Experience

Teladoc Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Provider Enrollment Manager

  • Jun 2021 - Present



Tufts Health Plan

• United States
• Insurance
• 700 & Above Employee

• Senior Compliance Specialist

  • Nov 2017 - Present

  Credentialing Compliancr, reporting and monitoring. Credentialing Compliancr, reporting and monitoring.



Masada Inc.

• Grayson, Ga

• Administrative Specialist

  • Jan 2011 - Nov 2016

  Masada Inc, a Youth Development Corporation, for children k4 - 12th grade, providing tutoring, after-school activities, full school curriculum. Masada is the repairer of the breach, meaning whatever may be broken, disrupted, dysfunctional in a childs' life can be made new through God's mighty hand. Masada Inc, a Youth Development Corporation, for children k4 - 12th grade, providing tutoring, after-school activities, full school curriculum. Masada is the repairer of the breach, meaning whatever may be broken, disrupted, dysfunctional in a childs' life can be made new through God's mighty hand.



DentaQuest

• Georgia

• PR Region 3

  • Aug 2012 - Nov 2012

  Georgia are representative, dental providers specializing in preventative dental dare for Government programs. Providing education and training for the providers within the state of Georgia. Georgia are representative, dental providers specializing in preventative dental dare for Government programs. Providing education and training for the providers within the state of Georgia.



HP Enterprise Services

• Tucker, GA

• Written Correspondence/Customer Relations

  • Nov 2010 - Aug 2012

  Explanation of administrative benefits regarding providers and members. Excellent phone and written skills, detailed, documentation and research skills. Explanation of administrative benefits regarding providers and members. Excellent phone and written skills, detailed, documentation and research skills.



Grayson Technical High School

• Substitute Teacher

  • Oct 2010 - Dec 2010

  Manage classroom activities, follow lesson plan as designated by teacher. Any other duties as assigned by administrative staff. Enjoy the students and the day. Manage classroom activities, follow lesson plan as designated by teacher. Any other duties as assigned by administrative staff. Enjoy the students and the day.



Grayston Technical High School

• Volunteer

  • Jul 2010 - Dec 2010

  Administrative duties as assigned for the local technical high school Administrative duties as assigned for the local technical high school



MedVentive/CVO

• Credentialing Specialist

  • Aug 2007 - Feb 2010

  Provided primary source verification for Boston Medical Center Health Net Plan and Tufts Health Plan delegated initial and recredentialing files efficient and accurately, resulting in two "Excellence" NCQA accreditations Adhered to NCQA and state standards to maintain Excellent NCQA accreditation Interacted with various practitioners, office management, and educational institutions to acquire necessary elements to complete credentialing and re-credentialing files Provided reports and queries regarding file status to ensure prompt turnaround Show less



Neighborhood Health Plan

• Relations Manager

  • Aug 2005 - Mar 2007

  Managed staff of 8 in day to day operations, special initiatives as determined by the company Facilitated weekly team meetings and supplied applicable resources to enhance staff performance Coordinated the Letter of Intent process to augment network as company dictated Partnered with internal departments to identify trends and resolve provider issues in a timely fashion Coordinated quarterly Program Manager Forums to address new products and services to contracted network providers Managed Beth Israel Deaconess Medical Center relationship, oversaw administrative and operational data as it pertained to Neighborhood Health Plan Created training materials and trained the Provider Network Department on new QNXT system Show less



Tufts Health Plan

• United States
• Insurance
• 700 & Above Employee

• Compliance Coordinator

  • Aug 2001 - Aug 2005

  Established, maintained and implemented workflows for selected policies and procedures Managed initial and re-credentialing process Served as a resource to address complex issues relative to the Cactus system Ensured compliance with state, federal and regulatory requirements to maintain our NCQA Excellent status Conducted off-site delegation audits Oversaw compliancy and corrective actions when necessary Assisted with departmental process improvements Analyzed various pieces of information including non-responder data Show less



Harvard Pilgrim HealthCare

• Sr. Provider Relations Consultant / Customer Service Team Leader

  • Aug 1995 - Aug 2001

  Acted as primary liaison with large medical entities Managed on-going customer service and maintained key relationships with provider units Collaborated with internal areas for meetings with external clients to resolve outstanding issues Performed physician recruitment for small provider units along with training of new and or developing products Supplied and interpreted quarterly reports to assist provider in improvement of quality, care and administration Educated providers on processes and procedures associated with Harvard Pilgrim Health Care Provided training in large and small forums to update, inform and assist in maneuvering products and information through Harvard Pilgrim Health Care Managed day to day operations of the Medical Group Division call center, staff of 15 Trained new staff and existing staff on updated systems and procedures Multiple systems used daily, Bank Boston Online, Spinning Image, TOPPS, AS400, Word, Excel and Access Adjudicated commercial and Medicare claims and handled supervisory calls Monitored calls and coached staff on customer service etiquette Interpreted claims payment, denials and billing errors for providers Show less