Operations & Network Management Leader with 16+ Years Experience
Resume:
Ryan DelosReyes
Palm Harbor, FL *****
*********@*****.***
Professional Summary
Proven success in leadership roles in Operations Management, Provider Network and Quality performance management and Financial KPI.
Account Management, Sales, Dispatching and Customer service. With overall experience 16+yrs. Great Communication skills, work well with others and proven success of meeting and exceeding goals and expectations.
Authorized to work in the US for any employer
Authorized to work in the US for any employer
Work Experience
Network Management Consultant
HCSC - Health Care Service Corp - Cigna MA-Tampa, FL March 2025 to Present
• (HCSC acquired Cigna Medicare)
• Managing the relationships with assigned provider groups and their staff (e.g. physicians, practice managers, care coordination teams), as well as executing with provider group on initiatives that benefit the customer, provider, and health plan
• Collaborating with administrator on strategic plans on growth, development, and vision for assigned territory.
• Ensuring provider updates are processed correctly and communicated back to necessary provider groups, and assisting with provider questions, grievances, and issues (claims, referrals, etc.)
• Ensuring Network adequacy and audit loading processes is correct.
• Collaborate with Provider Account Representatives, Certified Coders, and the Medical Center staff to ensure that those patients that been identified as having any Medicare Risk Adjustment (“MRA”) documentation and revenue enhancement opportunities .
• Proven planning, preparation and presenting skills, with established knowledge of reimbursement and bonus methodologies
• Assisting in initiatives and performing special projects and other duties as assigned by leadership
• Conduct as needed PPM/JOC with higher leaderships from partners and internal Matrix partners.
• Review KPI Monthly/Quarterly Quality and Financial Performance Reports with Provider groups/ PODS FFS and MSO Value-Based Care
• Review Quality performance to improve Stars HEDIS measures and Risk Management.
• Collaborates internal matrix partners to help identify areas of opportunity, builds action plan and collaborates cross functionally to support quality performance
• 65% Travel.
Network Account Executive - Provider Performance Management Cigna Group - Cigna MA-Tampa, FL
September 2022 to March 2025
• Managing the relationships with assigned provider groups and their staff (e.g. physicians, practice managers, care coordination teams), as well as executing with provider group on initiatives that benefit the customer, provider, and health plan
• Collaborating with administrator on strategic plans on growth, development, and vision for assigned territory. Participating with the administrator in monthly financial review with senior management and Matrix Partners.
• Ensuring provider updates are processed correctly and communicated back to necessary provider groups, and assisting with provider questions, grievances, and issues (claims, referrals, etc.)
• Ensuring Network adequacy and audit loading processes of adds, changes and terms of Providers and Group.
• Works with Provider Account Representatives, Certified Coders, and the Medical Center staff to ensure that those patients that been identified as having any Medicare Risk Adjustment (“MRA”) documentation and revenue enhancement opportunities are evaluated by their Primary Care Physician and the related encounters are submitted to the Health Plan.
• Proven planning, preparation and presenting skills, with established knowledge of reimbursement and bonus methodologies
• Assisting in initiatives and performing special projects and other duties as assigned by leadership
• Conduct as needed PPM/JOC with higher leaderships from partners and internal Matrix partners.
• Review KPI Monthly/Quarterly Quality and Financial Performance Reports with Provider groups/ PODS FFS and MSO Value-Based Care.
• Find strategies to assist partners to help close gaps/measures to improve Stars HEDIS measures and Risk Management performance by analyzing and interpreting financial trends for health care costs, administrative expenses and P4Q, Pathway to P4Q and CCF quality/bonus performance.
• Collaborates with Provider Relations and other provider facing teams to improve provider performance in Quality (Clinical and Member Experience measures). Provides clear insight into provider group dynamics, identifies areas of opportunity, builds action plan and collaborates cross functionally to support quality performance
• 65% Travel.
• ( Cigna MA was acquired by HCSC)
Provider Data Quality Management -Lead
The Cigna Group -Cigna MA-Tampa, FL
June 2021 to September 2022
• Responsible for the creation of Provider contracts and review executed contracts to ensure proper compliance and loading.
• Responsible for the coordination and tracking of Provider credentialing and submitting through the proper channels for approved credentialing process.
• Responsible for the loading of Provider data into multiple systems – i.e. claims, directory.
• Act as a SME (subject matter expert) for Provider demographic loading into all Cigna Medicare systems.
• Provide support for questions and issues raised by staff and provide answers as quickly as possible - supporting the timeliness of the review or outreach.
• Provide one-on-one training to individuals to drive performance and quality improvement.
• Track issues and opportunities from matrix partners and provide feedback to those respective teams. Provide performance of Providers ensuring membership enrollments
• Load contracts into MediTract and other data loads such as CAQH, QNXT, OnBase and other products and update in SharePoint sites to ensure tracking data.
• Provide support with providers/provider groups within the market and assist with issues, concerns, and build relationship to ensure our members are being serviced with quality of care.
• Support provider groups and build and maintain relationships with on going in touch provider visits, phone conference, Webex meetings to ensure providers are up to date with Cigna updates and CMS guidelines.
• Knowledge with several Cigna applications data base such as, SharePoints, OnBase, CAQH, NIPPS, and PDM/PDQ loading process.
• Knowledge with FFS provider groups and MSO/POD provider groups.
• Communicate across other department with updates, issues and network developments. Sr. Provider Data Analyst/Rep
Cigna-Tampa, FL
September 2020 to June 2021
• Responsible for the creation of Provider contracts and review executed contracts to ensure proper compliance and loading.
• Responsible for the coordination and tracking of Provider credentialing.
• Responsible for the loading of Provider data into multiple systems – i.e. claims, directory.
• Act as a SME (subject matter expert) for Provider demographic loading into all Cigna Medicare systems.
• Provide support for questions and issues raised by staff and provide answers as quickly as possible - supporting the timeliness of the review or outreach.
• Provide one-on-one training to individuals to drive performance and quality improvement.
• Track issues and opportunities from matrix partners and provide feedback to those respective teams. Provide performance of Providers ensuring membership enrollments
• Load contracts into MediTract and other data loads such as CAQH, QNXT, OnBase and other products and update in SharePoint sites to ensure tracking data.
• Provide support with providers/provider groups within the market and assist with issues, concerns, and build relationship to ensure our members are being serviced with quality of care.
• Support provider groups and build and maintain relationships with on going in touch provider visits, phone conference, Webex meetings to ensure providers are up to date with Cigna updates and CMS guidelines.
• Knowledge with several Cigna applications data base such as, SharePoints, OnBase, CAQH, NIPPS, and PDM/PDQ loading process.
• Knowledge with FFS provider groups and MSO/POD provider groups.
• Communicate across other department with updates, issues and network developments.
• Travel 25%
Provider Network Outreach and Education Specialist EQ Health Solutions Inc-Tampa, FL
February 2020 to September 2020
• Support the provider relations department and supervisor in all department activities.
• Receive and respond to inquiries from providers. Develop, coordinate and deliver educational activities to medical providers.
• Education providers with claims codes such as ICD-10,HCPC code and DX Items codes.
• Create the training, design documents, develop course design templates, assist in creating pre- and post-evaluations and assessments. Design and format educational materials in coordination with the client, department supervisor and subject matter experts.
• Conduct face-to-face presentations as well as webinars and go-to meetings. Assist with quality improvement initiatives and focused studies, as required. Provide courteous and prompt service to all internal and external customers.
• Prioritize and address requests and assignments in a professional manner to develop cooperative relationships and to ensure that customer confidentiality is assured. Identify opportunities and recommends methods to improve service, work processes and financial performance, e.g. expense management.
• Assist in the implementation of quality improvement initiatives. Perform other tasks as may be deemed necessary
• Be the primary contact for health care providers, such as physician's offices and hospitals answer questions from health care providers service contracts, available in-network services, and billing procedures.
• Maintain and conduct various Network Development and ensure all adequacy is being met with our contracting HP. Onboard new providers and handle all credentialing up to Contracting.
• Oversee contracts to ensure all accuracy and timeliness are being entered in the database. Review all upcoming expired contracts,credentialing and Federal & State Law licensing are current.
• Fielding inquiries from team leads, client managers, and project managers regarding interpretation of contract terms, contracting and compliance policies, procedures, risks, and contract status.
• Tracking data for reporting and metrics as defined and required by Supervisor, Finance, and the Leadership Team.
• Travel up to 75% if need be for Network Development Provider Network Contract Specialist
AMR CORP-Clearwater, FL
March 2017 to February 2020
• Handle overall daily day to day Accounts of NEMT Healthcare providers for the Sate of Florida and other regional States of the West Coast such as AZ, CA, CO,NM, OR, UT, WA Markets with duties of reviewing current rates,CPT,KPI,OTP Performance metrics and addition review current contracts and new with Transportation Providers to ensure streamline rates are met and competitive for our contracted Health Plans.
• Handle on boarding new providers for new markets to ensure network adequacy for all proper regions and upcoming new contacts AND ensure all FFS, CAPITATIVE and Overall rates meets market average cost and ensure low cost.
• Ensure that Network adequacy is provided for our client members and ensure proper services are met and all completed to their perspective destination such as Dr. Appts, Specialty Clinics, Day Care Pediatric Care Facilities and Adult Day care etc.
• Conduct routine inspections such onsite visits and surprise visits to ensure that all of our Network providers are meeting our standard protocol and requirements with CMS and Federal guidelines. Work with FWA Dept for any discrepancies of payment and fraud.
• Oversee all providers credentialing documents is up to date of licensing check and Company documents and insurance.Help with providers with their issues with billing, payment clearing, review ensure accuracy for a routine Audits with Health Plans that all is correct for trip payments.
• Reviewing, preparing, and evaluating agreements prior to signature to ensure accuracy.
• Fielding inquiries from team leads, client managers, and project managers regarding interpretation of contract terms, contracting and compliance policies, procedures, risks, and contract status.
• Tracking data for reporting and metrics as defined and required by Supervisor, Finance, and the Leadership Team.
• Review Providers portal to ensure their profile is up to date and check for any inaccuracy and fix them when needed. If needed help other depts. to ensure transportation and operations is flowing with minimal issues for our clients and ensure that all Members are confirmed and has Transportation for their scheduled date of service.
• Oversee P & L report and Complaints to ensure budgets and cost are met and all answered complaints are completed in a timely manner to meet our goals within the company and contracted Health Plans.
• Perform health plan provider orientations and conduct ongoing educational outreach with a focus on improving quality and financial outcomes within the provider network. Act as liaison between providers and the health plan to enhance the business relationship.
• Engage providers and educate them on Patient Centered Medical Home initiatives
• Ensure all providers are meeting all quality standards with our MCO & MTO Plans
• Oversee contracts to ensure all accuracy and timeliness are being entered in the database. Review all upcoming expired contracts,credentialing and Federal & State Law licensing are current.
• Provide daily training if need be with ACO COMMAND providers and members with any new or current implementation of policies of benefits.
• 50% - 75% travel to meet and provide peer 2 peer meeting with members or providers for new implementation and improvement of providers scoreboard. Senior Operations Supervisor/Driver Supervisor
Martz Group-Saint Petersburg, FL
April 2012 to January 2017
Martz First Class Motor Coach
• Coordinated schedules and monitor Drivers performance & Monitor Pre/Post Trips inspections
• Compiled and analyzed Drivers D.O.T Logs
• Assisted Safety Director in hiring and training of employees for Driver/Operators
• Planned training programs for new employees
• Maintained business relationships with clients and outside vendors
• Implemented company's policies by providing examples
• Supervised over 40+ driver/operators
• Managed and oversee everyday routines with drivers Pre-trip & Post-Trip inspections.
• Identified and solved issued relating to dispatch
• Assign drivers work and submit Payroll and input drivers assignments on a daily basis.
• Supervise on site events to ensure safety and assist drivers and passengers
• Clarence Cornell School certified for Safety & Compliance
• Reasonable suspicion Supervisory training per D.O.T 382.603
• Review Cost per trip and ensure cost is at reasonable before contract with new clients.
• Meet with new and current clients and provide feedback on our services and ensure we are meeting all company satisfaction with new and current clients. Administrative Support Services/Field Supervisor- PART-TIME ACE HOME CARE LLC-Tampa, FL
August 2004 to November 2016
• Handle customers service such as incoming orders, faxes received and fulfill orders as received.
• Follow-up status of accounts and invoices; making sure orders are made in timely manners and ensure correct quotations of prices issued.
• Reconcile accounts if amounts matches with invoices issued and assist in collections such as invoice and orders are paid in timely manner per-contract of agreement, follow-up outstanding invoices and issue refunds if necessary. Enter orders and invoices and other pertinent information to the computer for file and accuracy.
• Perform observation assessments and evaluations over the road with Patients and Nurses on a daily basis.
• Perform follow up with members to educate any questions they may have with health benefits and policies.
• Handle all credentialing process to onboard nurses and staff. Operations Supervisor
Progressive Waste (WSI)-Clearwater, FL
July 2008 to October 2011
Waste Services Inc.
•Responsible for employee (Drivers/Office Staff) 50 - 70 drivers and staff supervision to include manage productivity to each driver in accordance with regulator agency guidelines, performance review and evaluation, compensation issues, scheduling routes and duties and complaints.
•Organize and scheduled all necessary resources required to accomplish activities and coordinate daily operational needs with Maintenance team.
•Review and audit productivity related to route operations on daily basis and reconcile any discrepancies of drive time, attendance and open tickets.
•Manage check-in processes to ensure all documents are collected by the driver and communication key service, safety, and equipment issues and monitor Pre/Post Trip inspections.
•Evaluate drivers and staff on route and in the office for performance evaluation and observation assessment and coach for improvements.
•Visit customer and customer sites and resolve and issues do to safety or complaints and follow-up on a daily basis.
•Establish and maintain a clean, safe work environment in compliance with safety regulation and OSHA standards.
• Oversee drivers routes and observations on site on a daily basis to ensure Safety and Trash gets picked up in a timely manner.
Fleet Dispatcher (Commercial & Residential)
Republic Services Inc-Tampa, FL
July 2004 to June 2008
Republic Waste Services Inc.
•Responsible for employee (Drivers/Office Staff) 50 - 70 drivers and staff supervision to include manage productivity to each driver in accordance with regulator agency guidelines, performance review and evaluation, compensation issues, scheduling routes and duties and complaints.
•Organize and scheduled all necessary resources required to accomplish activities and coordinate daily operational needs with Maintenance team.
•Review and audit productivity related to route operations on daily basis and reconcile any discrepancies of drive time, attendance and open tickets.
•Manage check-in processes to ensure all documents are collected by the driver and communication key service, safety, and equipment issues and monitor Pre/Post Trip inspections.
•Evaluate drivers and staff on route and in the office for performance evaluation and observation assessment and coach for improvements.
•Visit customer and customer sites and resolve and issues do to safety or complaints and follow-up on a daily basis.
•Establish and maintain a clean, safe work environment in compliance with safety regulation and OSHA standards.
• Oversee drivers routes and observations on site on a daily basis to ensure Safety and Trash gets picked up in a timely manner.
Education
General Studies
St. Petersburg College-Clearwater, FL
February 2003 to May 2006
High school diploma
Hillsborough Community College-Tampa, FL
September 2001 to August 2003
East Bay High School-Gibsonton, FL
April 1995 to June 1999
Skills
• Office 365 (10+ years)
• MS Office (10+ years)
• Transportation (10+ years)
• access
• Managed Care (8 years)
• Microsoft SharePoint
• Excel (10+ years)
• Management (10+ years)
• Microsoft Office (10+ years)
• Scheduling (10+ years)
• time management (10+ years)
• Citrix (8 years)
• Powerpoint (6 years)
• Medical Terminology (4 years)
• Customer Service (10+ years)
• ICD-9
• Contracting
• Word (10+ years)
• Outlook (10+ years)
• Operations (10+ years)
• Networking 10 yrs
• Employee Evaluation
• Supervising (10+ years)
• Router (10+ years)
• Logistics (10+ years)
• ICD-10 (4 years)
• Operating Systems
• Negotiation (8 years)
• Dispatch (10+ years)
• Microsoft Powerpoint
• Grasshopper
• Cisco
• Negotiation
• Microsoft Outlook
• Relationship Management (7 years)
• Contract Negotiation (8 years)
• CPT Coding (6 years)
• Expense Management
• VPN
• As400 (4 years)
• Procurement
• HEDIS (5 years)
Certifications and Licenses
Driver's License
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