Contract Consultant/Provider Relations

• Aug 2022 - Present

Revenue Cycle/Account Management

• May 2019 - Present

Coordinate the submittal of electronic invoices through third-party vendors and diligently reviews the status of invoices submitted electronically. Proactively monitors clients/matters for new timekeepers and matters for proper system setup and effectively maintains client. Coordinate the submittal of electronic invoices through third-party vendors and diligently reviews the status of invoices submitted electronically. Proactively monitors clients/matters for new timekeepers and matters for proper system setup and effectively maintains client.

Director, Managed Care, Credentialing and Licensing

• May 2020 - Aug 2022

Oversees operation of the Managed Care, Credentialing and Licensing staff. Identifies opportunities and coordinates the outreach/execution/implementation of contracts. Responsible for meeting face to face with payors to obtain preferred provider agreements, negotiate contracts and reimbursement rates. Ensure contract HIPAA and Compliance both internal and external, ensure profitability and that the contracts lie within legal directives of service provision and reimbursement of MSA. Liaison with billing and collection teams for all payors. Ensure all facilities stay current with respectful jurisdictions. Ensure all facilities stay current with all Credentialing task. Show less

Network Development Consultant

• Nov 2019 - May 2020

- Essential HealthCare Solutions, LLC is a national consulting firm and healthcare management company. The core services include building provider networks and healthcare consulting. The team has extensive experience in provider network development, contract negotiations, contract execution, healthcare consulting and management services. Develops strategies and recommendations to refine network, identify gaps, and ensure coordination across the system for a national health plans network contracting. Show less

Revenue Cycle/Credentialing Specialist

• Jul 2019 - May 2020

Project Manager - Long Term Care

• Mar 2019 - May 2019

Manage the daily implementation throughout South Carolina. Assist and coordinate with variety of interdisciplinary teams and/or organizations in urban and rural areas in order to submit Long-Term Care Medicaid assistance applications. Provide quality service through collaboration, respectful communication, maintenance of a professional environment, partnership with those we serve, and anticipation of customer needs in accordance with customer agreements. Quality assurance to minimizes at risk LTC applications and resolve applicant issues immediately and communicates early warning signs of potential issues. Show less

Quality Specialist

• Oct 2016 - Mar 2019

The Specialists are responsible for interpreting and analyzing provided information to support contract compliance, and maintaining professional working relationships with contract staff, program leaders and health care providers. The duties include assisting with development of methodologies and data collection tools and protocol; developing and providing educational materials and programs; assisting with identifying and developing systems and processes to enhance contract requirements; and providing technical expertise based on assessment and contract requirement Show less

Director, Network Management

• Feb 2015 - Sep 2016

Responsible for the establishment of an effective health care delivery system including Hospitals, Primary Care Physicians, Physician Specialists, ancillary Vendors, and all others, with primary focus on contracting and negotiating contract terms. Responsible for providing accurate, relevant data, and reporting from Quality Department related to Care Gap reports and HEDIS measure to the provider community. Manage the operations of all credentialing and provider data management functions for multiple business units ensuring compliance with National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), Center of Medicaid/Medicare Services (CMS) and other regulatory standards. Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to the plan specifications for multiple business units. Oversee the provider setup processes ensuring accurately and timely setup for claims payment, member assignment and directory display. Ensure compliance with NCQA and DHHS credentialing requirements and participate in activities related to plan NCQA accreditation. Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives. Identify process improvement opportunities to decrease cost, improve quality and increase efficiency within the department. Review and update departmental policies and procedures to ensure compliance with NCQA, CMS and other regulatory agencies. Monitor Medicaid and Medicare sanctioning reports to ensure compliance with Health Care Financing Administration (HCFA) requirements regarding prohibition of excluded provider participation Facilitate Credentialing Committee activities and serve on Quality Improvement Committees, when needed. Show less

Consultant Compliance Specialist

• Aug 2014 - Feb 2015

Network development for MMP and training to all network providers. Develop, implement, and perform compliance auditing, monitoring and reporting activities based on established program, policies, and practices to ensure and maintain compliance with federal, state, and local regulatory and contractual requirements. Review and analyze deliverables and data reports to ensure timeliness of submission and identify trends in performance and improvement opportunities. Perform and monitor audits, risk assessments and documentation activities to ensure compliance. Identify, investigate, and resolve compliance issues and develop corrective action plans to mitigate future risks. Design, implement, monitor regulatory documentation and processes to address compliance issues and concerns related to all federal and state regulatory requirements, contract requirements and company standards. Show less

Rural Health Provider Services Coordinator

• Jun 2013 - Aug 2014

Responsible for monitoring, coordinating, and communicating with all state, federal, and CMS Regional Manager relating to Rural Health Clinics Policies. Coordinated CMS enrollment forms for new and revalidating RHCs. Responsible for monitoring, coordinating, and communicating with all state, federal, and CMS Regional Manager relating to Rural Health Clinics Policies. Coordinated CMS enrollment forms for new and revalidating RHCs.

Director, Provider Relations and Contract Negotiation

• Jan 2013 - Jun 2013

Responsible for day-to-day operations of contracting, Network Development, Contractual Compliance, Policy and Procedure development, Credentialing Department, IT/database assessments, and all reporting to SCDHHS related to Network Adequacy for 2 lines of business – Medical Homes Network and Managed Care Organization Plan implementation. Responsible for day-to-day operations of contracting, Network Development, Contractual Compliance, Policy and Procedure development, Credentialing Department, IT/database assessments, and all reporting to SCDHHS related to Network Adequacy for 2 lines of business – Medical Homes Network and Managed Care Organization Plan implementation.

Manager, Provider Relations and Contract Negotiations

• Dec 2011 - Jan 2013

Provides guidance to team members within latitude of established company policies. Recommends changes to policies and establishes procedures that affect group. Works on issues of diverse scope where analysis of situation or data requires evaluation of a variety of factors, including an understanding of current business trends. Follows processes and policies in selecting methods and techniques for obtaining solutions. Acts as advisor to team members in meeting schedules and/or resolving problems. Develops and administers schedules, performance requirements, and may have budget responsibilities. Recruit physician, hospital and ancillary service providers to sign network participation agreements that are in accordance with Corporate, health plan and State guidelines. Ensure that all necessary documentation and information are included. Recruit and develop network for a region and set of provider specialty. Lead assigned recruitments (i.e., physician, hospital and ancillary) and ensure they result in complete and accurate standard contracts that meet objectives Facilitate and oversee to the provider set-up and contract configuration to ensure accurate claims adjudication. Initiate contact and identify/complete geo mapping of potential providers by geographic and specialty needs and update database. Coordinate with internal departments and contracted providers to implement and maintain contract compliance. Show less

Liaison, Government Programs/Network Services Manager

• Jul 2005 - Nov 2011

Responsible for leadership in the development of startup Medical Home Network and spearheading of operational functions in IT, Network Development, and Human Resources, as well as day-to-day operations of Contracting, Network Development, Contractual Compliance, policy and procedure development, Credentialing Department, and reporting SCDHHS related to Network Adequacy. As a MHN model, plan approved in all 46 South Carolina counties. Responsible for leadership in the development of startup Medical Home Network and spearheading of operational functions in IT, Network Development, and Human Resources, as well as day-to-day operations of Contracting, Network Development, Contractual Compliance, policy and procedure development, Credentialing Department, and reporting SCDHHS related to Network Adequacy. As a MHN model, plan approved in all 46 South Carolina counties.

Program Manager

• Jun 1999 - Jul 2005

Actively collaborate and engage Medicaid enrolled healthcare providers from South Carolina, Georgia and North Carolina to resolve, manage, and direct day-to-day operations. Organizing programs and activities in accordance with the mission and goals of SC Department of Health and Human Services. Developing new programs to support the strategic direction and lower cost of SCDHHS. Creating and managing long-term goals. Developing a budget and operating plan for the program. Developing an evaluation method to assess program strengths and identify areas for improvement. Writing program funding proposals to guarantee uninterrupted delivery of services. Meeting with stakeholders to make communication easy and transparent regarding project issues and decisions on services. Producing accurate and timely reporting of program status throughout its life cycle to Director and CMS. Analyzing program risks with new programs. Conduct educational sessions in person and telephonic. Show less

Manager - Finance Dept (Home Health and Hospice)

• Apr 1989 - Jul 1999

Provide leadership to billing staff, work closely with leadership to communicate challenges and solutions related to billing. Ability to accurately processes and bills Medicare, Medicaid, private payer and patient claims in accordance with payer requirements and organization policy. Assists in the preparation of monthly billing and accounts receivable reports. Maintains accurate Commercial, Medicare and Medicaid billing analysis reports. Maintains complete and accurate billing and accounts receivable records. Prepares Medicare, Medicaid, private payer and patient remittances for data entry Alerts appropriate leaders regarding late or missing documents required for billing. Guides the collection of receivables by monitoring accounts receivables, resubmitting bills to overdue accounts, and alerting the billing manager of seriously overdue accounts. Maintains the confidentiality of patient and organization information at all times. Demonstrates positive and professional leadership at all times and work as a conduit for solutions to challenges that arise. Show less