•Generate, review, refine, and facilitate execution of complex client contracts. •Ensure that contracts meet all compliance regulations, internal policies, and technical requirements. •Manage the contract lifecycle from new contract requests, contract approvals, contract maintenance, and contract termination. •Maintain contractual records and documentation for all clients and projects for accuracy. •Establish and maintain strong business relationships with internal and external stakeholders to effectively manage contract inquires, issues, and disputes. •Analyze significant and/or unique contract requirements, assist with processing contract redlines, implement, develop and identify new contract policy and processes.•Provide guidance to internal and external stakeholders on both routine and special projects and objectives relating to contract activity. •Convert contract documentation into technical specifications.

•Perform full audit cycle, evaluate internal controls including corporate governance processes, risk management and control management over operations' effectiveness.•High accuracy rate and compliance with applicable legal requirements and policy and procedures serving as the foundation of the SOC 1&2 controls and compliance.•Review client workbooks for accuracy against statement of work, collect, analyze and summarize information.•Adaptability and proficiency in internal leading industry software, support ongoing process and system development especially in times of evolving government program changes. •Stay current on industry trends as it relates to Class of Trade assignments as well as with managed care and pharmacy benefit managers. •Collaborate with and support team members, contribute to a positive working environment by building solid relationships. •Work with data tools SQL, MS Excel, Tableau and with large data sets.

•Problem solving and analysis related to loss and expense management in the total loss department. •Review documentation to comply with internal quality and process standards as well as adhere to each state assigned processes. •Manage sales support staff, provide direction, support, motivation and prepare for state licensing exams. •Processed weekly payroll, managed incoming payments and oversaw daily deposits. •Responsible for resolving problems, identifying and analyzing trends, ensuring customer retention. •Personalized sales and service for book of business and new clients for auto, home, life and health insurance.

•Managed the admission/discharge information post-notification working with hospitals and clinical teams.•Managed requests for services providing information on available network services, manage the referrals process and census roles.•Plan, prioritize, organize and complete established objectives. Extract data to better help members receive medical or clinical services.•Reviewed all member charts prior to a physician appointment and create alerts/trigger to highlight STARS opportunities for the provider.•Assisted members in navigating their network of Providers by assisting with follow-up and Specialist appointments as needed.•Assisted with Program Eligibility verifications.•Performed Data collection, Data Entry and Quality monitoring activities.•Documented case information completely, accurately, and in a timely manner.•Demonstrated sensitivity to issues and show proactive behavior in addressing customer needs.•Provided ongoing support and education to team members.

•Responsible for assisting in development and implementing education, training and learning needs for end-users of various Information Systems initiatives•Assisted in the planned redesign of work flow & processes to optimize development of education and training in the clinical system capabilities to achieve critical objectives for improved patient safety and care delivery efficiency•Participated in the education and training related to the Mountain States Health Alliance information systems applications to ensure education and training represented best-practice, evidence-based, patient centered care knowledge, and met regulatory & user requirements•Worked collaboratively with clinicians serving on application project teams, and accountable for assisting with development and implementation of education and training in synch with project timelines•Worked collaboratively with other project members while actively participating in day-to-day planning and operations. Duties included monitoring project work plans that focus on clinical education and training content, working closely with other project team members to monitor individual progress and job performance, resolving (or escalating) issues, and coordinating activities and priorities with users, vendors and consultants•Participated in the development, education, training and implementation of the super user and core trainer roles for unit-specific support and for new application roll-out education and training.•Demonstrated sensitivity and understanding of the diverse cultural backgrounds of patients and caregivers•Performed continuous quality/performance improvement of healthcare systems through data collection, as well as, interpreting/evaluating the data and planning actions.

• Managed the medical audits requested by Recovery Audit Contractors (RAC), CMS, Medicaid, and other third party payers for the MSHA hospital facilities• Oversaw and implemented the auditing process• Ensured medical records and appeal documentation was submitted within the required timeframes• Established to meet Corporate objectives• Responsible for logging all accounts • Requested for audit by RAC and/or CMS into the Revenue Integrity Compass system and following those accounts through the audit process• Interacted with regulatory bodies as appropriate to ensure compliance• Responsible for producing reports from the RIC system and communicating the results of these reports to appropriate MSHA management• Collaborated with the Utilization and Recovery Departments, the Central Billing Office, HIM/Medical Records, Coding, Case Management, Finance, external parties contracted to assist with appeals management, and the external auditing agencies

• Assisted in the developing and implementing the education, training and learning needs for end-users of various Information Systems initiatives• Responsible completion of practitioner applications and locums for participation in managed care plans• Completed and Maintained Practitioner Re-Credentialing Applications• Adhered to NCQA standards, Maintained strict confidentiality• Worked closely with the Central Billing Office (CBO) to resolve any problems that might affect payment of claims• Worked closely with office managers in order to obtain practitioner signatures and specific information necessary• Maintained Coalition for Affordable Quality Health Insurance (CAQH) practitioner information

• Responsible for assisting in the developing and implementing the education, training and learning needs for end-users of various Information Systems initiatives• Oversaw the Refunds Department for MSMG physician offices and MSHA Hospital facilities• Processed Insurance & Patient refunds for MSMG Physicians Sites and 14 Hospitals • Posted patient and insurance payments• Provided information to implement Refund Process throughout MSMG Physician Offices to staff.• Responsible for TennCare/Medicaid Physician & Hospital accounts, handling eobs, pending reports, secondary claims, e-mails, phone calls• Handled all Workman’s Comp claims for BRMMC physician’s offices• Handled all Veteran’s Administration claims for BRMMC physician’s offices• Requested medical records from physician’s offices in regards to W/C and VA claims• Processed claims using the Misys/Medic software, SMS, HMS and Paragon• Worked claims per pending reports and assigned or “worked” accordingly• Communicated with Insurance Companies as follow up for underpayments or overpayments

•Responsible to the Clinical Director for the day-to-day business management of the Student Health Clinic at East Tennessee State University•Supervised office staff and student workers•Coordinated with providers and nursing staff to ensure efficient clinic operations•Coordinated office staff scheduling•Participated in the development of and maintaining updates and implementing policies and procedures as well as a new database that was used campus wide (Banner)•Ensured that end-of day functions were completed by office staff•Ensured clinic adherence to university policies and procedures•Inventory control; Processed manual invoices and checked for discrepancies, mail distribution; overseeing clinic maintenance

•Communicated with the major third-party payers including Medicare and Medicaid along with Blue Cross/Blue Shield, John Deere, Cigna and other large insurance companies.•Processed billable medical charges, patient billing and collections using the Medisoft medical software program•Performed insurance follow-up and denial management •Oversaw office audits with Wellmont Health Systems and received a 100 % rating•Maintained Physician’s credentialing information with Insurance Companies that the physician participated with •Maintained patient medical records and submitted copies to interested parties when requested•Scheduled patient appointments and surgeries at area hospitals and surgery centers, and handled all referrals

• Responsible for sales, quoting and customer service for a Multi-line Insurance office• Worked closely with customers to obtain personal information for applications for all lines of insurance policies • Balanced all daily incoming payments and deposits• Trained incoming office staff and prepared them for taking state insurance license exams • Interpreted accident reports and processed small claims• Oversaw building maintenance and inventory control