Responsible for managing the day-to-day activities of the Network Management department and staff. Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication. This position is also responsible for all provider network recruiting and contracting management activities. Ensures that the department and staff remain current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. Ensures department achieves annual goals and objectives.

Managing 20-27 associates - FT, PT, Temp. Under the guidance of leadership, the Manager provides for the utilization of resources to deliver quality intake services to our customers and to contribute to the achievement of the organizations financial objectives. Primarily responsible for the direct oversight of the day to day operations of the Patient Access Department, supporting the registration activities of patients, financial counseling, scheduling and all revenue functions.Demonstrate through plans and actions that there is a consistent standard of excellence to which all work is to conform.Ensures a positive customer service atmosphere in all interactions. Manage ongoing training programs for staff development. Participate on committees as assigned. Responsible for budget reconciliation. Maintain work standards, KPI's and productivity for all activities under the Managers control. Communicate regularly and effectively with subordinates and superiors regarding the status of the business operation. Complete or manage the completion of all necessary human resource documentation, adhering to all human resources expectations for associates, including compliance, related responsibilities, continuing education requirements, recognition of staff/team accomplishments etc. Insure that all policies, procedures, job descriptions, reports and other documentation are properly followed. Carry out special assignments or projects as assigned. Thorough knowledge of third-party payer billing requirements, reimbursement practices and regulatory requirements in both a provider and facility setting. Committed to the core values of the organization who possesses the ability to influence others commitment to those values and practices in the workplace. Effectively manage multiple processes and priorities while meeting customer expectations. Demonstrate strong interpersonal and communication skills, both written and oral, and the ability to effectively problem solve.

Building, nurturing and maintaining positive working relationships between Plan and its contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations. Maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues. Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products. Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to including language, terms and reimbursement requirements. Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance. Uses data to develop and implement methods to improve relationship. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues. A functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department. Maintains and delivers accurate, timely activity and metric reports as required. Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

Supervises the day-to-day activities of the UM Intake or other non-exempt or non-clinical staff/team to ensure that all processes are completed and deadlines are met. Maintains knowledge of phone/service level requirements for compliance with governing bodies. Oversight of team's responsibilities could include: processing urgent scanning/mailing requests, document/record archival, document/record retrieval, interaction with the State's Medicaid Agency, database data entry, database reporting, daily monitoring of telephone lines for aberrancy, call wait times, 'bumping', aux work, etc. Provides technical assistance and coaching to staff in a prompt and ongoing basis to ensure accuracy and completion of work according to regulatory guidelines, company policies, procedures, and process standards. Identifies the need for and develops policies and procedures, and training and education plans to assure that Intake or other pertinent staff process standards are clearly documented, and meet/support organizational goals. Maintains a current knowledge base of Intake or other appropriate staff processes and trains/mentors staff. Familiarity with multiple types of criteria. Works collaboratively with Utilization Management Supervisors, Managers, and Directors to identify and resolve work flow issues and obstacles to efficient departmental and individual performance. Maintains current knowledge of all Medical Affairs initiatives, attends assigned meetings and actively communicates with departmental representatives Intake Care Connector/pertinent staff work duties and participates in the development of Policy & Procedures, Standard Operation Processes, Training development/presentations to direct reports and other departments. May utilize work force management systems to effectively monitor the processing of inbound calls/contacts. Responsible for preparing reports and conducting analysis of Intake or pertinent staff productivity/attainment of goals.

Assisting the supervisor in the daily operation of the assigned UM area by training and mentoring new and existing associates.Participate in workflow development, ongoing education, and implementation.Adjusted DME workload with applicable productively and timeliness standards, remains knowledgeable in all workflows and timeliness requirements for all disciplines within the UM area. Manage staff time off requests, daily census, distributes assignments as necessary, assists with reporting requirements, and other duties as assigned. Provide coverage when the supervisor is unavailable.Perform quality audits per policy for new and existing associates as needed.Functions as a department resource for questions on processes and serves as a role model for staff. Review UM reports and provide feedback to the associates on the team as well as supervisor/manager.Review of pended, approved other than requested, and denial letters that are sent out to members and providers to ensure using mandated 4th grade reading level language. Performs duties of a DME Specialist as needed based upon workload needs.Participate in a committee to help standardized the look of documents and other resources across multiple lines of businesses.Participate in a committee to help standardized the look of documents and other resourcesacross multiple lines of businesses.

Responsible for creating, clinical review, and determination notification to vendors,physicians, and members via written and verbal communication. Verified that information in the computer system was up-to- date and accurate. Updated departmental standard operating procedures and database to accurately reflectthe current practices through participation in the Communication Advisory Committee. Assigned to be DME trainer for new hires, July 2015. Assigned as a JIVA Super User in August 2015, assisting trainers in ensuring staff stay ontrack; understand the new system, and how the workflow or processes will be managed.

Worked with Behavior Health Rehabilitation Services (BHRS) and Family Based program.Weekly payroll auditing, HIPAA auditing, other compliance auditing, and update EXCEL spreadsheets as needed.Quarterly client chart audits for company policy compliance.Developed authorization tracking spreadsheet to aid BHRS Administrator to ensure submission of re-authorization is timely.Create and manage motivational staff contests, created employee board for recognition of birthdays, anniversaries, life events, achievements, important program updates, and other program information.Redesigned crisis information binder for Family Based Counselors on call.Conducted new client intakes for both BHRS & Family Based programs to ensure all required paperwork is completed and obtaining information from outside sources.Manage Psychologist evaluation scheduling book.

Building and reviewing authorizations for all Health America members, including employees that were received by phone, fax, or online submission site.June 2008 became Durable Medical Equipment (DME) team co-leader.Monitored the amount of faxes being done by other team members.Provided feedback to department manager on number of faxes being done, ability to keep up with faxes, and where help is required.Created DME grid that was placed on a company-wide site.September 2008 took on all Direct Provider requests, WebMD requests, Gold Card requests, and Concurrent Review Faxes for Inpatient Admissions.Trained new employees on the floor.

Registration of patients coming into the hospital for Inpatient stays, Outpatient services.Verifying all demographic information to be valid and correct.Visiting members on floors to insure information is processed properly.March 2005 promoted to Associate II, Insurance verification.Verified effective dates benefit info to include co-payments, deductibles, out of pocket percentage or amounts, and authorization requirements.In summer 2006, took over verifying all outpatient procedures for authorization requirements and benefit for Hershey Outpatient Surgery Center.