Billie Johnson Email & Phone Number

United States

• Account Delivery Manager (ADM) responsible for the delivery of operational services within a MMIS account, cost and resource management, maintaining client relationship, driving improvement, and identifying cost savings and efficiencies.• Partners with the Account General Manager (AGM) and Account Delivery Leader (ADL) on overall account management, maintaining Service Level Agreements (SLA) and the successful delivery of the client contract requirements.• Successful oversight and delivery in multiple operational areas (Claims Data Entry and Resolution, Member and Provider Call Center, Member Enrollment, Provider Enrollment, Provider Field, Finance, Clinical, Quality, Training and Mailroom).• Interacts with the client on operational services within the MMIS account.• Reports out on KPI compliance at a minimum of a monthly basis internally and externally to client.• Manages people and non-people leaders’, individuals and team performance and goals.• Manages several operational area(s) or team(s) of company employees with well-defined, limited scope, including directing daily work activities/priorities, people recruitment and development, cost management, and direction setting within the area of responsibility.• Ensure operational excellence by establishing key metrics and ensuring team goals and contractual commitments are met or exceeded.• Supports and conducts meetings with account leaders to assess compliance with SLAs.• Generally, sets work activities of teams and projects of teams providing service delivery to solve various business systems and application needs.• Responsible for coordinating with other accounts and teams, i.e., process improvement, robotic process automation team, best practice and standards.• Responsible for managing vendor and client relationships.• Reports on performance and quality measures• Authorizes when to escalate and resolve implementation and operational issues to meet contract expectations.

United States

• Implementation, set up, manage, and direct the daily activities of the North America Provider Enrollment and Provider Data Setup/Management division with a revenue of $9.8M annually for 100+ associates and 8 leaders.• Provide leadership and guidance to the Operations team and monitor, evaluate, improve, and maintain the performance of direct reports by establishing goals and providing regular performance feedback and coaching.• Engages, leads, and drives the results of Business Process Outsourcing (BPO) resources in support of the various operations processes.• Responsible for improving efficiency and reducing costs using Lean Six Sigma principles.• Supervise staff from shared departments to ensure the day-to-day running of the PDM business.• Regularly evaluate the efficiency of business procedures according to organizational objectives and apply improvements.• Develop a standardized framework to document and maintain Standard Operation Procedures (SOP) for operational processes.• Acts as a resource for developing solutions to processing related issues by interacting with other key leaders and departments.• Review financial information and adjust operational budgets to promote profitability and maximize account margins.• Manage external relationships/agreements and project delivery.• Inventory/production and quality management to promote compliance with Service Level Agreements.• Build relationships within other departments and shared services to ensure company-wide operational compliance.

Columbus, Ohio

• Responsible for all practitioner, hospital, and ancillary contracts loaded into the system of truth to ensure no downstream impact (claims, provider directory, consumer barriers, etc.).• Managed credentialing, provider data setup/management, and network escalations staff of 15+ associates and 3 leaders.• Oversight of credentialing (delegated and non-delegated), privileging, bylaws, policy development, medical staff committee, and peer review support.• Ensure all credentialing processes are followed per NCQA guidelines.• Manage all pre-credentialing activities with providers, such as site visits, credentialing, and orientation to contractual requirements.• Responsible for oversight of network escalations from Contracting, Credentialing, Claims, Utilization Management, and Provider Contact Center.• Understanding of healthcare operations from end-to-end to support key providers in the HP network.• Responsible for the setup applicable to the contract specifications. Including, fee-for-service pricing, inpatient, outpatient, ambulatory, and emergency room.• Assist with conducting claims testing to ensure no downstream impact.• Represent the credentialing, PDM, and network escalations team by participating in internal meetings, external client/vendor meetings, and working sessions.• Assisted provider network with complex UB-04/CMS1500 claim submissions, denials and appeals.• Experience with CPT Codes, HCPCS, Revenue Codes, Modifiers, Places of Service, Dates of Service, Qualifiers.• Troubleshoot provider set-ups in support of claims processing operations.• Clarified boundaries and channels of decision-making throughout the organization to solve problems quickly and with clarity.• Participated in project management meetings and implementation for growth expansion across multiple states.• Participated in all internal compliance audits and regulatory reviews.

Columbus, Ohio Area

• Responsible for the oversight of 7+ Provider Relations Managers, including workflows, training, and communication standards.• Initiate and execute standard physician, ancillary, and facility amendments, contracts, and Statement of Work.• Prepare and analyze data to evaluate the need for additional health plan providers.• Ensure that provider contracts are executed correctly to ensure accurate provider credentialing and setup.• Manage all pre-contract activities with providers, such as site visits, credentialing, and orientation to contractual requirements.• Oversight for the development and retention of the organization’s network provider partners within each service area.• Participated in project management meetings and implementation for growth expansion across multiple states.• Collaborate with internal teams to ensure no network gaps that prevent Member barriers.• Interact with physicians, ancillaries, and facilities to ensure a smooth implementation of the new contract.• Oversight of onboarding providers into the health plan network regarding contract requirements, credentialing, provider setup/management, and submission of claims. • Build, manage, and sustain relationships with the members of the provider network.• Monitor data, present reports, and encourage ongoing provider engagement through regularly scheduled touch bases and meetings.• Ensure provider contracts comply with all regulatory compliance requirements and are in alignment with requirements.• Responsible for compliance with network adequacy standards.

Columbus, Ohio

• Train, develop and manage 12+ Provider Service Representatives.• Provide support to all operational areas, such as Contracting, Credentialing, Claims, Utilization Management, and Member Service staff.• Assisted provider network with complex UB-04/CMS1500 claim submissions, denials and appeals.• Experience with CPT Codes, HCPCS, Revenue Codes, Modifiers, Places of Service, Dates of Service, Qualifiers.• Knowledge of medications and medical services requiring prior authorizations.• Understanding of healthcare operations from end-to-end to support key providers in the HP network.• Participated in weekly provider grievance meetings, monitoring staff for Key Performance Metrics (ASA, AHT, Abandon Rate, etc.)• Oversight of provider escalations for credentialing, contracting, and claims.• Increased Average Speed to Answer from 3:45 to <30 seconds in 6 months.• Increased Average Handle Time from 45 minutes to < 6 minutes in 6 months.• Decreased Abandon Rate from 30% to <5% within 6 months.

Columbus, Ohio Area

• Designed and implemented a new training program for the Member and Provider Service Center to increase the company’s productivity by teaching new skills and knowledge to current and new hires.• Write lesson plans and host training classes on various topics for the service center and operational areas.• Provided support to local trainers to assist consumers and providers (physicians, pharmacies, facilities), regarding eligibility, medical, dental, and pharmacy benefits/drugs, claims, grievance and appeals, and prior authorizations.• Maintained Key Performance Indicators, such as engagement scores, training throughput, and 360-degree feedback.

United States

• Train, develop, and coach 5-25 new employees monthly across the United States.• Provided support to local trainers who handled inquiries regarding consumers and providers (physicians, pharmacies, facilities), eligibility, medical, dental, and pharmacy benefits/drugs, claims, grievance and appeals, and prior authorizations.• Maintained Key Performance Indicators, such as engagement scores, training throughput, and 360-degree feedback.

Columbus, Ohio Area

• Train, develop, and audit new hires for the member and provider service area for the Ohio Managed Care Plan.• Monitor the quality of the company’s parameters for services, including, member and provider eligibility, medical and dental benefits, pharmacy drugs and authorizations, claims, grievances, and appeals.

Columbus, Ohio Area

Member Services, Provider Services and Appeals & Grievances month end reporting for the grievance and appeal files, weekly transportation grievance reports, and Specialist/PCP access reports. The reports are downloaded via electronic transmission and exported from a database and transmitted to ODJFS on a monthly basis. End of month bar and chart graphing via Microsoft PowerPoint for the Member Service Team. Complete daily backlog for Appeals and Grievances, audits of call coding to ensure calls are coded correctly by the Member Service Representatives, and provide feedback of calls incorrectly tracked. Review Medicaid claims for billing issues. Investigate grievances and appeals on behalf of members and providers for denied services. Comply with all Ohio Department of Job and Family Services (ODJFS) deadlines to ensure compliance. Research and respond to questions, problems, correspondence, and provide the best solutions available to the members and providers when concerns arise.