Relations Representative Provider
Resume:
NANCY VASQUEZ
Stockton, CA 408-***-****
**********@*****.***
PROVIDER RELATIONS REPRESENTATIVE
Provider Relations Representative with experience in the healthcare industry. Expertise as the primary liaison between companies and health care providers, medical and professional groups and Independent Physicians Associations. Known for building key relationships with external partners resulting in trust. Key skills include:
Client Service Administration Compliance Communication
Research and Analysis Understanding of Financial Products
Provider Changes Large Group Install Renewals Critical Thinking
Time Management Microsoft 365
PROFESSIONAL EXPERIENCE
Gold Coast Health Plan
Provider Relations Representative I February 2023 – June 2024
Medi-Cal based Health Insurance non-profit. Remotely working with department to maintain provider delegated lists, provider data entry for all incoming and terminating providers to their prospective groups and offices, review incoming emails to solve claim complaints to include appeals and grievances.
Acts as a liaison to assigned providers/vendors to ensure that all the groups are effectively informed and updated by the health plan as necessary.
Develops and manages the relationship with large and complex provider groups.
Analyze and resolve complex issues effecting provider relations.
Analyze escalated claims for nonpayment, underpayment.
Review and obtain contact information for the entirety of the provider lists.
Data entry for new providers for large groups in a timely manner
Works with management in outreach to ensure a select set of facilities are in good health during extreme inclement weather.
Blue Shield of California
Provider Relations Representative September 2019 – January 2023
Working with department management, evaluates, plans, develops, and maintains HMO network of primary care physicians/groups including, IPAs and/or multi-site primary care groups, specialist physicians (individuals and groups) and ancillary services providers for health plan services.
Acts as a liaison to assigned providers/ vendors to ensure that all the groups are effectively informed and updated by the health plan as necessary.
Demonstrates an ability to develop and manage the relationship with large and complex provider groups including IPAs and PHOs.
Effectively manages individual providers with a focus on time and accuracy.
Analyze and resolve complex issues affecting providers including claims with contract discrepancies.
Ensure provider compliance with company policies.
Assist with monthly, quarterly and annual provider reviews
Customer Service Representative Rehire November 2019 Temp to FTE April 2020
Aerotek, Blue Shield of California August 2018
Responsible for Intermediate Large Group install and renewal.
Processed new and renewing large group applications during open enrollment.
Outreach to employers to verify applications showing errors.
Volt Workforce Solutions, Blue Shield of California September 2017 – March 2018
Intermediate Member Level Processor
Supported the Individual Family Plans in Primary Care Physician assignment during open enrollment.
Review and update applications from employers to confirm all members are updated correctly so there is no lapse in coverage.
Outreach to employers to verify applications showing errors.
Responsible for updating member information when system errors are found.
Volt Workforce Solutions, Blue Shield of California September 2016 – August 2017
Intermediate Correspondence/Phone Support Medicare Supplement.
Responded to and resolved customer inquiries, and resolves claims problems within established production and quality standards promptly and accurately.
Coordinated with other departments to ensure timely and appropriate responses.
Expedited and resolved complex issues and initiated claim adjustments.
Educated others on the Blue Shield product, providing accurate information and updates to policies and procedures, improving overall customer satisfaction.
Effectively navigated through multiple platforms or applications to efficiently locate information and complete processing tasks.
Senior Customer Care Representative April 2012 – March 2016
Provided telephone and online customer service/support for Medicare Supplement and Individual Family Plan members within high-volume call centers. Handled customer concerns within a timely manner and first call resolution.
Promoted to the Correspondence Processing team to process premium Email correspondence, reinstatements, refunds, and correspondence queue for all lines of business.
Assisted the Business Readiness team for User Acceptance Testing for the letter server access.
.4 points away from Level 2.
ADDITIONAL RELEVANT EXPERIENCE
Sunnyvale Acura Automotive Dealership, Service Writer
Oakland Volkswagen Automotive Dealership, Service Writer
Stockton Honda Automotive Dealership, Service Writer
Hayward Chrysler Jeep, Assistant Service Manager
First National Bank, Assistant Branch Manager
San Carlos Police Department, Community Service Officer / Dispatcher / Evidence Technician
EDUCATION
Bachelor of Science (BS), Criminal Justice Administration, University of Phoenix – Phoenix, AZ
POST Basic Police Academy. Monterey Peninsula College, Monterey, CA
Reserve Fire Academy, College of San Mateo – San Mateo, CA
Reserve Police Officer Academy, Canada College – Redwood City, CA
PROFESSIONAL DEVELOPMENT
Broadmoor Police Department. Reserve Police Officer, Volunteer, 5 years
MEMBERSHIP
Alpha Phi Sigma National Criminal Justice Honor Society, 2011 - Present
SOFTWARE SKILLS
MS Office - Word, PowerPoint
In-house programs necessary for the position
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