Experience

Mercy Care
• United States
• Hospitals and Health Care
• 1 - 100 Employee
• Network Manager

  • Mar 2021 - Present

Ellingson & Associates, LLC
• Estate Operations Manager

  • Apr 2020 - Present


Meritus AZ

• United States
• Insurance
• 1 - 100 Employee

• Manager, Network Development

  • May 2013 - Apr 2019

  Meritus Start Up and Operations Negotiated contract rates and language proposals, independently solve problems and prioritize work load to meet company deadlines. Analyze network adequacy reports and developed strategies to fill network needs from cost/utilization and competitor standpoints. Participated in provider and hospital JOC meetings. Organize and maintained specialized PMPM-Per member per month incentives to PCP providers. Developed and maintained provider manual, quick reference guide, quarterly newsletter and provider forms. Including working with IT department to develop the provider portal and provider look up tools. Developed and maintained departmental policy and procedures. Self-education and participation with all departments regarding rules and guidelines of CMS Issuers Guidelines, ACA (Affordable Care Act), QHP (Qualified Health Plans), EHB’s (Essential Health Benefits), network access plans, and provider network NCQA (National Committee for Quality Assurance) standards and guidelines. Meritus Wind Down and Receivership Developed, distributed and communicated continual education to providers and third-party administrators regarding the Meritus shut down and receivership orders. Developed and negotiated settlement agreements with hospitals and providers. Developed, maintained and lead the Proof of Claim process. Show less



Abrazo Health Care-Advantage Health Care Management Company, Abrazo Health Care/Phoenix Health Plan

• Provider Services Representative

  • Oct 2012 - May 2013

  • Developed and maintained an effective working relationship and served as the liaison between Abrazo Health Care/Phoenix Health Plan and the physician provider network. • Developed and maintained contractual relationships with providers and ensured the development of the network to meet the needs of the east valley of Maricopa County, vision, ophthalmology, dialysis, and therapy networks. • Provided educational instruction and support to the physicians and their staff thus projecting a positive image and creating good rapport. • Assessed the provider network to ensure the adequacy of the network. • Recruited providers to initiate and develop a contractual relationship. • Provided educational instruction regarding contracts, policies and procedures for providers through in-services, joint operation committees, correspondence and telephone. • Interfaced with all departments to further develop a working relationship with providers and facilitated resolution of issues between physicians and the appropriate internal departments. • Maintained provider and contractual information in a timely and organized manner. • Stay abreast of and ensure compliance with regulatory agencies including AHCCCS and CMS policies and procedures. • Assisted in the development and distribution of provider communications. • Scanned the external local health care market to increase awareness of trends and competition. • Developed and managed special projects as assigned. • Traveled 2-3 days per week in the field. Show less



The University of Arizona Health Network

• Provider Relations Representative

  • Oct 2005 - Oct 2012

  • Served as a liaison between the health plan and the network providers to provide education and support to provider offices on the health plan, CMS, and AHCCCS Policies and Procedures. • Recruited providers and performed analysis of the network from letters of intent received from interested community providers. • Negotiate tier 1 and 2 contracts, letters of agreements, and amendments while ensuring budget guidelines and ongoing CMS and Medicaid requirements of the network are met. • Facilitated and participated in provider education fairs, webinars, monthly JOC’s, and provider in-services with contracted physicians (PCP’s & specialists), hospitals (MIHS, Banner, IASIS, Abrazo, JCL), and ancillary groups (DME, radiology, dialysis) via face to face, written correspondence, and telephone contact. • Developed, wrote, and maintained desktop procedures. • Lead and developed workgroups and pilot programs that continued the success and met the goals of the Provider Relations Department. • Provided leadership to other Provider Relations Representatives. • Interfaced proactively with all health plan internal departments. • Performed other duties and assisted with special projects as assigned that are consistent with the goals and qualifications of the position. • Continued to develop and maintain a positive, strong relationship with Providers and internal departments within the Health Plan with a positive, professional image at all times. Show less



Arizona Health Care Cost Containment System (AHCCCS)-Healthcare Group of Arizona

• Lead Customer Care Specialists

  • Sep 2004 - Oct 2005

  • Provided support to Healthcare Group Operations Manager. • Reviewed, prioritized, and disseminated workload to team. • Development and distribution of Customer Care monthly and annual reports to management and Health Plans. • Communications and Relations with Employer Groups and Network Providers to ensure eligibility, billing issues, member enrollment, member termination, benefit changes, and overall customer care inquiries. • Responded to inquiries that enter the organization by telephone, e-mail, mail, walk-ins, web; provided detailed program information to the public; explained enrollment forms and procedures; provided solution options and complete resolution to general, complex or high-level inquiries/requests. • Prepared and issued/sent appropriate documents to customers; performed outbound, pro-active customer care contacts (verbal and written). • Maintained customer records via a Customer Relationship Management System (Seibel); document all customer contact into system; prepare and enter supporting file documentation into mainframe system (EXTRA). • Conducted analysis, reviewed and researched; and assisted in special projects. Show less