Customer Service Network Management
Resume:
Tawanda James, MHA, POPM
Profile
Analytical, organized, and meticulous
Healthcare Professional with 20+ years of
experience in the industry. Collaborative
team player with ownership mentality and
a history of delivering the highest quality
strategic solutions to resolve challenges,
while propelling business growth.
CONTACT
PHONE:
EMAIL:
**.*****@*******.***
Skills
Senate Bill 1264 Disputes
No Surprise Billing
Project Management
Cross-Functional Leadership
Customer Service Management
Mentoring
Auditing
Account Management Reconciliation
Finance
Scaled Agile 6.0 Certification
Provider Relations
Regulatory Experience
Appeals/Grievances (Member/Prov)
Revenue Cycle
Network Management
EDUCATION
Belhaven University
Graduated, Fall 2017
Master of Health Administration
Jackson State University
Graduated, Spring 2014
Bachelor of Science in Education/Interdisciplinary Studies WORK EXPERIENCE
Product Owner-EDI
Centene Corporation 2023-Present
• Served as subject matter expert for the assigned products while driving the operational aspects.
• Monitored internal/external relationships to ensure compliance with contractual requirements.
• Created reports and supported business review presentations to key stakeholders; including, but not limited to, Senior Leadership Team, Vendors and/or Government agencies.
• Manages projected including the implementations for delegated functions as needed.
Manager/Network Management Consultant -Managed Care Blue Cross Blue Shield of TX 2020-2023
• Develop and negotiate agreements with providers and facilities (including large independent hospital systems to minimize arbitration and mediation process.
• Lead implementation of strategies for SB1264 legislation disputes
• Recognize inconsistencies and gaps in policies & procedures, to improve productivity & data accuracy.
• Maintain effective communication with internal, external teams & key stakeholders to ensure project efficiency of regulatory requirements and timelines.
Medicaid Operations Specialist
Blue Cross Blue Shield of TX 2019-2020
• Manage vendor performance to maintain a less than 2% variance in compliance across multiple lines of business (CHIP, STAR and STAR Kids)
• Manage third-party vendors and government agencies to monitor and analyze aggregate and individual encounter data metrics (completeness, accuracy, and timeliness), through structured and organized meetings, clear and precise communications.
• Aid in management of Texas Medicaid Encounters data integrity request between encounters and claims
Tawanda James, MHA, POPM
Network Management Consultant
Blue Cross Blue Shield 2017-2019
• Developed contracts to ensure appropriate contract execution
• Facilitated provider orientations, training, and continuing policy education to provider office staff, billing staff, claim staff and precertification area.
• Ensured all expenditures comply with corporate and divisional expense guidelines.
• Analyzed final reports to determine fiscal impact of contract negotiations. Accounts Receivable Manager
Sta-Home Health 2013-2017
• Utilized EPIC Resolute HP/PB to process and research high dollar claims and adjustments.
• Trained new and seasoned team members on EPIC software.
• Acted as claims department SME on departmental and corporate projects.
• Analyzed claims issues/trends to determine next step resolution and process improvements.
Customer Service Lead- Federal Employee Program
Blue Cross Blue Shield of MS 1993-2013
• Supported a team of 40+ and motivated them to surpass expectation and goals
• Reviewed appeals and reconsiderations to providers and members
• Acted as claims department SME on departmental and corporate projects
• Analyzed claims issues/trends to determine next step resolution and process improvements
Contact this candidate