Responsible for the What-if modeling of managed care contracts, the production of monthly portfolio reporting, and performance of ad hoc analyses as assigned by Departmental Director, Manager and Consulting Contract Analyst.• Model managed care contracts through available modeling tools. Maintain service definitions. Organize results data so it is easily analyzed.• Assist in the design, development and implementation of ad hoc reports. Assist in identifying and documenting reporting requirements. Based on data sources identified, extract and manipulate data from databases. Assist with performing acceptance and QA testing as applicable.• Uses data mining tools to assist customers effectively with data requests.• Create Contract Hand-off packets for the Shared Services Center.• Audit monthly data loads of the End of Month data within the Enterprise Data Warehouse (EDW) and the Managed Care/DSS Business Objects Universe.• Produce training and education for outside users in addition to maintaining the education documentation.• Working with senior members of the department, develop a responsive relationship with customers emphasizing timeliness and accuracy.

• Collaborate with internal departments such as Healthcare Services, Product Strategy, and Customer Service. Address issues related to providers and healthcare community within assigned territory (Middle and West Tennessee regions).• Knowledgeable of Medicare STARS program, serving as subject matter expert and assisting with execution of strategy related to quality incentive program.• Support development and management of provider and office staff trainings for capture of STARS and Pay-for-performance codes.• Facilitate interaction between providers and appropriate BCBST departmental staff to troubleshoot quality incentive program provider concerns and/or issues; follow issue through to complete resolution.• Contribute to development and execution of multiple provider campaigns focused on improving clinically oriented HEDIS and HOS scores as well as customer satisfaction oriented CAHPS survey results.• Assist with execution of provider pay for performance programs aimed at aligning goals to achieve high quality care.• Provide onsite education to 130 providers quarterly helping them fully utilize self-service tools to improve their overall STARS rating. Aid in reduction of phone calls by 75% from providers to BCBST regarding quality incentive program and Pay for performance.• Educate providers on changes in HEDIS and Stars measures and their respective reporting requirements, internal initiatives designed to improve collection and reporting of HEDIS supplemental data, and on best practices in delivering high quality care.

• Received 150+ inquiries directly from providers via telephone, email, or visits. Identified root cause and satisfactory resolution.• Employed FACETS and other software products to review necessary claims configuration and adjudication.• Served as subject matter expert on authorization process and answered provider inquiries. Coordinated with providers to resolve authorization issues, maintaining in-depth knowledge of provider contracts, billing guidelines, and ad reimbursement methodologies.• Prepared technical expertise through reporting, data research, and analysis for effective resolution of complex provider inquires.• Oversaw comprehensive knowledge of BCBST/BlueCare processes that impacted provider community.

• Led all care coordination teams in supporting members and their families. Provided team guidance when needed.• Validated plans of care, resolved discrepancies with care coordinator, and initiated services for members.• Spearheaded team of 35 Care Coordinator Assistants, proactively monitoring Healthcare plans administration on marketplace to ensure governmental compliance and avoid penalties.• Trained 15 new hires for ECF and Choices 6–8 week programs with completion of 10 training cycles.• Oversaw performance metrics and completion of intricate tracking logs and reports. Coordinated implementation of ECF Choices program.• Built and maintained positive relationships with providers and referral sources.• Received incoming calls from members and providers for any issues or concerns. Worked closely with support center supervisor to identify problems and propose solutions.

• Facilitated Care Coordinator throughout daily operations ensuring sound decisions, established relationships, and researched and resolved inquiries to ensure completeness and accuracy.• Produced and interpreted reports for missing or expired authorizations, non-members with authorization, and multiple authorizations.• Fielded calls and emails from Care Coordinators, members, and customer service representative. Investigated and punctually resolved issues, dispatching delay correspondence.• Improve HEDIS compliance percentages for Diabetic CHOICES members by 10+% percentile for 3 of the 4 following Diabetic Care Screening measures: HbA1C testing, Nephrology screening, LDL screening, or Eye Exam.• Specialized in project management to resolve provider payment issues, conduct administrative tasks, and manage documentation.• Updated on knowledge about care options and referrals for various health needs.Actively listened and provided strong customer service to all clients.

• Oversaw all aspects of the business office of a 159-bed skilled nursing facility• Handled patient billing, petty cash, patient funds, cash receipts, census report, and consolidated billing invoices• Conducted audits on patient trust accounts-maintained records for Medicaid, private pay, and Medicare residents• Performed background checks on potential employees, administered drug screens, order supplies, issued gas cards, made bank deposits, and updated insurance information• Prepared the manifest, typed documents, inspected vans, transported clients to and from doctor’s appointments