Patient Care Experience

KATHLEEN VILLANUEVA

(***) ***.********************@*****.***

*** ******** ******, ********, ** 94547

PROFILE SUMMARY

Reliable, emphatic and driven Healthcare Professional who passionately and visibly promotes and supports the organization’s service excellence initiatives and its commitment to a patient care experience that is safe, high quality, and responsive to the patient’s needs. Thoroughly versed in network development and retention strategizing, network problem resolution, and network analysis for adequacy and recruitment targets. Continuously builds a culture of accountability and clinical excellence through strategic coordination and retention of the necessary administrative team, physicians, clinicians, and staff to achieve established goals and objectives. Strong analytic, negotiations and issue resolutions abilities combined with exposure to procedure interpretation and provider networking.

QUALIFICATION HIGHLIGHTS

• Ability to assess the viability and strengths of the physician network, and identify areas of opportunity, or risk.

• Manage all aspects of network administration while maximizing corporate continuity to facilitate delivery of programming that demonstrates rigorous, research-based standards.

• Employed appropriate and innovative solutions to increase communication while using time efficiently to track progress and meet goals.

• Oversight Internal HICE Audit

• Mediate competing interests in the service delivery process to construct solutions that enhance clinical outcomes and the patient care experience.

• Solid interpersonal skills and charisma to bring diverse constituencies and teams together in pursuit of common goals.

• Provides input to strategic decisions that affect the functional area of responsibility. Advanced analytical and computer skills, outcome-driven personality.

• Possess strong knowledge of data security and relevant legislation.

• Provided a stabilizing influence and promoted an excellent environment conducive to increasing efficiency, enhancing quality and strengthening financial results.

• Proficient in using VerityStream for credentialing database management

• Experienced with EPIC EMR system for patient care documentation

• Advanced proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook, Teams) reporting and communication.

• Extensive experience in managing provider enrollment and credentialing using PECOS/PAVE ensuring timely and accurate submissions for Medicare & Medi-Cal participation. CORE SKILLS

• Provider Network Strategy

• Provider Enrollment

• Provider Servicing Experience

• Quality/Performance Improvement

• Departmental Operations

• Management/Supervisory

• Provider Roster Management

• Data Management

• Writing Correspondence

• Managed Care (HMO/PPO

Products

• Report Writing

• Customer Satisfaction

• Oversight HICE Audit

• Effective Communication

PROFESSIONAL EXPERIENCE

John Muir Physician Network 2017– Present

Specialist - Provider Credentialing

• Demonstrates familiarity with internal (JMPN) and external (NCQA, State and Federal) regulations.

• Developing and maintaining confidential files and profiles on all JMPN providers reflecting current status, including, but not limited to: Board Certification, hospital affiliation, licenses, special certifications, malpractice insurance, QI information, American Medical Association Profile.

• Collaborate effectively with numerous cross department teams while acting as a liaison between Single Business Office and providers on health plan issues.

• Oversee HICE Audit

• Manage provider enrollment and credentialing using PECOS, CAQH, and PAVE, ensuring timely and accurate submission of applications for insurance participation and network inclusion

• Consistently utilize systems control to ensure that both existing and current information are properly stored and maintained. Examples of time-controlled credentialing information include, but are not limited to: state licensure, board certification, registrations (DEA), terms of appointment, National Practitioner Data Bank report.

• Oversee provider enrollment with contracted payors.

• Provider Data/Roster Management

• Demonstrates proficiency in the performance of data retrieval functions.

• Process all JMPN applications and re-applications in accordance with established policy, researches missing information and assembles total files for review.

John Muir Physician Network, Walnut creek CA 02/7/17– 2019 Care Transition Associate

• Verified patient benefits, eligibility and any associated co-payments for services.

• Assisted case managers and social workers with referrals by compiling and sending required documents for authorization for post-acute services such as skilled nursing care, DME,Home Health, Hospice,' infusion and alternative housing.

• Utilizes preferred post-acute care network in transitions to skilled facility or home health services.

• Obtained referral and tracking numbers as appropriate from some health plans.

• Offered extensive support in the generation of contracts for services not typically covered.

• Ensured all contracts are reviewed and signed by Director or VP Care Coordinator.

• Ordered appropriate durable medical equipment (DME) per physician order and ensures timely delivery.

• Reviewed/inpatient Review nurses and case managers; tracks denials and appeals as requested.

• Tracked admissions, discharges, avoidable days and denied inpatient days for statistical purposes and enter that information into the system.

• Consistently maintained professional conduct and good working relationships with co-workers, supervisors and other employees.

Saint Francis Memorial Hospital, San Francisco, CA 06/2000 – 02/2017 Patient Access Representative, Trainer

Maxim Health Care, Alameda, CA 02/1997 – 05/2000

Certified Nursing Assistant

EDUCATION

University of Phoenix, Concord, CA 2010

Bachelor of Science, Health Administration

Solano Community College, Solano, CA 1997

Associate Degree, Liberal Arts

De Anza High School, Richmond, Ca 1993

High School Diploma

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