Engagement Director Provider Relations
Resume:
Marcos Franquiz
Provider relations Executive
Tampa Florida
**************@*****.***
Market Engagement Director
Clear Spring Healthcare Plan – Tampa Florida
March 2022 to Present
Initiate and intensively perusing PCPs and Specialists in South, Central Florida, to ensure Clear Spring Healthcare Plan Counties expansion and full network of providers.
Also working with IPA’s, MSOs to close those medical gaps to satisfy CMS requirements.
Promote and educate contracted providers and groups, by initiating the training process to all our providers in our portal, this training will include, but not limited in how to manage this portal regarding provider registration, reports, utilization, marketing. Authorization, membership, eligibility, claims.
Working in a very Hostile market, where there was a lot of HMOs failure, hurting providers and hospitals with unpaid claims, a lot of competition and distrust, my team and I were able to build a network of more of 2,500 providers distributed between Palm Beach, Broward, Dade, Polk, Hillsborough, Osceola and Orange Counties.
Part of my duties was to assist my team answering questions from Doctor’s offices about benefit verification, entering claim data for processing and maintain a good relationship with providers, also as a Market Engagement Director I support my team to recruit new physicians and to collect the credentialing and orientation process, part of my duties is to serve as a resource for physicians, answering questions and providing information about network procedures or contracts. Monitor provider performance and resolve any issues. I help other Market Engagement Directors in other States when it is needed. Explain resources related to policies, processes, approval timelines and other actions. Oversee tools and systems to ensure accurate records and efficient service.
Clear Spring Healthcare Plan offers Medicare part D (Medicare Prescription Drug Plan MA-PD) products as well as regular Medicare part C or Medicare advantage, we have a variety of contracting option for our PCPs; full risk, partial risk, Cap, FFS, VBC contracts and for specialists only FFS.
Oversee a staff of four, supervising contracting schedules, work schedule, vacation, sick time, organizing meetings (one on One) to discuss performances, issues, network progress, personal goals.
Provider Partnership Manager
Sunshine Health Plan – Tampa Florida
May 2017 to March 2022
In charge of Pinellas and Pasco Counties building relationships in order to promote Sunshine Health and WELLCARE Plan products. Educate my network of providers with the implementation of incentives to those medical providers that follow HEDIS measures and high rate of closing of care gaps. Review of Financial reports with emphasis in medical lost ration/HBR funding and expense report as well as ER and hospital stay, review and educate in how to be pro-active with chronic condition members and the best options for treatment. Educate and help Providers to take action to ensure that their practices are operating in a way that help secure the best possible HEDIS rating on a consistent basis. Assist Providers in implementing the information systems required to support quality reporting and monitoring to achieve Higher HEDIS scores and to make sure in having good clinical documentation. Give support and make sure to take actions require to meet our Health Plan's goals regarding Web access through education and to make sure they are registered. To help my medical groups to achieve a decent HBR of 85% or lower by introducing the necessary tools and reports, help providers to resolve issues in a timely basis by constant communication and information. Make sure all my network is well informed in changes within the industry.
Be proactive and verify demographic information regarding locations, LOBs, provider information, after hours, etc. Educate providers in telemedicine, credentialing process and what is the needed documentation. Review providers panel and to remind them to do the required trainings every year.
Educate providers to refer in network vendors and specialists. Encourage PCPs to improve their performance in HEDIS and care gaps closure, bring members for well visits and support all CAHPS initiatives.
Identify opportunities to improve in cost performance, quality of care, HEDIS. Educate providers the differences between a CAP-FFS- and VBC contracts.
Responsible to do site visits review for facilities, new locations or a new provider. Do New provider's orientations and help credentialing to gather the necessary documentation for re credential of providers within the network. I worked in Orange and Polk Counties building good relationships with IPAs and medical groups.
Provider Relations Executive
Oncology Analytics – Plantation Florida
January 2015 to April 2017
In Charge of South Florida and Puerto Rico markets, developed and nurture a supportive, and consultative and lasting relationship with our customer's treating oncologist and Primary Care providers who are providing cancer services to our customer and members, Supported providers Oncologists, Hematologists and urologists in their needs to help our membership, educated our network in how to follow Medicare, Medicaid and Commercial guidelines in treatments and medications and protocols, review of Financial reports and incentives.
Support Providers (Oncologists, Hematologists and Urologists) in their needs to help our membership in finding ways to treat them accordingly. Educate our Network in how to follow Medicare, Medicaid and Commercial guidelines in treatments and medications and how to work our authorization and protocol process. In service our South Florida and Puerto Rico Networks making sure that our Providers have the necessary knowledge to work in these markets, also review of financials showing practices their strengths and weaknesses in order to improve our service as well as theirs. working together with MSOs and PCPs on risk to make sure the cost saving medications and protocols are effective on the financials of these groups.
Provider Relations Regional Manager
Florida Health Care Plus - Miami, FL
December 2010 to January 2015
Opened and built network of specialists and primary care providers to full fill the requirement of our membership and our Health Plan; in four different counties: Dade, Broward, Palm Beach and Pt St Lucie. Built strategic alliances with IPAs and MSOs in order to strength our presence and medical network in our areas of service. Renegotiated those contracts that were unfavorable to our Health Plan. Built a network of Primary Care providers with Partial and Full Risk contracts in order to improve our MRA and HEDIS reporting system. Strengthened our company's financials by leading implementation of the MRA HEDIS and Financial reporting system by educating our medical network in those specific areas. Defined a strategy and business plan for the network and the growing of membership, marketing strategies and business developing. Participated with marketing in medical events to improve our relationship with the community and our medical network.
Network Developer Executive
CarePlus Health Plan - Miami, FL
January 2006 to November 2010
Coordinated with management specific network needs, negotiated competitive rates for the network of medical providers, assisted in contracting, in those areas where gap existed, educated our network of medical providers in how to improve and reach our goals by working together with the MRA process as well as the HEDIS reporting system. Reviewed encounter submission trend as well as network documentation, educated our providers in how to improve the lives of our elderly membership with chronic conditions. Negotiated partial and full risk contracts as well as capitated only contracts, educated and reviewed our financial reporting system to our partial and full risk contracted network to facilitate and improve their financial understanding. Supported and assisted in marketing events to increase our membership and medical Network
Provider Educator Specialist
Jackson Health Systems - Miami, FL
March 1999 to December 2005
Developed and educated on Plan's policies and procedures and maintained a cost quality provider network for our Medicaid population, educated and monitored our provider network in any changes of policies by our state Government and AHCA system. Worked to do periodic changes in our medical directory and physician manual and procedures. Identified and obtained resources necessary for network maintenance, periodic site reviews to assess compliance with guidelines membership access and availability of services to determine a need for additional training and education. Updated and revised provider material to satisfy JMH, AHCA, and NCQA operational policies, assisted in the resolution of issues and promoted a positive relationship between the Health Plan, its members and medical network. Responsible for the inspections of all JMH public clinics, making sure they follow Federal and State guidelines. Educated our providers in how to process and offer our varies Medicaid products to our membership. Worked with our ancillary vendors to integrate their services into the overall care delivery system contracted providers depending on the network needs.
EDUCATION
Bachelor’s degree (Business Administration) St Thomas University - Miami, FL
Skills
Windows, Excell, Power Point, Share Point, Salesforce, Outlook Microsoft, Concur, Office 365, Credentialing Stream, Atlassian Jira, Workday
Additional Information
Analytical skills Bilingual, Contract negotiator, Business developing, Market industry Knowledge, provider outreach, provider relations, compliance, marketing, risk and partial risk contracts.
Core Accomplishments
Open and develop of network of specialists and primary care providers in different Florida Counties; Dade, Broward, Palm Beach, Orange, Hillsborough, Polk, Osceola Pinellas; to full fill the Health Plan's and membership expectations of service and to help the marketing department to increase membership. Educated our primary care network to understand our financial reporting system and to understand and follow the objectives and goals of the Health Plan, helped our complete network in how to follow CMS and AHCA guidelines, MRA reporting and HEDIS reporting. Educated our network of specialists in the Plan's billing, guidelines and procedures. Educated the primary care network the benefits of a partial and full risk contracts and how they can improve their financial status and membership management
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