Account Management

DARLA A. MCMUNN

Profile

Background in Payor contracting and financial analysis with a strong emphasis on provider/payor relations (Hospital and Physician). Skilled in the planning coordination of various special projects. Highly focused and results-oriented in supporting complex, deadline-driven tasks; able to identify goals and priorities as well as resolve issues. Strong background in claim processing and claim adjustments. Experience

Sr. Provider Relations Advocate

United Healthcare – Pittsburgh, PA

03/2010 to Present

In my current role of Provider Relations Advocate I am accountable for the full range of provider relations and service interactions within UHG, including working on end-to-end provider claim and call quality, ease of use of physician portal and future service enhancements, and training & development of external provider education programs. Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers. Directs and implements strategies relating to the development and management of a provider network. I identify gaps in network composition and services to assist the network contracting and development staff in prioritizing contracting needs. May also be involved in identifying and remediating operational short-falls and researching and remediating claims. Provider Relations Claims Support Analyst

AmeriChoice/Unison Health Plans – Monroeville, PA

03/2001 to 03/2010

Analyze and recommend course of action for unpaid, denied and incorrectly processed claims Oversee overpayment recovery projects Engaged in training new Provider Relations Representatives on system configurations Provide support to the Provider Relations Department for Claims policies and procedures Analyze the Claims processing system to ensure proper contractual payments Utilize test environments to ensure correct processing according to Medicaid and Medicare standards Organize and complete task requests in a timely manner Liaison between provider relations, claims and system set up departments to resolve matters of contention. Auditing contracts to ensure accurate claims processing system load. Claims Examiner

AmeriChoice/Unison Health Plans – Monroeville, PA

Proper adjudication of both Physician and Hospital claims. Research of development of claims policies and procedures. Carried out functions associated with inpatient claims and audits.

03/1999 to 03/2001

9223 Glen Moor Ln, Port Richey, FL., 34668 412-***-**** ********@*****.*** Claims Examiner HealthAmerica

– Pittsburgh, PA

02/1994 to 03/1999

Proper adjudication of professional medical and hospital claims Research and development of claims policies and procedures

Education

High School Diploma:

Swissvale High School - Swissvale, PA

Skills

Technical Skills

• MS Office Suite: Proficient with

MS Word, Excel & PowerPoint

• Reporting: IMPACT, ODAR,

Orbit Business Objects, SharePoint

• Claim Platforms: Proficient with

COSMOS, CSP Facets

• Provider Service: Proficient with

CareOne, EDSS, iBAAG, I-CUE,

IDRS, ISET, Macess, ORS

References: Available upon request.

Jun 1987

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