Gary Smiley Email & Phone Number

Burlingame, California, Us

Duties/Responsibilities Leads the following departments: (1) Provider Network Development team... focusing on growing a robust sustainable network of providers to support existing employer groups and their employees while growing the network for upcoming launches. (2) Continued Coverage team...focusing on recruiting providers so that new members joining the network will have continuity of care with their existing providers while enhancing the overall network. (3) Prescriber network team...focusing on recruiting providers for medication management services. Ensuring wellness and readiness for the overall Network.Fosters community and interdepartmental cohesion across multiple departments and stakeholders from clinical quality, provider success, customer success and partnerships teams. Intentionally and authentically developing trusting and collaborative relationships at all levels, and building long-term partnerships to ensure network-wide success.Collaborates with department leaders to ensure operational success across Lyra Health.Created a cohesive team with a culture of cross-departmental collaboration.Cultivated and built relationships across different teams at multiple senior levels, internally and externallyWorks with direct reports on performance management activities such as performance reviews and development discussionsOversees all projects and assignments within Engagement scope, reporting out on strengths, wins, and areas of opportunityEnsures compliance with relevant quality standards and SLA's Engages in professional development activities (e.g., leadership and DEIB trainings)Dedicates time to mentoring employees

Burlingame, California, Us

Independently plan and execute daily strategy, schedules and recruitment approaches.Clinical interviewing and recruitment of behavioral health doctors and providers Complete and maintain recruitment tracking reports.Facilitate credentialing intakes.Work on and complete special projects as assigned.Understand & review Network Adequacy reporting results that will drive recruitment activity for gapsReview and understand market analysis to strategically negotiate fees and administrative protocols.Identify opportunities for process improvement and streamlining.Collaborate with colleagues to promote cross-departmental alignment with business objectives and organizational goals.

Leads territory network development and contract management activities for a growing and complex managed behavioral health care organization for the Tricare contract under the Department of Defense. Network development, contracting, and rate negotiations for assigned territory. Physician and facility recruitmentNegotiate rates and contract terms with currently contracted and new providers, around Beacon’s need for services, draft provider services agreements, oversee the resolution of language changes and secure executed contracts with providers for rehab, detox, Intensive inpatient and partial outpatient opioid treatment programs.Develop recruitment plans and ensure rates negotiated are within established guidelines.In conjunction with internal and external stakeholders, secure executed agreements with identified out of network providers for inclusion in the Health Net network.Perform reimbursement analysis on providers that are outside of the targeted rate schedule or performance standards and develop strategies for cost reductions, member needs and increasing quality.Ensure that Contract Language is in compliance with plan agreements and within all state and federal regulatory and NCQA standards.Strategize with other members of the management team and client/plan to ensure access and availability of providers meets current standards

Sunnyvale, California, Us

Manages key enterprise and physician relationships.Responding to customer service inquiries. Compiling customer service information and recommendations, incorporates these to strategic plans to meet customer service objectives. Preparing /completing action plans, implements production, productivity, quality and customer-service standards, resolves problems, completes audits, identifies customer service trends, determines system improvements and implements changeDetermining customer service requirements by maintaining contact with customers; conducts surveys, forms focus groups; bench-marking best practices; analyzing information and applications related to consumer genomicsImproving customer service quality results by evaluating and customizing processes; establishes and communicates service metrics; monitors and analyzes results; implementing changes. Identify opportunities to increase client engagement and subscription levels. Ensure relevant and timely feedback into product development and future road-map requirements Prospect for potential new clients and turn this into increased business.Cold call as appropriate within your market or geographic area to ensure a robust pipeline of opportunities. Meet potential clients by growing, maintaining, and leveraging your network.Identify potential clients, and the decision makers within the client organization.Research and build relationships with new clients.Set up meetings between client decision makers and company’s practice leaders/Principals.Plan approaches and pitches. Work with team to develop proposals that speaks to the client’s needs, concerns, and objectives.Participate in pricing the solution/service.Identify common new business prospects and cross-sell integrated search and affiliate proposition. Building and executing a performance evaluation and development framework that promotes continuous improvement and learning.Identifying Business Development opportunities. Salesforce savy

Alameda, California, Us

Progressive, strategic Provider and Public Relations Representative with a proven reputation for building valuable relationships with the contracted Network of Physicians and Hospitals. Network Management experience that solves business challenges and drives results. Expert proficiency in the following areas: Multi-level understanding of Medicare, Medi-Cal and Commercial insurance Products and these products relate directly to the health plan and provider.Skilled at massaging complex provider issues, aligning goals with strategy and empowering integrated (creative and technical) Very personable, can-do leadership style; poised under pressure Superior consultative and communications skills Strategic efforts to enhance physician network, growth, and retention Provider/vendor negotiationsServing as the principal point person for the South East Bay Network. Responsible for overarching connection of health plan with provider, nurturing relationships while handling complex provider contract and claims issues, providing training and education in line with best practices for DHMC,DHCS, and CMS. Providing timely training per Alliance and state requirements and orientations for providers and their office staffs for new providers, upon request from an office, or as needed to introduce new programs or new policies and procedures. Fostering and maintaining proactive positive relations throughout the provider network by communicating with provider offices through face-to-face visits, letters, telephone calls, faxes or emails for the purposes of promoting the Alliance, sharing data and information about the physician’s practice. Recruiting both new providers for participation in the Alliance network and existing providers for new lines of business and/or projects.

Alameda, California, Us

Handle escalated member and provider concerns with the dual goal of ensuring satisfaction and retention. Work in conjunction with the Provider Services and Member Services Departments to resolve problem situations in claims, authorizations and eligibility.Make decisions within department guidelines and policies. Accurately interpret and communicate member benefits.Assist in provider and member education regarding Alameda Alliance for Health policies and procedures. Education of providers in regards to Authorization/Utilization procedures.Monitor and review authorization/utilization process and resultant documentation on a continuous basis for quality and accuracy. Receive, prioritize and prepare referral authorization request including inpatient stays, ER visits, newborn new member profiles, notice of action correspondence, CCS data entry for review as received by mail, fax, electronic media and phone.Run daily reports to monitor authorizations on hold status, hospital inpatient stays for outlier days, and denial status.Respond to and interpret Alameda Alliance for Health’s protocol and guidelines for authorizations, screening, authorizing and finalizing requests to be approved within established guidelines/protocols.Receive and process disputed claims, related to an authorization.Drafting and creation of complicated medical approval, denial, deferral, and modification letters in accordance with Managed Medicare and Medi-Cal guidelines and Alameda Alliance policy and procedure.Participation in Utilization Management and Case Management concurrent review.

Insurance verification, patient intake, providing explanations of clients’ insurance policy, co pay’s and deductibles. Coordination of services and equipment delivery with related vendors, clients, and referrals. Obtains necessary clinical and related documentation for insurance and billing purposes. In-house training of customer service staff of company policy and procedures. Performance of onsite and offsite demonstration of new equipment with contracted providers. Purchasing of equipment, project orders and quotes for DME equipment. Supervision of staff and participation in reviews of Customer Service Reps.

Us

Written letters of Medical necessity. Technical assessment of clients’ needs with clinical staff. In service training of staff and clinical clients as it applies to power mobility items. Maintained constant working relations with doctors and occupational therapist. Management of warranty and technical repair issues of equipment. Maintain quality management documents, case files, and correspondence in an organized, confidential, and secure manner

Liberal Arts

Education record