Experience

Plan de Salud Menonita

• Puerto Rico
• Insurance
• 1 - 100 Employee

• Delegation Oversight Auditor

  • Dec 2020 - Present



MOLINA HEALTHCARE DE PUERTO RICO

• SAN JUAN PR

• PMG & Provider Contract Specialist

  • Mar 2017 - Dec 2020

  Reporting to the Provider Engagement Team Manager served as liaison between the PMG administration and the different entity working units: Contracting, Providers, PNO, PAU, A & G, Pharmacy and Financial. Operate in Subject Matter Expert capacity to support Primary Medical Groups Administrations and their providers under de Government Medical Plan. Hold ownership of physician credentialing/medical licenses renewals contract service. Identified expired documents and insurance to ensure compliance with strict company, healthcare and government standards. · Actively participated in the planning and development of MHPR Expansion Project by contracting new PMG and re- contracting existing PMG and providers. · Developed presentations according to specific PMG requirements according to the new PLAN VITAL with 168k beneficiary’s contract's dispositions and regulations. · Challenged to establish formally the credentialing area, processed 95% of 1300 providers. Show less



MSO of Puerto Rico, Inc.

• Hospitals and Health Care
• 100 - 200 Employee

• Primary Medical Group Advisor

  • Mar 2015 - Feb 2017

  Commissioned by Regional Executive Director to structure and execute tiered strategic plans to streamline operations, maximize PMG services and incorporate advanced technologies to ensure compliance with ASES & MSO’s Regulations & Dispositions for the servicing 230k Beneficiaries. Assumed charge of all aspects of PMG business, records, medical care eligibility review, claims tracking and management and provider contracting. · Operating as change agent applied lean management processes to orchestrate significant improvements in operating models creating a more agile and efficient operation while providing quality care. · Leveraged PMG’s expertise to represent company’s during ASES and the MSO contract's dispositions and regulations for the PR Medicaid Healthcare Medical Plan beneficiaries. · Strategically advised company’s business units: Contracting, Providers, PNO, PAU, A & G, Pharmacy and Financial. · Spearheaded and project managed the EMR- MU, Quality and Mental Health Programs · Managed workflow: ensured all services were billed to appropriate commercial or government insurance carrier, HMO or PPO. Show less