MARKET CONSULTANT HEALTHCARE ADVOCATE Professional Summary Ambitious dedicated managed care professional robust organizational, communication customer service skills. Multi-disciplinary industry expertise emphasis provider outreach, research\analysis data integrity. Seeking position partake new innovative improvement processes proactive provider education efforts. Education Training BBA Business Administration Human Resources Management University New Mexico － City State Business Administration Human Resources Management Skill Highlights Government relations knowledge Provider education communication Personal professional integrity Database management Relationship team building Organizational planning Sound decision making Excellent research skills Claims analysis review specialist Project management Professional Affiliations Member Alpha Chi Omega Sorority Professional Experience Market Consultant Healthcare Advocate August 2015 Current Company Name － City State Provides field market market strategy, expertise, execution Risk Adjustment Clinical Quality Programs (HEDIS/Stars) prospective retrospective programs Providers. Acts designated resource Provider group gain engagement. Performs data analytics help identify high risk members develop strategy plan practice. Consults help improve coding accuracy, documentation management patient assessment information. Facilitates access medical records chart review purposes. Utilizes programs SalesForce, Tableau, Concur, SharePoint track various activities reporting. Provider Network Specialist February 2014 August 2015 Company Name － City State Supported contracting efforts "close pricing gap" Blue Community HMO Blue Advantage HMO networks health insurance exchange, along involvement beginning stages additional exchange network implementations 2015. Validated designations Essential Community Providers contracted exchange HMO lines business. Strengthened maintained provider relationships located within Northeast region New Mexico, including Taos PHO La Vida IPA. Audited monthly rosters received Taos PHO La Vida IPA insure correct system representation within PPW Provider Finder. Validated credentialing status, network pricing links utilizing Vistar, PPW, Legacy Premier Premier Pricing. Utilized Blue Chip, PRAP PQRS additional claims issues review. Collaborated amongst peers create provider training presentations informational provider packets. Created standard contracts amendments lines business. Completed Single Case Agreements Assisted maintaining Centennial Care Medicare Appeals Grievances. Participated Behavioral Health Roster Project Lovelace named Medicare Advantage Contract project. Claims Third Party Liability Supervisor December 2013 February 2014 Company Name － City State Ensured compliance HIPAA regulations requirements. Maintained daily operations processes within department monitoring employee workflow distribution. Championed compliance departmental policies, well interface Quality Assurance regarding procedure compliance. Streamlined departmental individual performance metrics took proactive action necessary timely basis maintain desired workflow outputs. Developed implemented system operational changes improve service production efficiency. Collaborated Training Quality Review team implement new revised procedures. Strengthened claim approval process including, limited to, providing assistance support negotiators complex and/or difficult claims determine negotiation leveraging points. Collaborated, coordinated, communicated across various disciplines departments. Championed internal audit rebuttal reviews one-on-one feedback direct staff. Boosted company efficiency client satisfaction streamlining processes deemed inefficient. Attended Lean Six Sigma Rapid improvement events identify optimal value stream maps. Identified process boundaries determined opportunities automate processes functions. Provider Relations Field Representative November 2012 December 2013 Company Name － City State Conducted visits participating Fee Service New Mexico Medicaid Providers. Enhanced delivered formal trainings, webinars, provider-related outreach. Applied knowledge established procedures resolve escalated provider questions, management requests. Acted initial contact escalated issues provider relations support staff. Examined claims reports ensure proper recoding transactions compliance state federal regulations. Investigated claim processing outcomes. Supervisor September 2011 November 2012 Company Name － City State Facilitated enrollment process prospective employees vendors seeking participation within Mi Via Self-Directed Waiver program. Maintained relationships Employers Record (EORs) ensure prospective employees vendors completed provided necessary documentation begin employment. Demonstrated enrollment oversight ensured enrollment processes met participant expectations state regulations. Allocated resources appropriately meet deadlines. Organized workflow departments ensure efficient accurate outcomes. Recruitment Specialist February 2010 September 2011 Company Name － City State Generated qualified candidates open positions. Presented job opportunities qualified customer service care representatives, along senior leadership positions. Guided prospective candidates negotiated contract terms. Screened potential candidates house external interviews. Performed reference checks, exit interviews background verifications candidates. Facilitated training on-boarding 120 employees, new client 2nd Quarter, 2010, bringing projected $25,000 monthly revenue site. Bolstered recognition client internal transition leads. Excelled within deadline-intensive environment, ensuring accurate on-time completion recruitment efforts. Reduced employee attrition 2% 4th quarter 2010. HRIS Administrator September 2008 November 2010 Company Name － City State Managed Leave Absence FMLA process. Determine eligibility, processed employee requests, tracked FMLA leave taken remaining hours approved intermittent use close-out file upon completion. Coordinated Workman's Compensation claims initial accident reports medical treatment return work documentation. Acted liaison Liberty Mutual, SITEL claimant. Supported benefits administration site home based employees, including open enrollment, new hire orientation qualifying events. Guided site employee recognition programs including, employee referral bonus service awards ceremonies. Mediated, documented resolved employee relations issues. Maintained personnel file compliance site home based employees. Championed campaigns community outreach; Juvenile Diabetes Research Foundation (JDRF), United Way, Toys Tots Road Runner food bank. Initiated employee involvement participation. Skills Premier, automate, Behavioral Health, benefits administration, contracts, Critical thinking, client, client 2, customer service, Database management, decision making, Diabetes, documentation, employee relations, Government, HIPAA regulations, insurance, internal audit, team building, leadership, exchange, negotiation, network, networks, Organizational, personnel, policies, presentations, Pricing, processes, Project management, Quality, Quality Assurance, recruitment, Research, Six Sigma, Sound, workflow