As a project-based consultant, I have worked with a variety of health plans to analyze data, track claims payment/denials trends, resolve provider disputes and identify/relay opportunities for process improvement.

I facilitated the provider application and enrollment process for Medicaid, Medicare, and commercial payers for healthcare providers employed by and contracted with NorthBay Healthcare Group. I prepared and submitted supporting documentation to enroll physicians, specialists and allied health professionals with contracted health plans and government payers using systems like PECOS, PAVE, and CAQH I am responsible for provider data management and maintaining provider records internally and externally using our credentialing database hosted by Verity/CredentialStream. I also act as the liaison between clinic operations, Managed Care, Medical Staffing and Revenue Cycle Leadership.

Responsible for performing intermediate and advanced level daily/monthly quality assurance reviews to ensure accuracy of claims processing end-to-end and other key business processes, using the QNXT and Micro Strategy applications. The essential duties and responsibilities are as follows: •Audit/analyze intermediate and advanced level claims and utilization management transactions•Meet or exceed audit productivity and quality standards to maintain the integrity of the claim sample.•Determine error sources and accurate entry of claim audits into the Quality Database daily.•Facilitate audit meetings and present audit findings to stakeholders•Interpret and understand Medi-Cal contracts and knowledge of state guidelines and regulations.•Ensure the accurate application of managed care agreements as they apply to product lines.•Review error trend reports and participate in rebuttal process for continuous improvement; providing feedback to Quality Assurance and Claims teams.•Provide one-on-one training to Claim and Quality Team associates.•Perform focused audits based on trends identified in daily claims process and submit recommendations/business requirements for process improvement or QNXT reconfiguration.•Attend and actively participate in meetings with all stakeholders in the organization providing information and insight on audit findings and lead, facilitate, and manage cross-functional process improvement initiatives

As the Provider Contract Specialist, I was responsible for support of the Network Operations Contract Manager in the review and monitoring of managed care, ancillary and physician contracts as well as the following:• Negotiate, prepare and assist with execution of provider service agreements and letters of agreements with in and out of network providers• Work collaboratively with credentialing, billing and the Information Systems teams to support special projects• Address internal and external inquiries regarding network expansion activities, reimbursement rates and membership metrics• Requiring impeccable attention to detail, this role ensured that the (IKA) contracting/reimbursement system configuration was accurate and aligned with the terms of the various provider agreements

•Monthly capitation reporting•Determines financial status by comparing and analyzing plans and forecasts with actual results•Improves financial status by analyzing results and variances; identifying trends; recommending actions•Reconciles transactions by comparing and correcting data•Increases productivity by developing automated applications; eliminating duplications; coordinating information requirements.•Provides information to management by assembling and summarizing data; preparing reports; making presentations of findings, analyses, and recommendations.•Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.•Budget Analysis

Responsible for the development, maintenance and coordination of key hospital reimbursement activities. Activities include but are not limited to understanding governmental and managed care payor systems, developing and maintaining payor contract data applications and their downstream results, Accounts Receivable valuation, monthly contractual analysis, reimbursement analysis and payor performance.

I was with Tenet Healthcare for 8 years! I started as a Refunds Specialist, was promoted to an Underpayment Collector, then Plan Specialist, QA Coordinator II and before resigning to relocate back to California, I was a Managed Care Financial Analyst with the following duties/responsibilities: • Contract analysis/audit, loading, modeling, maintenance and amendments utilizing the MedAssets Contract Management system • Managed Care contract implementation activities with Contract Negotiators• Research and identify contract discrepancies and communicate with Medical Economics Market Management• Prepare impact reports corresponding with contract profile updates, annual Medicare updates and other factors• Responsible for providing education and recommend solutions to resolve issues surrounding contract terms interpretation and implementation• Model/analyze proposals, ensuring that the modeled terms of the contract accurately reflect the written proposal