Centene Corporation is a Fortune 500 company that provides high-quality healthcare services to members in all 50 states. Since its founding in 1984, Centene has worked to transform the health of communities, one person at a time. Centene is the largest Medicaid managed care organization in the country and provides a portfolio of services to government sponsored healthcare programs.Collaborate with provider staff to develop and implement operational and clinical process improvements to help providers achieve higher performance.Identify, develop, and establish key performance metrics to measure performance of providers related to their value based contracts.Identify improvement opportunities based on key performance indicators and develop action plans.Develop and provide training and support to provider staffs to assist them in understanding performance metrics and implement operational and clinical improvements.Promote collaboration across provider groups to enable sharing of best practices and performance improvement opportunities.Resolve various system, process or resource issues to address provider feedback and concerns.

Ultimate Health Plans, Inc. (“UHP”) is a fast growing Medicare Advantage health plan with its headquarters located in Spring Hill, Florida. UHP plans provide all the benefits of Original Medicare Parts A and B, plus additional benefits not available with Original Medicare.Responsible for Provider Operations and Network Management oversight of UHP provider relations, network development and provider configuration activities. Ensured adherence to organizational, state and federal regulatory and external accreditation requirements.Managed 7 regional provider relations representatives and network managers.Evaluated employee performance and conveyed constructive feedback to improve skills.Participated in network expansion efforts into 6 new markets, which were approved for network adequacy by CMS.

Increased profitability of assigned accounts by $120 per member per month for over 3,250 Medicare Advantage lives by focusing on risk adjustment, utilization management, and HEDIS improvements.Responsible for business development, marketing strategy, contracting, and credentialing activities of Medicare Advantage primary care centers in a value based care model.Chaired weekly meetings with executive leadership to identify opportunities for improvement, establish milestones, and tailor best practices to individual businesses. Maintained and onboarded a network of IPA primary care centers in a value based care model with Medicare Advantage health plans. Conducted business development, marketing, contracting, and credentialing activities.Assisted management with interviews and hiring of new representatives.

Molina Healthcare is a Fortune 500 company that provides managed care health services under Medicaid and Medicare programs and through the state insurance marketplaces. Its health plan segment serves approximately 4.5 million members (as of September 30, 2017) across 12 states and the Commonwealth of Puerto Rico.Managed all aspects of provider relations for all contracted and prospective providers for all products including Medi-Cal (Medicaid), Medicare, and Covered CA (Marketplace Exchanges/Affordable Care Act).Recruited, developed, and evaluated performance of provider services representatives. Decreased turnover rate from 100% to 0% by selecting candidates for culture fit, utilizing teaching skills to develop effective and efficient new hire orientation, and creating ongoing coaching platforms.Resolved high profile provider claims by effectively maintaining relationships with other departmental managers and bridging communication gaps. Created innovative strategies to increase provider performance and quality ratings, including Healthcare Effectiveness Data and Information Set (HEDIS), by using data to develop a targeted provider visit list. Developed auditing tools and standard operating procedures used to measure compliance to Senate Bill 137 (provider directory accuracy legislation) and timeliness of new provider orientations reported to California Department of Health Care Services.Oversaw provider credentialing and re-credentialing activities to ensure operational excellence and contract requirements.

Responsible for provider network operations in San Diego and Imperial County regions. Averaged 194 provider visits per month, qualifying as a top performer.Identified root cause of incorrect member assignments, provider claim denials, and directories by revising provider data in QNXT and Cactus (data management software applications). Forward thinking project completed prior to provider directory legislation (Senate Bill 137) passed in July 2016.Project managed credentialing process and contract configuration by collaborating with cross functional departments.Planned, executed, and used public speaking skills to facilitate provider meetings and major events: formal provider dinner attended by Molina’s plan president and CEO. Negotiated favorable contracts with event vendors. Played crucial role in implementation of new Molina programs while managing major industry changes: new Molina risk adjustment incentive program (HEP/ACE), new Molina Pay for Performance (P4P) program, Affordable Care Act enhancement payments, new industry program - Covered CA, Healthy Families transition to Medi-Cal, Low Income Health Program (LIHP) transition to Medi-Cal, and new industry program - Cal MediConnect.Conducted provider orientations for primary care physicians, hospitals, specialists, ancillary providers, and IPAs in English and Spanish. Promoted to Supervisor of Provider Services.

Managed network of delegated, capitated, and fee for service contracted providers in primary care, specialty care, ancillary, and long term care for all lines of business. Identified critical area of improvement after an audit during my first year of employment (Q3 2013). Proactively developed organizational systems of provider orientation data for future audit preparedness.Led regional initiative that increased provider portal registration, Electronic Data Interchange (EDI) registration, and Electronic Funds Transfer (EFT) registration in support of departmental goals. Contributed to a 10% increase in EDI from 2012 to 2013.Trained all new hires including Provider Services Representatives II and Provider Services Claim Research & Resolution Representatives.Volunteered to support contracting efforts and conduct new provider orientations for a new Molina market (Imperial County). Promoted to Provider Services Representative II.

Community Health Systems, Inc. is a non-profit health care safety net of five Federally Qualified Health Centers (FQHC) in Southern California. The Fallbrook Family Health Center, a Community Health Systems, Inc. clinic, offers primary care, pediatric, maternal, dental, behavioral health, and optometry services. Highly visible role responsible for grass roots business development, community engagement, and public relations. Managed Facebook content and increased number of followers by 23% in less than one year.Designed and strategically distributed marketing materials written in English and Spanish.Procured new patients by building business relationships with uncommon healthcare partners such as local shops, radio stations, grocery markets, food pantries, and schools. Contributed up to 74% of the total monthly patient encounters. Increased clinic’s service area by expanding outreach efforts to new service areas. Averaged three community outreach events per week (departmental average was three per month). Developed and implemented three successful new programs: iTeen (a teen clinic), Patient Enrichment Series (patient health education), and Staff Enrichment Series (continuing education for staff).Planned, marketed, and executed promotional health events and a major company event: Ribbon Cutting Ceremony.Nominated as Chairperson of the San Diego CAA & Community Partners Coalition.

Supported behavioral health provider with a large caseload, in a public health clinic. Increased efficiency through the use of Excel spreadsheets to better organize patient data prior to the implementation of Electronic Medical Records (EMR).Determined patient eligibility, as per the Mental Health Assessment Assembly Bill (AB-2726) guidelines.Utilized bilingual skills to write patient correspondence in English and Spanish.Attended Individualized Education Program (IEP) meetings for current patients receiving services for autism spectrum disorders, depression, anxiety, and trauma recovery.Selected to represent the clinic at a county healthcare conference, “Bridges out of Poverty”.

Played violin and sang, in Spanish. Notable venues: San Diego Latino Film Festival, Day of the Dead Oceanside Fair, and Old Town Festival.

Worked as part of a team to plan and execute special events for the Cultural Arts & Special Events (CASE) program from the Associated Students of San Diego State University. Events included movie screenings, film festivals, concerts, open mic nights, fashion shows, university lectures, coffee shop music performances, Aztec Nights, GreenFest, and Homecoming.

Played violin and sang, in Spanish. Notable venues: International Mariachi Festival of Guadalajara, Tuscon International Mariachi Conference, Salinas Mariachi Festival, and Calexico Mariachi Festival.