Contracting for Sharp Health Plan -- Experience working with SOWs for vendors ranging from data services, website services, consultants. Master Service agreements and amendments for vendors including credentialing software, IRS reporting, Auditing. Provider Group Captitated Agreements with DOFRs included. Ancillary, Professional medical, Professional Behavioral Health,, Facility Agreements for individual and group providers as well as large facility agreements relating to Behavioral Health services - fee for service, all inclusive case rates, per diem rates, POC rates. Single case agreements/Letters of Agreement for out of network services. Sharp Health Plan is a HMO but does have Medicare and individual policies as well as POS products. This would include amendments and restated agreements as needed for all types of contracts. Familiar with all laws for State of CA and Federal Laws. Working with the DMHC and their guidelines as well as NCQA requirements. Also, work with Sales on Broker and General Agent Agreements and amendments. Familiar working with NDAs and BAAs as well.

Data and report management. Including running reports for internal review of claims, member data etc. Creating reports while working with EPIC to work on finding any inconsistencies upon initial deployment of the EPIC suite of programs. Worked with outside vendors for Pharmacy/RX, Vision, Cobra vendor on member eligibility files. As well as working with 834, 835 and 837 data sets in EDI transactions. Extensive use of Excel and pivot charts for data.

Worked with Sales Associates and Manager on leads for new PPO product.

Provide executive program support in formulation, development and execution of initiatives and metrics thru data review. Work with Employee Involvement Teams to create new SOPs, streamline communication and development/testing of share point website. Varied responsibilities and conflicting deadlines requiring skill in planning, organizing and directing the work of both myself and others.

 Participate in insurance contract development and review during negotiation process including reports and analysis of data.  Preparation of oral, written and visual communications to disseminate information to all levels of the both internal and external organizations.  Detailed review and formulation of data with use of pivot tables to demonstrate expected results of contract changes.  Subject matter expert for all issues relating to third party health insurance.

 Completion of manager training program, subject matter expert for the department attending both regional and national meetings with executive staff.  Foster relationships between departments thru open communication and monthly updates.  Provided a smooth transition and training for newly hired PR Manager at the end of interim period.

 Managed insurance contract agreements to implement improvements using modeling scenarios to manipulate data.  Rate re-verification review of contract provisions and reimbursement methods with the national office.  Developed strong working relationships with insurance payer representatives thru written and oral communication.

 Analyze and research claim denials to take action thru appeals and retro-authorizations.  Work with internal departments to implement policy improvements to avoid future denials.  Assist in training new DM staff, authored standardized appeal letters, and created SOP (standard operating procedure) for claims follow up.

 Reconciliation and follow up of third party claim payments/explanation of benefit determinations.  Process improvement team for training Standard Operating Procedure, mentor new team members, created training guide templates.  Monitoring denials to find patterns and develop improvements in collections thru follow up to increase collections and improve the revenue cycle.

Responsible for billing outpatient/inpatient claims to third party health insurance, workers comp, tort and legal policies. Using states/local/federal law requirements as a guide. Collaborate with internal departments including Insurance Verification, Coding and Accounts Receivable to resolve both front and back end issues to enhance and streamline the revenue cycle. On the job training of new employees and development of local policies and procedures for the billing department.

Assist patients, physicians and insurance carriers with billing inquiries verbally and in writing.Research/reconcile patient accounts to determine appropriate responsibility and accuracy of charges.Knowledge of state and federal laws relating to insurance coverage, payment mandates and health care coverage requirements (ex: ACA-Affordable Care Act). Assist with implementation and testing/troubleshooting of the electronic billing/payment software thru EPIC Systems for billing/account management.

Respond to medical claim denial appeals, review prior authorization requests and medical records. Problem solving with analytical skills using qualitative and quantitative methods for reviewing issues.Participate in quality improvement initiatives with management to support correct reimbursement. Suggestions/enhancements led to claim processing within 30 days, preauthorization request completion within 14 days.

Knowledge of medical coding guidelines including HCPCS/CPT/ICD9, understand and interpret policy benefits/exclusions and insurance language in general. Accurate and timely adjudication of health insurance claims in accordance with Federal and State laws. Customer service via both written and verbal methods with both internal/external customers, including policy holders/medical providers/insurance agents/underwriters.