Provider Relations Operation Coordinator (Customer Service) - WellCare/TotalMed - Kapolei, HI
(2019-08 - 2019-12)
- Coordinated provider relations representatives visiting providers' office(s) and hospitals to obtain data and providers office staff and hospital administrative staff partners to collect mandated state and federal certificate / license data to ensure processing of contracting/credentialing for health plans; updated, added, completed amendments and requests weekly for ~15 files
- Processed new-providers and/or organization into health plan(s)' database as in-network provider, performed data updates and/or corrections/changes in group for each hospital or organization's delegated list of providers
- Resolved services rendered at a providers' office(s), hospital claims, payment issues as liaison in coordination with provider relations representatives (internal WellCare reps)
- Performed root-cause analysis of delays in provider loading for resolution, including research, analysis, audit, and identifying documentation of contract case notes; obtained required documents for contracts and credentialing
- Provided data-analysis support on claim rejections via data analysis from record creation and documentation to provider in health plans system, to research, audit rejections or ensure a resolution
Medical Management Specialist - Hawaii Medical Service Administration (HMSA) - Kapolei, HI
(2018-11 - 2019-06)
- Developed and organized medical management via operational reports and resource metrics
- Researched, analyzed, audited, and identified data in multiple systems (non-communicating databases) to enable nurses, medical analysts, or health care specialists to review and submit reports to management for action (about 18 reports daily) to enable decisions for authorization
- Analyzed incoming data to determine pre-certification or nurse/analyst review (allowability) for standard allowable procedures or non-procedure request such as Durable Medical Equipment (DME)
Career Transition - Job Search - Hawaii
(2018-07 - 2018-11)
Moved to Hawaii for husband's military deployment and training
Utilization Management Representative II - Anthem - Norfolk, VA
(2014-04 - 2018-07)
- In a high-volume call environment, fielded incoming telephone inquiries from ~50+ clients, ~50+ providers, ~50+ (daily) and in-house departments, including authorization inquiries and case management referrals from member-services' department; identify / coordinate national-member benefits, health-risk assessments, and other services related to Medicaid waivers (program) and long-term services
- Quoted benefits and quality assurance service grids to determine contract/benefit eligibility; submitted outpatient authorization requests ~35+ for providers; referred ~35+ cases requiring further clinical review(s) to nurse reviewer(s)
- Monitored federal, state, and company compliance during implementation of Addiction & Recovery Treatment Services (ARTS)/Commonwealth Coordinated Care Plus (CCC+) programs by assisting authorization submission and contact personnel in Medicare Medicaid Program (MMP), Behavioral Health, and AmeriVantage markets; researched/compared benefits and eligibility to build authorizations for new markets; researched provider relations reps for contract Q&A's
- Researched/analyzed client inpatient/outpatient service needs; collaborated with nurse care managers to ensure members received appropriate resources, including transportation to/from scheduled appointments with health care providers and/or specialists, and supplemental benefits (e.g., gym membership, pest control, home meals)
- Provided formal training for subordinates on navigation through: Facets core administration software platform managing claims, billing, enrollment, and provider networks, workers' compensation, medical case management, WGS, SharePoint customizable platform to manage patient data, streamline workflows, and enhance collaboration with providers, members and other departments
Administration - Sentara Norfolk General Hospital - Virginia
(2014)
Worked in administration for a 530-bed academic medical center prior to 2014
Authorization/Verification Home Infusion Specialist - Home Choice Partners/DaVita - Virginia
(2014)
Medicare/Medicaid Billing Specialist - Fidelis EMS Billing - Virginia
(2014)
