Gladys Torres Email & Phone Number

Remote

As a Provider Contract Installation Specialist I am responsible for the development, setup, maintenance, and optimization of provider contracts and network configurations to ensure accurate pricing, claims routing, and compliance with contractual obligations. This role involves working with multiple internal teams, analyzing claims data, resolving disputes, and maintaining essential documentation to support business operations.• Manage Provider OPI (specific network assignments) and Employee OPI (network prioritization).• Facilitate claims routing and accommodate customer intent through effective OPI setup.• Implement recycle holds for network, provider file, or reimbursement issues to prevent claim errors.• Review and resolve contract-related CSI tickets (e.g., provider underpayment, pricing discrepancies).• Use tools such as DBeaver to query pricing data and ensure reimbursement accuracy.• Analyze provider and network details, pulling claims data to verify discounts and contract adherence.

California, United States

As a Provider Installation Specialist, I use to manage contract installation and administration, including structure and billing setup, eligibility collection, and database loading. I prepare plan materials, ensure accurate contract processing, and conduct audits to maintain quality standards.• Conducted thorough audits to ensure accuracy, providing targeted feedback and guidance.• Investigated and addressed non-standard requests with analytical problem-solving.• Ensured audit documentation met quality standards, aligned key risks and controls to audit test objectives, and completed work paper documentation.• Evaluated internal workload, provided feedback, and suggested improvements

Handled customer service issues such as eligibility, benefits, claim issues, reimbursement, prior authorizations, appeals, and disputes. Played a key role in supporting the manager to facilitate team skill enhancement, ensuring they met their objectives, assigning projects to team members on time, and providing progress reports by compiling data.• Processed reimbursement requests, tracked expenses accurately, and collaborated for proper documentation and approval.• Provided support to the manager in meetings, including those related to Star HEDIS. • Ranked as the top performer in closing risk Stratification Assessments, greatly improving care management. Maintained record accuracy with precise clinical data entry.• Efficiently managed expense tracking, ensuring precise documentation and approval of financial transactions.

Phoenix, Arizona, United States

Demonstrated excellence in customer service, sales, collections, billing, and account management. Developed training materials, built strong client relationships, handled escalations, managed emails, and proficiently navigated various computer systems.• Assisted in transition from Siebel to MAS operating systems.• Developed job aides, billing training, sales training, and retention training for fellow co-workers.