Provider Network Consultant, Provider Dispute Resolution, Physician Ad

Alexika L Tucker 562-***-****

*** * ******* ****** 562-***-****

San Pedro, CA 90731 **********@*****.***

Professional Objective: Obtain a position that enables me to utilize my educational and clinical skills, preferably in a direct outcome-based program that engenders healthy living and enhances the quality of life for individuals.

HIGHLIGHTS: SKILLS AND ABILITIES

• Excellent analytical skills, problem solving ability and strong critical thinking skills

• Skilled in design, implementation, data collection, analysis and presentation of results

• Experienced and proficient as a supervisor and staff trainer

• Exceptional oral, written and interpersonal skills

• Extensive knowledge of the healthcare industry including; claims adjudication, provider dispute resolution, CPT, ICD-9 and HCPC coding, procedures and guidelines

• Strong working knowledge of MMC Chapters 2, 3 & 4, PCUG and PDBM

• Experienced in planning, leading and facilitating teams to a common vision and developing strategies and plans to accomplish objective

PROFESSIONAL EXPERIENCE

12/2011 – PRESENT: HUMANA, Irvine, CA

Provider Network Consultant

Responsible for developing and maintaining positive working relationships with participating Independent Practice

Association (IPA) physician groups by conducting on-site visits, communicating administrative policies and procedures, regulatory requirements and facilitating the resolution of provider issues.

• Coordinated and conducted provider trainings including the customization/development of informational and educational reference materials relevant to assigned IPAs to continuously improve the knowledge and effectiveness of the provider network

• Conducted on-site IPAs visits to review service related issues

• Responsible for facilitating outreach strategies in line with organizational goals and demonstrated the ability to implement them in accordance to the IPA group’s unique needs

• Facilitated JOC Meetings with contracted IPAs and was responsible for the management of issue resolution arising from meetings

• Coordinated with internal departments to resolve provider and IPA group issues by actively participating in meetings to enforce policy and procedures and implement necessary operational changes

• Analyzed the provider network for improved access and geographic coverage for physician, ancillary and hospital providers

• Researched escalated claim disputes and conducted analysis to resolve root cause issues

• Managed provider demographic information changes (TIN numbers, service address) and facilitated high-level provider directory audits to ensure accuracy

• Oriented new providers joining the network

• Worked closely, in assigned markets with the Marketing/Sales Department staff and primary care physician practices to achieve/exceed membership growth projections within guidelines

11/2010 – 02/2011: MOLINA HEALTHCARE, Long Beach, CA

Manager, Medicare Membership Accounting

Managed and provided direct oversight of the Membership Accounting Team. Assisted in the development of internal desktop processes, policies and procedures and SOPs. Maintained appropriate departmental reporting statistics and quality improvement practices.

• Managed direct reporting staff consisting of 10 full-time and 8 temporary employees

• Developed project plans which identified key issues, approaches, performance metrics and required resources to ensure timely deliverables and successful completion of projects

• Oversight of Integrigard submissions, TRR processing, claims resolution processes and Acumen reporting

• Promoted and developed communication between lines of business and technical staff

• Provided substantive data on financial reconciliation and performance metrics as input into daily dashboard reports

• Facilitated the preparation and analysis of monthly enrollment/disenrollment reports by state/health plan

• Facilitated revision of Membership Accounting Dept. P&Ps specifically; LIS/BAE, 4Rx, E&D Letter Generation, Enrollment Intake and Validation Process and Transmission of Enrollments to CMS and Enrollment Mechanisms

• Responsible for daily/weekly/monthly production reports

• Provided subject matter expertise in membership reconciliation and enrollment issues

• Completed yearly performance evaluations and goal projections utilizing Scorecards for direct reporting staff

• Contributed to BRD in regards to reconfiguration of QNXT database requirements to support MARx redesign

• Facilitated the documentation/reporting of substantive data required for internal CMS regulatory audit

09/2010 – 11/2010: UNITED HEALTH GROUP, Cypress, CA

Senior Physician Advocate/Provider Dispute Resolution, Los Angeles County

Senior point of contact for submission/resolution of provider disputes. Responsible for developing and fostering relationships with key providers to enhance UHG’s presence within the provider community.

• Managed, developed and maintained positive business relationships with new/existing providers to secure strong partnerships and maintain revenue of products and services within assigned geographic territory

• Responsible for timely and accurate responses to provider inquiries regarding claims, benefits and complex issues that included medical or payment policy, contract fee schedule and provider appeals

• Provided trend analysis/review of errors, outputs/solutions to Operations Leadership using information from provider disputes

• Facilitated the development, review and revision of organizational and departmental policies, procedures and process flows to ensure compliance with relevant regulatory and organizational guidelines

• Prepared narratives, graphs and flowcharts to be utilized for departmental presentations

• Developed, implemented and maintained operational processes to meet provider services goals, provider contract requirements, compliance with industry standards and Government mandates

• Active participation in escalated claims issues by facilitating on-site meetings with providers/practice managers and coordinating research of claims issues internally to ensure resolution

• Coordinated and conducted education activities with the objective to modify chronic, inefficient claim filing patterns or behaviors

01/2008 – 09/2009: UNITED HEALTH GROUP, Cypress, CA

Provider/Member Relations Advocate/Claims Resolution

Served as a provider/member relations advocate to resolve complex claims issues and ensure provider/member retention. Facilitated provider education in regards to claims dispute and billing and authorization procedures.

• Worked as critical integration point between providers and all functional areas until issues were successfully resolved

• Created and maintained relationships across the organization to leverage support for MAPD products including regulatory, benefit administration, claims and utilization management

• Tracked, maintained and documented product for benefit related issues and decisions, identifying risks and escalating as appropriate

• Handled complex claims, adjudication, reconsideration and enrollment/disenrollment issues

• Acted as information resource for staff members and served as subject matter expert to call center

• Facilitated pilot project to track/trend misrouted calls resulting in decrease of 80% volume within 2 months of start-up

• Contributed to the achievement of department unit productivity and quality goals

• Provided detailed reports to upper management in regards to provider/member needs, perception and improvement opportunities

01/2007 – 05/2007: WINDSTONE BEHAVIORAL HEALTH, Costa Mesa, CA

Supervisor/Project Director, Behavioral Health Wellness Pilot Program

Supervised and provided direct oversight of behavioral health wellness program consisting of 10 licensed clinicians and 15 full-time employees

• Responsible for creating and implementing departmental staffing module

• Compiled data for monthly behavioral risk adjustment initiative reports

• Created P&P manual and operational/programmatic metrics report

• Formalized organizational charts

• Implemented and maintained effective employee personnel and progress report system

• Facilitated staff meetings and in-service seminars to ensure regulatory compliance

• Responsible for recruitment and training of clinical and support staff

• Formalized documentation for internal CMS regulatory audit

• Proactively identified process improvement opportunities and project initiatives that enhanced organizational effectiveness

• Demonstrated and promoted teamwork to ensure member continuity of care and maintain positive work environment

05/2003 – 01/2007: UNITED BEHAVIORAL HEALTH, Van Nuys, CA

Member/Provider Relations Advocate/Western Region Claims Specialist

Highly visible position responsible for Member/Provider dispute resolution and coordination of comprehensive and culturally sensitive therapeutic behavioral health services for Orange County Medicaid members

• Worked directly with Orange County Mental Health Agencies: Cal-Optima/Healthy Families, to provide appropriate referrals and coordinate care

• Developed and maintained positive working relationships with participating physicians groups (PPGs) and mental health facilities by conducting periodic on-site visits, communicating administrative policies and procedures, regulatory requirements and facilitating the resolution of provider issues

• Conducted pertinent research to evaluate, respond and reconcile incoming provider disputes accurately, timely and in accordance with established regulatory guidelines inclusive of appropriate review of claims and prior claims payment history

• Conducted provider education including the customization/development of information reference materials specific to assigned PPGs/mental health facilities to continuously improve knowledge and effectiveness of the provider network

• Actively participated in internal meetings to implement necessary operational changes

• Contributed to company-wide claims improvement work group responsible for identifying and streamlining claims workaround policies to increase efficiency and accuracy

06/1996 – 05/2003: LOS ALAMITOS UNIFIED SCHOOL DISTRICT, Los Alamitos, CA

Discrete Trial Training Program Facilitator

Responsible for developing, coordinating and implementing the District’s Autism program and related services in classroom setting for developmentally disabled children ages 3-8 years

• Responsible for organizing and facilitating individual and group lesson planning

• Program data collection and analysis

• Individualized student progress assessment and program modification

• Intensive behavior modification and one-on-one Discrete Trial Training Therapy

• Utilization of various communication system and evidence based service training/research programs i.e. PECS, ASL and TEACCH

• Community Based Instruction (CBI)

• Individualized staff training and progress assessment

06/1996 – 05/2003: GREATER ANAHEIM SELPA, Anaheim, CA

In-home Autism program facilitator

02/1992 – 04/1994: INNOVATIVE DIALYSIS, Long Beach, CA

Junior Accounts Manager

Accounts supervision of dialysis management company (20 centers nationwide)

• Accounts payable/receivable

• Payroll processing

• Assisted with facility contracting

• Assisted with Pharmacy Benefit Management (PBM)

• Account spreadsheet management

• Claims research and adjudication

• Month-end reconciliation reporting

• Annual fiscal reporting

11/1989 – 01/1992: LOS ANGELES COUNTY MUSEUM OF ART, Los Angeles, CA

Membership Accounting Representative and Art Rental Gallery apprentice

06/1998 – Present: AUTISM RESOURCE AND RESPITE CENTER (ARRC), San Pedro, CA

In-Home Behavior Modification Program Facilitator

Self Employed

1989 – Present: Classical Piano Instructor

Self Employed

EDUCATION

Psychology, National University Costa Mesa, CA

TECHNICAL

Microsoft Office Suite: Word, Outlook, Access, Excel, Power Point

QNXT, CRM, COSMOS, NICE, RIMS, INGENIX, UNET, FACETS, GPS, ORS, NDB, FRM, O/C Medi-Cal IRIS

Typing (80 wpm)

COMPANY SPONSORED TRAINING:

Building Physician Relationships, Whitewater Group, Chicago, IL 09/2010

Advanced Microsoft Office, Element K, Long Beach, CA 11/2010

Effective Management, Conflict Resolution, Long Beach, CA 01/2011

Contact this candidate