Experience

Allergy Partners PLLC
• United States
• Hospitals and Health Care
• 100 - 200 Employee
• Manager, Payer Relations

  • Oct 2020 - Present


Allergy Partners P.A.

• United States
• Medical Practice

• Director of Managed Care

  • Apr 2013 - Oct 2019

  Oversees and participates in the development, negotiation, implementation, monitoring and management of all Allergy Partners managed care agreements. Oversees Credentialing Department. Evaluates and recommends financial parameters and reimbursement methodologies. Implements new managed care programs in conjunction with executive staff. Keeps staff and practices apprised of developments in the managed care marketplace. Directs and participates in financial analysis of revenue projections based on contractual rates with payors, adverse trends, terms and appropriate recommendations or conclusions. Analyze and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements. Provide recommendations/feedback to executive staff regarding financial and/or operational issues with payors. Facilitates promotion of programs to provider networks in conjunction with corporate staff and practices nationwide. Develop and audit payor fee schedules based on negotiated reimbursement rates by contract and/or product line. Coordinate the communication of fee schedules to practices. Maintain and distribute participation information by payor by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated by Allergy Partners. Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance initiatives. Management and direction of Managed Care Department, to include Credentialing Department, including personnel management, setting of departmental policies, goals and objectives, and preparation, administration and control of departmental budget. Allergy Partners network of 55 practices spans across 23 states, with over 100 physicians and 900+ employees.



Coventry Health Care

• Contract Implementation Specialist

  • Jan 2008 - Apr 2013

  Responsible for the processing of primary care physician and specialist physician contracts into multiple systems. Vital input and monitoring is essential in order to produce correct claims payment, provider directories, and various reports to ensure compliance with federal and state regulations. Fee schedule development, physician and ancillary, to include capitation. Investigate any issues/set-up problems with the appropriate departments. Act as internal contact for all departments impacted by the assigned provider contract. Facilitate ongoing internal meetings to share and distribute contract information and to review the action plans and answer questions. Point person for pended claims/provider issues for the state of Florida, responsible for tracking and trending issues and following up with staff in markets throughout Florida for timely resolution of critical issues.  Major Accomplishment: Maintain many database records accurately and proficiently in order to produce reports for tracking and trending, presenting findings/recommendations to management



CompBenefits

• Insurance
• 1 - 100 Employee

• Senior Managed Care Coordinator

  • Oct 2006 - Dec 2007

  Responsible for ensuring all aspects of account/payor relations. Key responsibilities included: marketing/branding to all referral sources, new plan implementations, resolving claims related issues, site visits, identifying and correcting provider network issues, providing provider network, integrity of eligibility data, and capitation payment calculations. Provided sales and marketing support to the CEO and COO. Monitored revenues and profitability of the plans.  Major Accomplishment: Recognized for excellent marketing and client relation skills.



WellCare

• Taiwan
• Medical Equipment Manufacturing
• 1 - 100 Employee

• Network Development Specialist

  • Feb 2006 - Oct 2006

  Responsible for analyzing and developing statewide and national ancillary contracts. Identified network gaps based on demographic research to execute marketing activities to target market in order to complete sale and execute contracts. Contract negotiation utilizing Medicare/Medicaid allowables in addition to carve-out rates and capitation arrangements. Managed provider inquiries: identified potential claims trends and followed up with provider and internal departments to ensure that identified problems have been resolved. Assisted with market expansion initiatives. Required daily use of considerable discretion, judgment and independent problem solving.  Major Accomplishment: Provided exceptional provider relations in maintaining relationships with contracted providers.



CareCentrix

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

• Reimbursement Analyst

  • Oct 1999 - Feb 2006

  Liaison to Cigna, our largest contract. Responsible for root cause analyst of payment barriers. Communicated claims issues to upper level management at both companies. Responsible for enhancing client relations via travel to Cigna claim sites nationally. Gathered and organized account-related information and provided input on key customer opportunities. Key responsibility included reduction of outstanding A/R. Responsible for high profile reports/projects at both companies. Responsibilities also included Quality Assurance for CareCentrix Billing Department. Worked extensively with the following programs; AS400, Access, Microsoft Word, and Excel.  Major Accomplishment: As a result of my work, there was a reduction of 30 million dollars and 28 day reduction of Days Sales Outstanding (DSO)



MedPartners

• United States
• Hospitals and Health Care
• 200 - 300 Employee

• Provider Relations Manager

  • Jan 1998 - Jan 1999

  Responsible for operations and development of Provider Relations Department. Responsibilities included contracting/development and education of various health care provider in a network of counties in the Tampa Bay region. Developed contract pricing and implemented service standard to include educational programs. Developed annual departmental budget. Liaison for physician and ancillary providers.  Identified, managed and participated in various events in order to market and recruit providers to build exposure and increase provider network.



Beechstreet Corporation

• Wellness and Fitness Services
• 1 - 100 Employee

• Managed Care Specialist

  • Jan 1996 - Jan 1998

  Responsible for contracting and selling our services with providers in order to build a complete provider network to include workers compensation line of business. Responsible for territory in Florida, Tennessee, Alabama, and Mississippi. Duties included: Marketing, Contract Interpretation and Execution, Provider Service, and Education.  Major Accomplishment: Consistently recognized as top producer and for providing superior client relations. Responsible for contracting and selling our services with providers in order to build a complete provider network to include workers compensation line of business. Responsible for territory in Florida, Tennessee, Alabama, and Mississippi. Duties included: Marketing, Contract Interpretation and Execution, Provider Service, and Education.  Major Accomplishment: Consistently recognized as top producer and for providing superior client relations.



Humana

• Brazil
• Professional Training and Coaching

• Provider Relations Representative

  • Jan 1994 - Jan 1996

  Responsible for recruitment and retention of Primary Care Physicians (PCP) / Specialist to provider network. Conducted on-going evaluation of network, education and acted as a liaison between internal departments and providers office.

• IMS Network Coordinator

  • Jan 1993 - Jan 1994

  Responsible for marketing and training of software which allowed for electronic submission of claims, referrals, and eligibility data from PCP/Specialist to Humana.

• Trainer

  • Jan 1992 - Jan 1993

  Assessment, design, development, marketing and implementation of education programs, formulation of new procedures to improve service, ensuring continuity among departments. Responsible for training staff on all system application and interpersonal skill workshops.

• Senior Account Service Representative

  • Jan 1991 - Jan 1992

  Responsible for the City of St. Petersburg account in addition to providing system application training to the large case (excess of 1000 insured) Account Service Representatives. Performed supervisory duties, assisted with peer appraisals, and monitored service reports. Responsible for evaluating current policy, update when appropriate. Established standards for service calls to clients which resulted in the highest client satisfaction surveys and retention of commercial group via renewal of business to date.

• Account Service Representative

  • Jan 1990 - Jan 1991

  Responsible for approximately 80 accounts. Coordinated and implement enrollment presentation, conducted on-going question and answer sessions with commercial member groups, and trained and educated Benefits Managers on the administration of the plan.

• Senior Customer Service Representative

  • Jan 1989 - Jan 1990

  Researched and resolved customer inquires. Responsible for maintaining high levels of customer satisfaction for Hillsborough County School Board members, the largest commercial account in the Tampa market. Claims Processor, Jacksonville, 1989 Received recognition from Service Assurance for maintaining the highest quality/lowest error rate (1.2%) in unit. Successfully completed medical terminology course by Dean Vaughn.



United States Air Force

• United States
• Defense and Space Manufacturing
• 700 & Above Employee

• Financial Manager

  • Jan 1985 - Jan 1989

  Responsible for maintaining Government Contract Accounts Payable and Receivable in accordance with compliance standards.  Major Accomplishments: o Airman of the Quarter, American Society of Military Comptroller - Committee Chairman, 1988-89 o Medal of Accommodation for Superior Performance, 1986-1989. o Honorable Discharge Responsible for maintaining Government Contract Accounts Payable and Receivable in accordance with compliance standards.  Major Accomplishments: o Airman of the Quarter, American Society of Military Comptroller - Committee Chairman, 1988-89 o Medal of Accommodation for Superior Performance, 1986-1989. o Honorable Discharge