they relate to inpatient and outpatient claims, verification of members eligibility, and pre-authorization. Manage ancillary and hospital provider portal registration. Assigned facility issues to the various relationship managers via esaws. Facilitated in the resolution of various claims issues using webstat, qcare, and eswas. SME in texting new systems to be implementing in department Sr. CREDENTIALING SPECIALIST-PROVIDER RELATIONS, EMBLEMHEALTH October 2006- January 2011
Collected and analyzed primary source verification, which included licenses, education, training, malpractice, sanction reports, and specialty board certification via telephone, fax or online. Prepared and submitted completed credentialing and re-credentialing files for auditing. Presented Provider applications which were flag for discrepancies to Medical Director Review. Provided accurate and timely response to inquiries regarding provider status, as it relates to the credentialing and re-credentialing process. Performed data entry corrections resulting from Visual Cactus system data audit reports. Monitored License and DEA status in provider system and sent termination letters or other correspondence, as required. Prepared weekly credentialing inventory reports, monthly provider network updates and other management reports. Prepared and submitted post-Committee enrollment instructions for ƌĞĨĞƌƌĂů ƚŽ ƚŚĞ WƌŽǀŝĚĞƌ KƉĞƌĂƚŝŽŶƐ ƵŶŝƚ ĨŽƌ ŝŵƉůĞŵĞŶƚĂƚŝŽŶ͘ DĂŶĂŐĞ ĐŽŵƉĂŶLJ͛ Ɛ ƉƌŽǀŝĚĞƌ ĨŝůĞƐ to note termination of providers disciplined or sanctioned by a government agency and or suspended from participation in one or more government programs. Supervised and developed fresh staff members. Developed monthly enrollment reports and queries and submitted them to ŵĂŶĂŐĞƌ͘ ƵĚŝƚĞĚ ĚĂƚĂďĂƐĞ ĨŽƌ ĚŝƐĐƌĞƉĂŶĐŝĞƐ ŝŶ ƉƌŽǀŝĚĞƌ͛ Ɛ ŝŶĨŽƌŵĂƚŝŽŶ͘ Established and revised department workflow. Trained and supervised all new staff and temps Marketing Representative, UnitedHealth Group/Americhoice October 2006- January 2011
Developed prospect sales strategies and performed sales presentations including the creation of formal sales proposals. Provided Americhoice with market intelligence in-order to capitalize on network expansion. Conducted Public education seminars in -order to raise awareness as to the diverse types of government health insurance available to those who qualify. Explained potential eligibility for government health insurance. Met and corresponded with prospects and broker/consultants to promote Americhoice products. Advocated for individuals and families to help get the health insurance coverage they needed. Educated potential members regarding the features and benefits of health insurance including cost sharing mechanism such as deductibles, co-pay, premiums, co-insurance and how they work. Expanded America Choice provider network by recruiting Providers for Americhoice Government Programs Network and assisted in helping them join the network. Achieved sales objective and increased membership Education
BACHELOR OF SCIENCE, ^d͘ :K,E͛ ^ hE/s Z^/dz Yh E^͕ Ez Skills
Project management Data analysis Communication
Organization Problem-solving Management
Market Research Quality Assurance Auditing
Community outreach Contract Management Account Management Marketing Sales WƌŽǀŝĚĞƌ͛ Ɛ ĞĚƵĐĂƚŝŽŶ
Recruitment
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