Senior Provider Engagement Specialist - MOLINA HEALTHCARE OF MISSISSIPPI - Ridgeland, MS
(2025-05)
Serve as a primary liaison between Molina Healthcare of Mississippi and participating network providers, supporting effective communication, program implementation, organizational objectives, and regulatory requirements.
- Coordinate provider engagement activities designed to strengthen provider relationships, satisfaction, retention, and participation in healthcare programs and initiatives.
- Collaborate with clinical, quality, operations, claims, and other internal departments to investigate and resolve complex or escalated provider concerns.
- Support the implementation and communication of organizational programs, policies, procedures, and quality improvement initiatives.
- Develop and deliver provider education regarding healthcare programs, operational processes, policies, tools, resources, and performance expectations.
- Monitor provider performance through dashboards, reports, and key performance indicators to identify trends, opportunities, and areas requiring additional support.
- Analyze operational information and provider feedback to assist leadership with strategic planning and program improvement.
- Track provider concerns and facilitate timely follow-up and resolution across appropriate departments.
- Maintain accurate documentation of provider interactions, issues, interventions, and outcomes.
- Promote compliance with organizational policies and applicable state and federal healthcare requirements.
Grievance & Appeals Coordinator - MAGNOLIA HEALTH PLAN - Ridgeland, MS
(2015-01 - 2025-05)
Coordinated the investigation, documentation, processing, and resolution of member and provider grievances and appeals involving claims, quality of care, and quality of service.
- Managed cases according to established state, federal, contractual, and organizational turnaround-time requirements.
- Researched complex cases and collaborated with internal departments to obtain documentation and information necessary for resolution.
- Identified denial, grievance, and service trends and communicated findings to appropriate departments and leadership.
- Maintained knowledge of healthcare regulations, member benefits, member rights and responsibilities, and organizational policies and procedures.
- Reviewed medical records, clinical documentation, detailed bills, claims information, and supporting documentation to determine appropriate next steps and resolution.
- Supported compliance with Medicaid, CHIP, Marketplace, and organizational grievance and appeal requirements.
- Educated members regarding health plan benefits and services for MississippiCAN, Mississippi CHIP, and Ambetter products.
- Served as a resource to members and providers by explaining program requirements, benefits, processes, and available resolution options.
- Maintained comprehensive and accurate case documentation to support regulatory and internal audit requirements.
- Collaborated with clinical, claims, customer service, provider relations, and other operational teams to resolve complex cases.
- Delivered service-focused solutions while maintaining professionalism and sensitivity during challenging member and provider interactions.
Medicare Secondary Payer Recovery Supervisor - CAHABA GOVERNMENT BENEFIT ADMINISTRATORS (GBA) - Ridgeland, MS
(2011-10 - 2014-12)
Supervised and supported a team of approximately 20–30 employees responsible for Medicare Secondary Payer Recovery operations and customer service activities.
- Coordinated daily program operations to ensure workload, quality, productivity, and service-level expectations were achieved.
- Investigated and resolved escalated customer service concerns involving beneficiaries, staff, and other stakeholders.
- Monitored staff performance and provided ongoing coaching, training, counseling, and technical assistance.
- Ensured operational activities were completed within required timelines and in accordance with Centers for Medicare & Medicaid Services (CMS) requirements.
- Managed the submission, review, intervention, and resolution of Medicare appeals, grievances, and complaints.
- Served as a subject matter expert and provided technical guidance regarding program policies, procedures, and complex cases.
- Monitored and audited high-volume customer interactions to identify escalation needs, compliance concerns, and opportunities for improvement.
- Assisted with workload distribution and resource coordination to maintain production and quality standards.
- Ensured adherence to HIPAA privacy requirements and applicable CMS policies and procedures.
- Supported leadership with operational issue identification, staff performance management, and service improvement initiatives.
Medicare Secondary Payer Recovery Supervisor - CNI / MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR (MSPRC) - Ridgeland, MS
(2006-12 - 2011-09)
Supervised daily Medicare Secondary Payer Recovery program activities and supported staff responsible for beneficiary and stakeholder inquiries.
- Coordinated workloads and monitored performance to ensure production, quality, timeliness, and compliance expectations were achieved.
- Assisted staff with complex cases, escalations, appeals, grievances, and customer service concerns.
- Interpreted and applied Medicare program guidelines, CMS requirements, operational policies, and procedures.
- Provided coaching, training, technical guidance, and performance support to staff.
- Investigated escalated issues and collaborated with appropriate stakeholders to facilitate timely resolution.
- Maintained confidentiality and compliance with HIPAA, CMS, and organizational requirements.
- Assisted management with identifying operational trends and opportunities to improve workflow, quality, and service delivery.
