Jaclyn Bickers Roth

Sr. Executive Healthcare

Consultant

I have nearly 20 years in the healthcare

industry working for several major issuers

with experience in Medicaid, Medicare, and

Commercial Markets. I primarily focus on

Provider Engagement, Network

Development and Operations. I have

experiencein Quality as well. I chaired

committees i.e. QAPI and QHC approving

new and established policies and regulations

to follow NCQA standards.

My strengths include, implementations,

network strategy, public speaking,

timeliness, supporting operational

functions, claims analysis, project

management, and ability to manage positive

working relationship internally and

externally.

TECHNICAL/PROFESSIONAL SKILLS

Facets, Salesforce, PEGA, Macess,

SharePoint, MMIS, Microsoft Office,

Cactus, CRM software

WORK EXPERIENCE

Foster Business Consultants

Sr. Executive Consultant

12/2021 -

• Implement new lines of business for major issuers with experience in Medicaid, Medicare, and Commercial

Markets with a focus on Provider Engagement and

Network Development.

• Implementation, network strategy, and supporting operational functions have been primary roles

• Making corporate decision for the Health Plan while managing projects and new developments of workflow

• Supports all of Provider Network Management, PNM, Operations, Enrollment, and Provider Data Management

• Manages Quality Services Committee Meetings

o Chairs Committee

o Builds Packet for meeting

o Request deliverables from identified departments identifying a lead to present during meeting from

each department

o Assist with NCQA requirement deliverables, work

plan and agenda

o Define the attendees’ responsibilities as voting members

o Determining quorum

o Following up on all specific change requested to documents reviewed during meeting

o Developing an admn team to support committee

o Calling on votes for approval of documents

• Develops Corporate and Local Policy and Procedures

• Meets with Leadership from the Health Plan on a regular basic

• Develops work groups to manage projects,

• Develops structure for how departments should be set up based on staffing.

• Works with Compliance to determine if health plan is meeting state, federal and accreditation agencies policies and procedures

• Develops policy and procedures along with Compliance

• Stays up to date with new regulations or any Acts that are put in place, including The No Surprises Act

• Developed an attestation form online for providers to utilize and keep demographics current that will be used across multiple Lines of Business

• Understanding of accreditation agency requirements and responsibilities

• Determine project deadlines and making sure all are met timely

• Set goals for staff and acknowledge accomplishments

• Create workgroups for specific projects, adding the right staff to workgroups, appointing a lead associate to coordinate responsibility

• Meets with leadership weekly to discuss any escalated issues or any new agenda items

• Work with configuration on fee schedules

• Contract providers

o Negotiate rates

o Work with providers on any redlines outlined on

contract

o Once signed by both parties sending copies to

provider as well as health plan data team to load data

• Work with configuration to make ensure contracts are loaded to pay at agreed rate

• Create Out of Network Fee Schedules

• Identify gaps within network on existing health plan

• Build new markets based on line of business that’s being launched i.e. commercial, Medicaid, Medicare, etc

• Works with compliance making sure all federal and state regulations and requirements are followed

• Work with corporate staff as well as local staff on developing workflows for daily performance

• Project Management – Lead multiple projects of a variety of different needs, i.e. CRM, Demographic tool, fee schedule tool

Molina Healthcare

Provider Relations Manager

11/20 – 12//21

• In conjunction with the Director, Provider Network Management & Operations, develops health plan-specific provider contracting strategies, identifying specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of the Plan's patients or members.

• Oversees and leads the functions of the external provider representatives, including developing and/or presenting policies and procedures, training materials, and reports to meet internal/external standards.

• Manages and directs the Provider Network staff including hiring, training and evaluating performance.

• Assists with ongoing provider network development and the education of contracted network providers regarding plan procedures and claim payment policies.

• Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards.

• Oversees appropriate and timely intervention/communication when providers have issues or complaints (e.g., problems with CONTACT INFORMATION

Phone:

502-***-****

Email:

adzki0@r.postjobfree.com

claims and encounter data, eligibility, reimbursement, and provider website).

• Serves as a resource to support Plan's initiatives and help ensure regulatory requirements and strategic goals are realized.

• Ensures appropriate cross-departmental communication of Provider Network initiatives and contracted network provider issues.

• Designs and implements programs to build and nurture positive relationships between contracted providers, ancillary providers, hospital facilities and Plan.

• Develops and implements strategies to increase provider engagement in HEDIS and quality initiatives.

• Engages contracted network providers regarding cost control initiatives, Medical Care Ratio (MCR), non-emergent utilization, and CAHPS to positively influence future trends.

• Develops and implements strategies to reduce member access grievances with contracted providers.

• Oversees the IHH program and ensures IHH program alignment with department requirements, provider education and oversight, and general management of the IHH program Independent Contractor

Project Manager/Contract

Manager 01/19 -11/20

• Develop strong interpersonal relationships with assigned providers.

• Manage provider contracts from the initial outreach throughout the negotiations of reimbursement

• Determined Network Adequacy

• Lead projects during implementation of health plans

• Manage multiple states including KY, TN, OH, MS, TX, LA, ID, IA

• Develop contracts for multiple health plans with leadership

• Manage multiple markets including government and commercial

• Conducted day to day calls and emails

• Manage the contracting process for prospective providers including provider groups and hospitals

Caretaker for Parent

Personal Time

07/2018-11/2018

● Became full time caregiver caring for my

father.who suffered from Alzheimer’s

Aetna Better Health of Kentucky

07/17 – 07/18

Sr. Network Consultant for Physicians and Hospitals

• Maintained regular contact with key provider organizations and serves as a liaison to internally resolve complex issues.

• Developed strong interpersonal relationships with assigned providers.

• Researched and resolved Provider inquiries

• Assisted with physician recruitment by identifying specific providers within a designated territory, facilitating the distribution of provider agreements, negotiating rates for new physicians, and renegotiating contracts for existing physicians within established limits.

• Participate in the identification of sufficient number and location of providers to meet access requirements and member needs.

• Assist with the development and implementation of provider training programs as well as internal training programs.

• Engage with each provider group to support practice improvement and facilitate information sharing

• Manage provider contracts

• Determine system setup to oversee flow of claims payment making sure provider payments is satisfactory

• Collaborated with providers as well as internal staff managing issues that providers encountered to determine the root cause and make necessary corrections

Anthem Blue Cross and Blue Shield

12/13 – 06/17

Louisville, Kentucky

Provider Relations Medical and Hospital Specialist, Consultant Sr.

• Managed over 10,000 accounts for Primary Care Providers (1,746), Ancillary Providers, Specialists (3,212), and Hospitals

• Facilitated monthly meetings with top tier Physicians and Hospital groups in Region 5 (approx. 22 counties)

• Researched and resolved provider inquiries

• Managed the contracting process for prospective Anthem Kentucky Medicaid Providers and groups

• Liaison between departments

• Updated provider data in Facets, i.e. provider address, phone number, provider type

• Tested mock claims for to determine if edits were setup correctly

• Managed large and small claims projects

• Drafted policies and procedures to be published on provider portal

• Trained Provider Relation Representatives on system functionality, care gap reports and orientating new Providers

• Worked directly with the Department of Medicaid to ensure provider satisfaction

• Provided practices the opportunity to earn additional compensation for meeting quality metrics through the Provider Quality Incentive Program and Shared Savings Program

• Engaged with each Provider groups to support practice improvement and facilitate information sharing

• Facilitated Provider Network implementation - participated in contracting providers to the new Health Plan at plan inception

• Implemented out of state markets as new state contracts were awarded, i.e. Iowa

• Worked directly with the marketing team to strategically develop plans to gain new business within the state of Kentucky

• Created relationships with local government to create better flow of communications

• Leveraged prime relationships with key stakeholders to better develop business opportunities

Hewlett Packard

06/10 - 12/13

Provider Field Specialist

• Assist Providers with billing issues

• Conduct Provider visits at their facility or Virtual Rooms

• Conduct Provider Workshops at different locations around Kentucky and Virtual Rooms

• worked with the States of Georgia and Nevada on the implementation of Interchange (computer system)

• Teach providers and staff how to bill KY Medicaid

• Research Claim denials for Providers

• Call all new providers and welcome them to the Medicaid program

• Create Spreadsheets

• Communicate with providers and staff via telephone or face to face contact

• Review provider contracts

• Work with the Department of Medicaid staff to resolve provider issues

• Conduct Orientation for new Kentucky Waiver Providers

• Review Manuals for new updates and changes

Contact this candidate