Provider Relations Project Manager - Centene
(2021-08)
- Provide support to the external provider representative to resolve provider data issues
- Research and effectively respond to provider related issues
- Submit provider data entries to resolve provider-related demographic information changes
- Initiate and process provider add, change and termination forms
- Create and maintain spreadsheets used to produce provider directories for multiple products.
- Track, update and audit provider data
- Identify adds, deletes and updates to key provider groups and model contract
- Research and identify any processing inaccuracies in claim payments and route to the appropriate site operations team for claim adjustment
- Provide assistance to providers with website registration
- Facilitate provider education via webinar
- Work with other departments on cross functional tasks and projects
- Facilitate new provider orientations
- Facilitate provider trainings
- Performs other duties as assigned
- Complies with all policies and standards
- Manage multiple provider issues and claim-related cases simultaneously, tracking each item from intake through resolution to prevent delays, missed follow-ups, or stalled outcomes.
- Maintain accurate Salesforce documentation, status updates, audit trails, and reporting to support clean handoffs, readiness reviews, and timely escalation.
- Serve as a primary point of contact for provider status updates, expectation-setting, claims education, and clear, professional communication throughout the resolution process
Remote Quality Review and Audit Analyst - Cigna HealthSpring - Nashville, TN (Remote)
(2015-12 - 2021-06)
- Performed Retrospective claim Audits Conducted medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, and any additional applicable rule set.
- Utilized HHS’ Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC) identified from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year.
- Applied longitudinal thinking to identify all valid and appropriate data elements and opportunities for data capture, through the lens of HHS’ Risk Adjustment.
- Performed various documentation and data audits with identification of gaps and/or inaccuracies in risk adjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission program. Inclusive of Quality Audits for vendor coding partners.
- Collaborated and coordinate with team members and matrix partners to facilitate various aspects of coding and Risk Adjustment education with internal and external partners.
- Conducted medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, and any additional applicable rule set.
Provider Engagement Administrator - Cahaba GBA
(2012-03 - 2015-09)
- Serve as primary contact for providers and act as a liaison between the providers and the health plan
- Triages provider issues as needed for resolution to internal partners
- Receive and effectively respond to external provider related issues
- Investigate, resolve and communicate provider claim issues and changes
- Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics
- Perform provider orientations and ongoing provider education, including writing and updating orientation materials
- Manages Network performance for assigned territory through a consultative/account management approach
- Evaluates provider performance and develops strategic plan to improve performance
- Built complete review files by gathering, organizing, and analyzing medical records, billing documentation, claim forms, coding details, and client policy data to support accurate determinations.
- Used independent judgment to prioritize, triage, escalate, and resolve complex claim issues while maintaining clear written summaries and communication with clients and internal teams.
- Tracked deadlines, response timelines, documentation needs, and follow-up actions to keep claims moving and prevent lapses.
Billing office Manager - Colonial Haven Health & Rehab - Greensboro, Al
(2010-02 - 2012-02)
- Billed and Coded for a 96 bed Facility
- Completed basic office duties
- Weekly Audits of patients’ charts, attended QA and family meetings
- Remained current with all federal, state, local and company policies and procedures
- Managed a team of 15, coordinated work schedules, staff meetings, PTO request, flow and production of the facility, worked with staff to set and meet goals of following policies
- Remained compliant with all rights and confidentially of patients and families’
- Maintained ongoing working relationships with patients and families, employees, and physicians
- Conducted monthly reviews with staff on medical records, followed all HIPAA, OSHA, etc. and provided training as needed.
- Provider networking created and/or reviewed contracts with physicians, insurance companies.
- Obtained Physician/ insurance Pre-certs
- Worked in Microsoft software to keep charts, reminders, letter, spreadsheets, etc.
- Knowledge of medical terminology, medical coding (ICD-9/CPT) (inpatient/outpatient and therapy)
- Maintained accounts and collections, patients’ finances, set and maintain new reimbursement goals
- Admission/discharge plans, attending meetings to comply with company updates
- Insurance billing and coding (VA, Medicare, Medicaid, BCBS, Humana, etc.), assisted with implementation of new and upcoming projects
- Responsible for overall flow of the facility
- Providing excellent customer service
- Monthly Patient and company billing, payroll, assist employees with benefits and other concerns
- Maintained inventory
- Provide community outreach, insurance verification, claims and audits, collections, month-end reports, maintain certifications for physicians, etc.
- Organized medical, billing, insurance, and authorization records to support complete files, accurate reimbursement, and timely claim resolution, including VA-related billing exposure.
