Experience

Corizon Health

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Provider Relations



CareCentrix

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

• Network Coordinator

  • Mar 2012 - Jun 2012

  Coordinate provider recruitment efforts by soliciting new providers supply appropriate Information and contracts and answering question and provider concerns . Track and Follow up on credentialing process and maintain status report to network mgmt. . Perform provider orientations . Support on provider contract analysis and negotiation . Provide superior level of service to providers respond to provider issues in timely manner. Coordinate provider recruitment efforts by soliciting new providers supply appropriate Information and contracts and answering question and provider concerns . Track and Follow up on credentialing process and maintain status report to network mgmt. . Perform provider orientations . Support on provider contract analysis and negotiation . Provide superior level of service to providers respond to provider issues in timely manner.



United Health Care Group (NM-Sector) – Optum Health

• Provider Relations Specialist

  • Jan 2010 - Jan 2012

  Responsible for the full range of provider relations and service interaction within Optum Health. . Responsible for assigned territory in NM sector. . Proactively recruit and contract providers – through CAQH. . Conduct site audits/assist on crendentialing process . Educate and train new providers . Assist on claim resolution with providers Provider Development/Contracting; Responsible for all Single Case Agreements – for state of New Mexico and Out of Statemaintain and report on daily basis to CollaborativeResponsible for negotiating rates on contracts Proactively load funding and contracts in system Proactively work with UM dept. on Auths set-up Handle provider Claims inquiries.



Aetna, a CVS Health Company

• United States
• Wellness and Fitness Services
• 700 & Above Employee

• Provider Relations Representative/Network Consultant

  • Jan 2007 - Jan 2009

  Provide network management including onsite support, education and training assistance to contracted physicians, ASC, DME and dental providers for AHCCS Acute, ALTCS, and Responsible for strengthening the development of new contracts while maintaining existing business in accordance with the AHCCCS Medicaid program and MCP requirements. Proactively analyze constituent data and identify trends of denials while conducting claims research team to determine root causes.Visit 25 providers per week and conduct site audits presenting talking points mandated by the health plan.

• Provider Relations

  • Jan 1996 - Jan 2009

• Care Coordinator

  • Jan 2006 - Jan 2007

  Assess and recruitment for disease management.Act as a liaison for nurses. Prove in-service preventative care to contracted providers.



Shaller Anderson/Aetna

• Authorizations Tech

  • Jan 1999 - Jan 2006

  Respond to requests for authorizations of services in accordance with policy and procedure.Independently approve escalated services in accordance with policies and establish criteria.Train new employees in the work flow.Assist providers in discrepancies. Respond to requests for authorizations of services in accordance with policy and procedure.Independently approve escalated services in accordance with policies and establish criteria.Train new employees in the work flow.Assist providers in discrepancies.



Shaller Anderdson /Aetna

• Member Outreach Representative

  • Jan 1996 - Jan 1999

  Assist with Health Fairs and Community Events.Educate Providers at facility in preventative care for members.Provide information and problem resolution to members in regards to benefits and eligibility.Assist members and providers in a timely and professional manner by answering ACD calls.Answer questions and resolve issues based on phone calls and letters, interpreting benefit coverage, eligibility, and process physician changes. Assist with Health Fairs and Community Events.Educate Providers at facility in preventative care for members.Provide information and problem resolution to members in regards to benefits and eligibility.Assist members and providers in a timely and professional manner by answering ACD calls.Answer questions and resolve issues based on phone calls and letters, interpreting benefit coverage, eligibility, and process physician changes.