Experience

CenCal Health

• United States
• Insurance
• 100 - 200 Employee

• Sr. Provider Service Representative

  • Sep 2017 - Present

  The primary objective of my position is to lead and facilitate the contracting, communication, and management of provider relationships in support for developing the provider network through contracting negotiations, relationship development, and ongoing service. With direction from the Associate Director of Provider Services. I am responsible for advocating, appealing, recruiting, contracting, educating, maintaining, and improving provider participation and satisfaction.

• Provider Service Representative

  • Aug 2014 - Sep 2017

  •Facilitate provider recruitment, contracting and retention efforts, conduct on and off site visits, provide orientation, ongoing education and training to providers and staff; ensure contract compliance of, and access to the Provider Network for all new and existing programs; keep provider data accurate and up to date •Advocate on behalf of the providers, investigate provider issues, prepare recommendations for resolution, compose responses, and document all communication •Educate… Show more •Facilitate provider recruitment, contracting and retention efforts, conduct on and off site visits, provide orientation, ongoing education and training to providers and staff; ensure contract compliance of, and access to the Provider Network for all new and existing programs; keep provider data accurate and up to date •Advocate on behalf of the providers, investigate provider issues, prepare recommendations for resolution, compose responses, and document all communication •Educate providers: make presentations as required; prepare materials, coordinate meetings, oversee expenditures, and evaluate effectiveness of presentations; assist in preparation of educational, promotional, and presentation materials and publications for providers and the public, and disperse those materials as appropriate; assist in publishing Provider Bulletins •Assist with special projects, including compliance with regulatory responsibilities; make recommendations for improvement of any and all procedures and systems at CenCal Health •When appropriate, represent the Provider Services Department on internal CenCal Health committees; analyze access barriers in relation to the provider network; assist in the creation of new features and functionality for the website, and educate staff and the provider network on all new features •Ensure contract compliance and high-quality standards by assisting providers in all phases of the contract process •Other duties as assigned by the Provider Services Representative Supervisor or Director of Provider Services

• Claims Customer Service Representative

  • Jun 2010 - Aug 2014

  Medical/Vision, Inpatient/LTC, Outpaitent, DME/Hearing and Medical Supplies Intake and respond to all provider telephone inquiries within 24 hours. Log all calls received in the Provider tracking system. Review test Explanation of Benefits (EOB) for accuracy of claims payment, denials and suspends. Conduct meetings with Providers that are experiencing a high volume of denials, that have new billers, or any provider requesting assistance with any type of claim related… Show more Medical/Vision, Inpatient/LTC, Outpaitent, DME/Hearing and Medical Supplies Intake and respond to all provider telephone inquiries within 24 hours. Log all calls received in the Provider tracking system. Review test Explanation of Benefits (EOB) for accuracy of claims payment, denials and suspends. Conduct meetings with Providers that are experiencing a high volume of denials, that have new billers, or any provider requesting assistance with any type of claim related issue. Analyze provider’s claims to assure the most accurate, timely and efficient processes are occurring. Present at Provider Workshops Research and adjudicate higher level claims review. Complete processes and timelines required by AB1455 Claims Settlement Practices and DHCS.



HealthSouth

• Hospitals and Health Care
• 700 & Above Employee

• Medical Biller

  • 2000 - 2009

  •Registering the patient and verifying their insurance coverage •Collecting the information required to create a claim •Working directly with the insurance company, healthcare provider, and patient to get a claim processed and paid •Reviewing and appealing unpaid and denied claims •Handling collections on unpaid accounts •Managing the facility’s Accounts Receivable reports •Answering patients’ billing questions •Registering the patient and verifying their insurance coverage •Collecting the information required to create a claim •Working directly with the insurance company, healthcare provider, and patient to get a claim processed and paid •Reviewing and appealing unpaid and denied claims •Handling collections on unpaid accounts •Managing the facility’s Accounts Receivable reports •Answering patients’ billing questions