Responsible for building and maintaining effective provider relationships with IPA/Medical groups, including their contracted physicians and individual PPO providers. Educating and servicing the designated provider network in the operational and compliance aspects of provider contracts; with specific focus on the Provider Relations components related to Medicare Star, BSC Quality Metrics and the BSC Exclusive Provider Network, Access and Availability, provider satisfaction surveys and Age Sense Sensitivity Workshops. Responsible for facilitating a high volume of physician visits annually. In addition, partnering with internal and external constituents to effectively resolve services issues in a timely manner. Ability to present in a group setting, independently drive issues to resolution and multi-tasking are required. Work closely with the Medicare quality team to educate providers on the CHAPS and HOS metrics and work with the education and communications department and vendors.

Sales in provider development, outreach marketing, grass roots community events, health fairs, presentations and other activities as assigned to support attainment of enrollment and membership goals for all product lines (Healthy Kids, Medi-Cal Managed Care, Medicare MAPD, Cal Medi-Connect Plan and Cover California. Meeting with providers, IPA management, and community-based organizations and meeting with beneficiaries, conducting presentations and in-services. Explaining MAPD (SNP) benefits for Medi-Medi patients to administrative staff and PCP. Ability to engage executive leadership at Independent Physician Associations (IPAs) & medical groups to build alliances, partnerships and relationships focused on membership growth. Responsible in managing 50 CIA agents. Responsible for the assigned geographical area and be aware of its culture and diversity. Have good customer service and communication skills and assist with retention ability to develop strategic business model that is sustainable & yield measurable growth. For a period, I was also the outreach marketing coordinator for the department and was responsible generating leads for potential enrollment. Develop and manage relationships community-based organizations and our provider network.

Managed patient/participant medical plan of care, which included quarterly, semi-annual and annual assessments for 134 patients. Worked closely with the assigned care team which also consist of the Physician, RN, and MA and interdisciplinary teams. Responsible to properly refer patients after an assessment to the right disciplinary departments for further evaluation. To provide advocacy for the participants in relation to their needs and problems with a goal of preventing unnecessary institutionalization to skilled nursing facilities and subacute facility. Assist in finding proper housing to assisted living, board and care. Be able to resolve complex cases such as continuity of care. Assist participants to develop strategies and empower them effectively in addressing or overcoming their problems. Coordinate all needed resources identified in their individual plan of care and work closely with the participants families and conduct family and team conferences. Document all interventions. Assess and identify complex behavioral issues, completing in-home visits. Report suspected abused to proper authorities. Work closely with resources available to all participants from different program and community assistance. Assist with forms, and re-determination for Medi-Cal. Responsible in assisting with grievance reports as needed by the supervisor, attend special meetings and projects and support other duties assigned. Responsible in identifying and assessing new potential patients for the PACE program. Was part of the retention team, safety committee team and member of the Core Value Awards committee. For a period, I was also in the Marketing and Long-Term Care Sales Department as the Health Service Associate. Was the top sales agent for the team and the department. Developed marketing plans with emphasis on senior outreach for enrollment in the Adult Day Health Care Centers and PACE (Program of All-Inclusive Care for the Elderly).

Case Management for the Social Service Office-Senior Housing for over 300 residents. Operate social services and programs for participating seniors, prepare monthly reports, assist with Social Security, Medi-Cal, Medicare, Meals on Wheels, and Housing Authority, in-home visits, and assessments, making necessary evaluations to report any suspected abuse to the proper authorities, such as Adult Protective Services (APS), fraud prevention, and referring residents to Community Based Organizations such as Adult Day Care Centers (now known as CBAST) and community education. Work with health plans and neighboring health clinics and other community resources to visit the senior housing and host presentations and informational booths. Work closely with the management office of the residence for any disputes and advise and collaborate and advocate for the residents as needed.