Michelle Schlingmann Email & Phone Number

Commerce, California, United States

Responsible for the set up and management of Member Services, Credentialing, Provider Relations, EDI, Encounter workflows, analytic dashboards and Delegation Oversite. Member of the Delegation Oversite Committee and Policy and Procedures Committee. Selected and implemented various platforms, assisted in building website. Received 100% on Credentialing Audit with various payors

Commerce, Ca

Responsible for overall direction of Provider Services and strategic planning, including provider recruitment, relationship development and services, credentialing and contracting, provider quality, compliance and incentive initiatives, and provider reporting, gap analysis of network and data and information management. Using data analytics to identify opportunities for improvement in the areas of access and availability, HEDIS measures, and Encounter data to development provider training, newsletters, health educational materials and score cards to individual providers and groups in order to improve IPA’s overall performance and RAF scores. - Experienced in various Managed Care payment Methodologies, Shared Risk arrangements and risk pools, PCP adjusted RAF, DRG, APR-DRG, Risk Adjustments.- Work Collaboratively across the organization to develop and implement solutions to address operational issues- Establish and maintain strong interpersonal relationships at levels with the organization- Strong team building and leadership skills including continuous training, goal setting and evaluations - Ensure timely implementation of Medicare and Medi-Cal regulatory compliance and effectively communicating the changes to all stakeholders impacted by the change

Ensures acquisition and re-contracting efforts of Participating Provider Groups (PPGs), Ancillary and direct specialist providers to Care1st's provider network. Provides Supervision, training, consulting and oversight to the members of the Contracting Team in conjunction with working collaboratively with the Director and Vice President of Contracting. Key functions and Experience:- Successfully lead and retained a team during a company acquisition, implementation and data migration effort- Worked collaborative with various departments to roll out contracting software and LOA tracking tools. - Successfully rolled out Medicaid and Medicare regulation changes to internal and external stakeholders and Provider groups. - Worked with the Quality and Provider Relations team to proactively review Network adequacy gap, and develop an plan fill the gaps prior to CMS and DHCS submissions deadlines. - Cross network analysis- Took initiative to role out several process improvements within the Contracting Department to streamline work flows and reduce administrative burden and clearly documenting the workflows and desktop procedures. -

Monterey Park, Ca

-Develop/manage contract relationships with MBHOs, Groups, Organizations, and providers that support the Plan’s behavioral health network. - Vendor on boarding and Implementation management - project management- Set up and run meetings with the functional department leads to review new vendor agreements to ensure the contract is set up to meet the needs of each department based on company Policy and Procedures.- Coordinate delegation audits during contract negotiations - work closely with the EDI team to review Eligibility issues - Familiar with 834, 837 files and companion guides- Ensure contracts are administered and implemented accurately.-Assess training needs of provider network and assist in the development of training programs with the behavioral health department; implements and conducts appropriate training programs for providers, staff, and administrators. - Establishing Provider network validation process- Responsible interaction with Providers and escalate recurring or critical issues, such as quality of care or access by new patients-Coordinate and resolve all provider/Organizational issues, concerns and inquiries,

Monterey Park, Ca

Work with internal departments and negotiate Letters of Agreements with non-contracted physicians, hospitals, and ancillary providers. Ensure non-participating providers who are needed in the network are recruited.Specialize in Statewide Contracts.Conduct contract analysis to evaluate cost-effectiveness and need of potential contracts.Assist Manager with training of contracting staff and contract negotiations.Manage contracting efforts through entire procurement process. Ensure contracts are administered and implemented accurately.Assist in Claims issues and ensure timely resolutions to any incorrect denials. Provide outstanding customer service to in-network ancillary providers. Develop a strong partnership with shared risk IPA's when helping to expand a network to ensure quality providers are chosen. Provide guidance and a resources to the Utilization Team. Analyze department needs and develop process improvements and assist in the implementation.

Los Angeles, California Area

Maintains and organizes all files and databases needed to complete the credentialing process for Ancillary Contracts.Update participating payers when changes occur in Ancillary profile.Maintains a comprehensive reference tool that indicates provider billing information and ancillary participationInteracts with Clients and the appropriate Origin functional areas to ensure all issues are addressed and resolved in a timely and appropriate manner to ensure client satisfactionAssist with identifying network gaps, tracking provider recruitment (LOI's) and contracting.Review and analyze issues related to claims, system set up and reimbursement. Ability to identify the root cause of the issue and work in collaboration with other departments to correct.Assist with special projects (such as rate implementation, reimbursement, benefit updates and network expansions.CMS filings for expansion and audits which insures network adequacy.

Cerritos

Work in conjunction with Case Managers to plan, implement, and coordinate members clinical needs.Coordinate and schedule patients for post hospital discharge appointments, submit authorizations for services based on MD/NP Orders using Portal SystemsCoordinate care for patients including: home health referrals, durable medical equipment, medications; home infusion; specialty referrals, psychiatry and psychiatric placement in locked facilities; skilled nursing placement; long term convalescent facilities; coordinating out -patient procedures including: MRI; Paracentesis; Doppler studies; sleep studies; diagnostic imaging; hospice referrals; urgent care; ambulance referrals, Social worker

Cerritos, Ca

Manage patients who have ESRD and require Dialysis. As well as manage the patients that need kidney transplants by helping them go through all their screenings.The goal is to keep them out of the Hospital and help them enjoy life as much as they can while managing their disease.

Business, Management

Education record