Coordinated training sessions for providers, ensuring proper understanding of policies and procedures. Increased efficiency by implementing automated processes for routine tasks related to provider relations management. Played a key role in resolving complex billing issues between providers and payers. Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties. Analyzed claims data to identify trends and provide recommendations for cost-saving initiatives. Completed in-depth investigations into issues pertaining to discipline and grievance management and recommended strategies. Monitored provider performance metrics, ensuring consistent delivery of quality patient care. Maintained up-to-date knowledge of industry regulations, updating policies as needed to ensure compliance. Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities. Provided support during audits, ensuring accurate records were maintained for all providers in the network. Supported organizational growth through active participation in strategic planning discussions focused on expanding the provider network. Developed, reviewed and prepared provider education material, increasing efficiencies in processes. Researched and resolved disputes, billing discrepancies, and claims efficiently to maintain customer satisfaction, boosting satisfaction ratings. Learned and adapted quickly to new technology and software applications. Used strong analytical and problem-solving skills to develop effective solutions for challenging situations. Conducted regular site visits to evaluate provider performance and compliance with contractual obligations. Collaborated with internal departments to resolve provider disputes in a timely manner.

Supports and coordinates day-to-day compliance activities and projects as assigned Assist with audits and coordinating audits (PERM, DOAA, and Benefits Testing); implementing a corrective action plan- CSRs implementation, policies, provider education, etc.; Federal and state legislation implementation and tracking, state plan amendment updates, and procurement assistance Assists with the subsequent development and implementation of policies, Advance Planning Documents and audit responses Coordinates, develops, and assists with systems integrations from a regulatory compliance and contracts perspective Responsible for keeping knowledge current and monitoring changes to federal, state, and local laws/ regulations to ensure compliance by maintaining professional affiliations and participating in various professional activities Communicates with the appropriate members of the Team on a regular basis to ensure compliance with regulatory agencies on applicable areas that relate to their specific departments Reviews the state and federal Office of Inspector General's (OIG) annual and semiannual work plan for relevance to DCH Regularly reviews any regular communication from the OIG, CMS, and audits and makes appropriate recommendations regarding systems Coordinates initiatives and special projects as assigned by Medicaid Chief or her designee. Analyzed data to identify root causes of problems and recommend corrective actions. Identified and managed service risks within company, recommending best practice enhancements and guidelines updates. Generated ad-hoc reports to evaluate specific business requirements. Implemented successful change management initiatives to improve overall organizational performance. Monitored customized reports, summarizing and presenting data in visually appealing format.

Maintain contractual records and all documentation for all state-wide vendor contracts Coordinates contractual payment of contracts for transportation and facilities services for state agencies Performs PeopleSoft requisition entries, manages contracts, associated purchase orders, invoices, renewals and all other related activities Manages and performs the entry of requisitions for human service contracts; gathers required documentation and ensures process is complete through execution Initiates, enters, manages, and processes payments for Operational Support Services (OSS) contracts Provides training, performs research, and assists as needed to ensure OSS contracts are appropriately managed. Spearheaded training sessions for new hires, increasing their understanding of company contracting procedures and guidelines. Ensured timely execution of contracts by closely monitoring deadlines and coordinating efforts with internal teams. Managed high-value contracts with a keen eye for detail, identifying discrepancies and inaccuracies before finalization. Addressed contract disputes and provided advice and guidance to resolve issues. Enhanced client relationships by providing exceptional support during the contract negotiation process. Developed training materials to unify contract management processes and procedures. Assisted in the development of standard operating procedures, improving overall efficiency within the Contract Administration department. Assessed risks inherent in contract changes and potential impacts, informing management in detail of concerns to avoid liabilities.

Serves as the point of contact for new vendors and/or established vendors, and GVRA/VR staff Initiate negotiation of provider/vendor contracts, service agreements (services, terms, and pricing) Adheres to department operating routines, including policy and procedures, communication and customer service standards Conduct Annual reviews and random site visits of service providers Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities. Reduced grievances and arbitration needs by educating frontline managers on techniques for enhancing interactions between labor and leadership. Conducted regular site visits to evaluate provider performance and compliance with contractual obligations. Contributed to and enhanced audit processes to maximize quality management standards. Streamlined provider onboarding process, reducing time to complete required documentation. Provided support during audits, ensuring accurate records were maintained for all providers in the network. Increased provider satisfaction scores 70% by collecting and credentialing demographic updates, investigating claims and inquiries and overseeing network integrity. Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.

Conducts site visits to service providers to provides education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and review HEDIS information Monitors and supports providers using utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve and maintain regions Ensures contract SLA's are met, such as meeting with PCP's and Specialists on a monthly, quarterly, or annual basis to address provider panels, after hour's availability and EMR meaningful use Records and resolves all provider and member complaints and inquiries initiated by local, State and Federal regulatory agencies, as well as governmental contracted entities into company tracking system Participated in cross-functional teams tasked with improving overall performance metrics within the organization’s Provider Relations department. Developed comprehensive training materials and program for new Provider Relations Representatives, facilitating a smooth transition into their roles. Organized and participated in provider workshops, seminars, and meetings to foster ongoing engagement with network partners. Contributed to and enhanced audit processes to maximize quality management standards. Analyzed data trends to identify opportunities for improvements within the provider network and implement targeted strategies accordingly. Collaborated with internal departments to resolve complex provider issues, maintaining positive relationships and open communication channels. Served as a liaison between healthcare organizations and insurance companies to ensure seamless communication regarding claims processing and payment matters. Reduced claim disputes by effectively communicating policy changes and updates to providers.