Provider Network Resume Sample

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Annabell Hilll
663 Florida Freeway,  Los Angeles, CA
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Work Experience


Provider Network Account Executive
04/2017 - PRESENT
Los Angeles, CA
  • Implement process to ensure all new deployments are in 100% compliance with operational monitoring standards. This includes testing network resiliency as part of all new deployments, including verification of alarms, monitoring and as-built documentations
  • Manage resources to meet on-call support schedules, sufficient coverage for daily activities
  • Complete performance appraisals for direct reports, including defining goals, annual reviews and promotion recommendations
  • Review existing processes for IT work flows and provide recommendations for improving service delivery responses
  • Enforce STRICT adherence to established operational policies in regard to network changes, configuration, service availability, and operations procedures
  • Lead the implementation of TWC’s agreed, uniform architectures and common operating practices (methods, procedures, and tools)
  • Aggregate and review metrics and performance measures across the Enterprise DC, and act as the central point of contact for all firewall and security operations activities
  • Shared values and style consistent with TWC’s corporate values: dedication to innovation; high business ethics; diversity; corporate responsibility, customer-focused and quality service
  • Experience developing and maintaining provider contracts and/or relationships
Provider Network Representative
02/2014 - 12/2016
New York, NY
  • Experience of provider payment programs and billing practices
  • Experience of insurance products and network configurations
  • Experience interpreting analytical data
  • Frequent local travel with occasional overnight stays
  • Responsible for Monitoring and Managing Provider Network by assuring appropriate access to services throughout the Plan’s territory in keeping with State contract mandates
  • Completes requests for initial site visits within time period specified by Department standards. This includes requests for review of an existing participating physician’s new office location
  • Prepare and distributes internal notifications as needed, which include changes in demographics and/or provider status to include but not limited to tax id changes, terminations and panel closures. Documents all updates/changes in provider database
  • Prepare contract documents in accordance with current policy (i.e. Exhibit B/C documents)
  • Informs health plans on addition, deletion and panel closure of participating providers. Maintains Provider Rosters and ensures monthly updates and distribution
AVP, Provider Network Mgmt & Ops
10/2008 - 11/2013
Houston, TX
  • Research provider claims projects as needed
  • Screens and responds to new/potential provider inquiries. Facilitates credentialing process including sending and collecting the application and attachments, reviewing for completeness and forwarding to the Credentialing Department
  • Oversees the Network Services Provider Database. Maintains Provider contract matrices
  • Develop and collects survey data to include but not limited to provider/patient satisfaction, access surveys, Provider Relations Department survey and creates presentation reports
  • Track, trends and monitor timely and complete submission of encounter data from physician network
  • Industry experience. (Aetnas system and Managed Care Industry)
  • Those that are most complex, a higher number of multiple practice locations and multi-specialty practices and multiple providers
  • A total practice annual pay amount over $1M
  • The Account Executive II is responsible for managing an ongoing Provider Network Management organization project or program

Education


University of Texas at Brownsville
2004 - 2008
Bachelor's Degree in Business

Professional Skills


  • Responsible for receipt and entry of provider data and validation of provider information using state files prior to submission to Provider Maintenance
  • Intermediate computer skills: Outlook, Word, Excel, Right Fax, and Salesforce
  • Experience utilizing financial models and analysis in negotiating rates with providers
  • Experience in Provider Contracting and/or Network Development
  • Experience in performing network adequacy analysis
  • Experience in a network management-related role, such as contracting or provider services
  • Experience in fee schedule development using actuarial models

How to write Provider Network Resume

Provider Network role is responsible for interpersonal, software, insurance, oncology, database, training, collaboration, recruiting, finance, auditing.
To write great resume for provider network job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Provider Network Resume

The section contact information is important in your provider network resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Provider Network Resume

The section work experience is an essential part of your provider network resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous provider network responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular provider network position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Provider Network resume experience can include:

  • Strong project management and team leadership, and collaboration skills
  • Demonstrates age appropriate communication skills for the population served
  • Working with Ancillary Providers to include Home Health, Skilled Nursing, DME etc
  • Experience in a Provider Services position working with LTSS and HCBS providers
  • Work independently in a high volume work environment with shifting priorities
  • Demonstrated ability to resolve disputes, identify resolutions and execute contractual closure

Education on a Provider Network Resume

Make sure to make education a priority on your provider network resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your provider network experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Provider Network Resume

When listing skills on your provider network resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical provider network skills:

  • Strong interpersonal skills, including establishing rapport and working well with others
  • Stellar interpersonal skills with the ability to relate to all levels of practice staff and operational partners
  • Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required
  • Experience with provider contracting including development of product pricing and utilizing financial modeling in making rate decisions
  • Experience developing product pricing and utilizing financial modeling in making rate decisions
  • Ensure teams are obtaining, validating and analyzing data impacting network availability and access

List of Typical Experience For a Provider Network Resume

1

Experience For Provider Network Account Executive Resume

  • Identifies and maintains strong partnerships with appropriate internal resources and stakeholders
  • Valid driver’s license Current auto insurance
  • Validate potential recovery claim project activities
  • 2+years of claims analysis experience in a healthcare environment
  • Strong with MS Excel, Access, Word, MS Access, MSOffice, Pivot Charts, Analytics
2

Experience For Provider Network Representative Resume

  • Drive program design and implementation to improve quality and affordability through improvements in appropriateness and effectiveness
  • Previous experience with provider network data
  • Facilitates the member transfer process for terminating providers to retain existing IPA membership
  • Conducts provider training and onboarding
  • Coordinates efforts with the health plans and employer groups to organize marketing events and health fairs
  • Assists the Contract Management Coordinator as necessary to assess issues/problems being encountered by providers and staff
  • Claims processing and Provider data maintenance knowledge required
3

Experience For Provider Network Administration Manager Resume

  • Research State Rules and Regulations, surrounding the CMS Programs and ensures Facets is configured accurately to include State Fee schedules, GME, DRG changes
  • Organizes, coordinates, and conducts PCP and Office Manager Forums, new provider in-services, and provider office visits to ensure IPA membership growth
  • Recruits additional providers to maintain and grow volume
  • Participates and coordinates the IPA, physician, hospital, and community events
  • Ensures that at least 95% of the DOC panels are complete and closed PCP panels do not fall below 85% threshold
4

Experience For Provider Network Data Analyst Resume

  • Establishes and maintains thorough knowledge of health plan contracts. Works with health plan representatives to resolve issues pertaining to providers in their assigned networks
  • Work with multiple computer systems and ability to manage priorities to achieve success
  • Provides articles and other materials, as necessary, for the CMS Provider Manuals and IPA Quarterly Newsletters Supplements
  • Reviews the Encounter Data and Electronic Authorization Submission reports to identify providers for in-services
  • Maintains the IPA Development log for meetings with CEO and Board of Directors
  • Maintains and submits the Daily Provider Educational Visit log
5

Experience For AVP, Provider Network Mgmt & Ops Resume

  • Attends the IPA Board of Director, UM, and QI meetings, as assigned
  • Maintains and keeps in total confidence, all files, documents and records that pertain to the operation of business for Cap Management Systems
  • Experience in the managed care/health insurance industry.; business or health related discipline such as Healthcare Administration or Healthcare Management or equivalent business experience
  • Oversees continuous provider network development and expansion to support the organization’s current and future products
  • Detail - oriented, adaptable and self - motivated
  • Utilize critical thinking skills and sound judgment in decision making. Review work performed by Network Operations NSR staff members to determine level of accuracy in accordance with established guidelines
  • Recognize areas of improvement within Policies and Procedures
  • Relevant Work Experience:2 years’ experience in a Healthcare setting performing credentialing/ re-credentialing, primary source verification, data-entry or Provider file maintenance functions
6

Experience For Healthcare Provider Network Contractor Resume

  • Serves as a resource to Network Management Account Executives for contracting and provider set up questions/issues
  • Responsible for Provider demographic management which includes additions, deletions or corrections and initial provider loads to Provider Maintenance
  • Responsible for panel adds, holds and changes, member reassignments and member interventions as requested from Providers as mandated by State
  • Responsible for the PMP/PCP Add and Terms with the State, as mandated by State
  • Responsible for updating the provider contract database with new information or modifications to existing provider contracts accurately and within established timeframes
  • Addresses issues that have a negative impact on Plan’s financial status through “in-servicing” providers who demonstrate patterns which are not cost-effective
7

Experience For Healthcare Provider Network Program Management Resume

  • Develops positive working relationships with applicable provider’s staff
  • Addresses issues that have a negative impact on Plan’s financial status through “in-servicing” providers who demonstrate practice patterns which are not cost-effective
  • Schedules meetings at provider’s convenience demonstrating reasonable flexibility in adjusting schedules for appointments before and/or after normal working hours
  • Works with Account Executive I’s to identify and resolve issues and coordinates with Manager of Network Management to escalate concerns to appropriate parties
  • Addresses issues that have a negative impact on Plan’s financial status through “in-servicing” providers who demonstrate practice patterns, which are not cost-effective
  • Schedules meetings at provider’s convenience demonstrating reasonable flexibility in adjusting schedule for appointments before or after normal working hours
  • Assists in the training and acts as a mentor for new Account Executive I’s
  • Monitors assigned Account Executive I through “ride along” or like efforts at least bi-annually; provides employee performance report to Manager of Network Management regarding “ride along’s.” or like efforts, and participates in evaluation of assigned Account Executive I in collaboration with Manager of Network management
8

Experience For Provider Network Process Engineer Resume

  • Acts as HPHC liaison with Dell Provider Relations staff, providing account management support and maintenance of the provider’s overall relationship with HPHC
  • Communicates to internal constituents regarding critical issues that impact the providers’ overall performance and satisfaction, includes determining when issues are not being effectively resolved and appropriately escalating issues to management as needed
  • Understanding of contractual and financial relationships across health care products
  • Develop data supported solutions demonstrating return on investment
  • Assists as necessary to assess issues/problems being encountered by providers and staff
  • Build and manage relationships with provider constituencies
  • Responsible for updating the provider contract database with new information or modifications to existing provider contracts accurately and within established time frames
  • Relevant Work Experience: 2 years experience in a Healthcare setting performing credentialing/ re-credentialing, primary source verification, data-entry or Provider file maintenance functions
  • Travel to the following states Territory District 5 - Washington, Oregon, Nevada, Arizona, Hawaii, New Mexico, Alaska, Idaho and California. Candidates can live in any of these states and work remotely except for Hawaii or Alaska
9

Experience For Service Provider Network Software Resume

  • Maintains complete understanding of reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance
  • Supports the credentialing and re-credentialing processes, investigation of complaints and any potential quality issues
  • Responsible for the coordination and tracking of Provider credentialing
  • Knowledge of healthcare provider networks, contracting and credentialing requirements, contracts, and terminology
  • Maintains a functional working knowledge of the provider portal. Maintains and delivers accurate, timely activity and metric reports as required
  • Provide regular account updates and reports to management regarding account negotiations, retention and performance
10

Experience For Associate Provider Network Recruiting Specialist Resume

  • Responsible for the loading of Provider data into multiple systems – i.e. claims, directory
  • Knowledge of Provider onboarding process, system applications, and procedures
  • Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up
  • Uses data to develop and implement methods to improve relationship
  • Help develop geographically competitive, broad access, stable networks that achieve objectives for unit cost performance and trend management
  • Evaluate and negotiate contracts in compliance with company templates, reimbursement structure standards, and other key process controls
  • Ensure that network composition includes an appropriate distribution of provider specialties
  • Provide input and recommendations for process improvement
  • Work closely with Operational Subject Matter Experts to manage expectations between MSLA and assigned accounts

List of Typical Skills For a Provider Network Resume

1

Skills For Provider Network Account Executive Resume

  • Experience managing staff and at least 3 years of project management or project lead experience
  • Organizational skills and sense of urgency
  • Proven Regulatory knowledge and experience
  • Project management expertise with proven ability to set and prioritize short, mid and long term objectives
  • Experience in a Sales or Network Management - related role, such as contracting or provider services (preferably in the Dental space)
  • Experience in managing profit and loss statements, capital expenditures, and practice budgets in excess of $35 million
  • Experience or knowledge of financial models and analysis in negotiating rates with providers
2

Skills For Provider Network Representative Resume

  • Experience with utilizing/knowledge of actuarial models
  • Experience in a Provider Network Management and Provider Relations, handling complex network providers with accountability for business results
  • Experience using financial models and analysis to negotiate rates with providers
  • High level admin/program coordination experience preferably in a health care setting
  • Management experience in a network management-related role handling complex network providers with accountability for business results
3

Skills For Provider Network Administration Manager Resume

  • Management experience leading multiple teams
  • Experience working with large healthcare systems in the State of Virginia
  • Experience in customer service or entry level inside sales
  • Experience in network development, contract operations, health plan operations, or provider relations
  • Extensive phone experience, preferably with Health Care Providers
4

Skills For Provider Network Data Analyst Resume

  • Prioritizes client requests as appropriate
  • Demonstrates and supports commitment to corporate goals and objectives
  • BS or relevant 2 or more years of experience
  • Experience with Value Based Reimbursement
  • Experience in the health care industry
  • Working in a normal office environment
  • As a stakeholder, facilitate decision making through cross-team collaboration and communication through status reports, project metrics and executive reporting
  • Oversees and ensures timely resolution of client issues, including eligibility, network concerns, ID card issues and other related claims processing issues
5

Skills For AVP, Provider Network Mgmt & Ops Resume

  • Serves as a key resource for lower-leveled consultants and for other contracting staff
  • Maintains an updated and working knowledge of workers’ compensation and federal laws that impact the reimbursement of medical service disputes
  • Medical terminology and medical billing
  • Proactively identify, monitor, minimize project risks and contribute in finding mitigations and solutions
  • Facilitate provider education, training them in order to increase their familiarity and satisfaction with Humana’s systems and strategies
6

Skills For Healthcare Provider Network Contractor Resume

  • Participates in the planning and execution of quarterly client visits
  • Attends required training on an annual basis
  • Facilitate the agreement assignment process for new and existing provider groups
  • Possesses in-depth expertise in data analysis and data mining
  • Knowledge of Provider Contracting and Network Development
  • Dental Provider Contracting / Services
  • Works independently and requires a high level of judgement, discretion and decision making abilities
7

Skills For Healthcare Provider Network Program Management Resume

  • Knowledge of EMR, CPT and ICD-10 coding
  • Serves as a communication link between professional providers and the company. Conducts more complex negotiations and drafts documents
  • Identifies and resolves network access gaps or perceived gaps
  • Work with multiple cross-functional teams of Hardware, Software, Marketing, Manufacturing, Support, Documentation, etc. to design, build and deliver best in class products and solutions
  • Responsible to ensure that the projects follow the established process and procedures
  • Accountable and ownership for the project outcomes within the constraints of cost, schedule and quality
  • Partner with development stakeholders to drive quality initiatives
8

Skills For Provider Network Process Engineer Resume

  • Work with Cisco’s vendor teams where needed
  • As a self-starter, work independently in this role with little or no direction
  • Manages day-to-day client contacts and requests of assigned accounts and elevates issues to the next level as appropriate
  • Manages client relationships to ensure client’s needs are met
  • Ensures timely delivery of client monthly/quarterly reports
  • Interfaces and manages operational issues with LaCare functional areas
9

Skills For Service Provider Network Software Resume

  • Develops LaCare performance improvement plans when necessary, and monitors performance guarantees
  • Manages contract compliance with each client and reports non-compliance to manager
  • Investigates and attempts to resolve all customer complaints and elevates unresolved issues as necessary
  • Drafts and updates LaCare client policies on a routine basis as necessary
  • Proactively develops an understanding of existing client’s key issues and business requirements and works with internal team to meet business requirements
  • Maintains current knowledge base of program services, policies and procedures regularly reviewing and reacting to policy updates and departmental procedures
  • Adheres to AMFC policies and procedures
  • Creates and supports an environment which fosters teamwork, cooperation, respect and diversity
  • Establishes and maintains positive communication and professional demeanor with AMFC employees and clients at all times
10

Skills For Associate Provider Network Recruiting Specialist Resume

  • Adheres to AMFC policies and procedures. Supports and carries out the Mercy Mission & Values
  • Responsible to answer provider calls and resolve questions/issues
  • Responsible for the monthly distribution and coordination of provider directory as mandated by State
  • Responsible for tracking issue resolution against established timeline, alerts responsible department of upcoming due dates to ensure adherence to department standards. Escalates issues that remain open more than established threshold
  • Responsible for preparation of statutory and plan reporting, as required
  • Responsible for the gathering. production of and analysis of complex statistical data to identify financial and non-financial impacts and potential process and system improvements

List of Typical Responsibilities For a Provider Network Resume

1

Responsibilities For Provider Network Account Executive Resume

  • Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers
  • Anticipate operational and provider needs and proactively develop solutions to meet them
  • Act with a sense of urgency to research questions or issues brought by the team. Identify the right parties or resources to resolve these issues. Follow up with these parties to drive resolution and provide on-going feedback to individual(s) who raised the question or issue
  • Evaluate and negotiate contracts in compliance with company templates, reimbursement structure standards, and other key process control
  • Supports and carries out the AmeriHealth Mercy Mission & Values
2

Responsibilities For Provider Network Representative Resume

  • In a Provider Services field work position
  • In the managed care/health insurance industry
  • Develops LaCare performance improvement plans when necessary, and monitors performance guarantees.Manages contract compliance with each client and reports non-compliance to manager
  • Own output of the entire system made up of all related processes
  • Develop, translate and execute strategies or functional and operational objectives at the segment level
  • Direct work that impacts the entire enterprise and marketplace
3

Responsibilities For Provider Network Administration Manager Resume

  • Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched and resolved within established SLA timeframes
  • Participate in encounter rejection reconciliation activities
  • Requests/runs queries to identify root causes of claim denials, incorrect payments and claims that are not correctly submitted for payment
  • Act as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers
  • Maintain tracking system of operational issues, progress, and status
4

Responsibilities For Provider Network Data Analyst Resume

  • Focus on technology and business issues, as well as, communicate appropriately with both technology and business experts
  • Develop and execute strategies that span a large business unit or multiple markets/sites
  • Comprehensive knowledge of all Microsoft Office applications, with emphasis on Excel and Access
  • Knowledge of Microsoft Office applications Driver’s license and vehicle are required
  • Locations include San Antonio, TX; Wausau, WI; Cincinnati, OH
  • Travel to provider sites, minimal about 5 - 10%
  • Project/Program Management: Exceptional organizational skills with demonstrated success in end-to-end project/program management and ability to execute flawlessly on initiatives to support organizational goals
  • Communication: Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others; Experience speaking in individual and group settings
  • Vendor Management: Ability and willingness to calmly and effectively resolve escalated vendor complaints research and respond to issues and solve problems
5

Responsibilities For AVP, Provider Network Mgmt & Ops Resume

  • Technology/Systems: Proficient in MS Excel, Word, Access, and PowerPoint; understanding of, experience with, claims and network management reporting systems
  • Relationship Management: Network outside and inside the organization to build positive strategic relationships and form alliances with key individuals and groups
  • Teamwork: Possess excellent interpersonal skills; demonstrated leadership and problem solving skills, flexibility, creativity and dedicated conscientiousness. Demonstrate a cooperative spirit and collaboration with others. Employ flexibility, creativity and dedicated conscientiousness in work environment
  • Multi-Tasking: Ability to multi-task, effectively shifting back and forth among multiple activities or sources of information; demonstrated ability to work in an autonomous, self-directed manner
  • Decision-making: Make sound, quality fact-based decisions, exercising seasoned judgment with a focus on ensuring complete and accurate work, within defined timelines, to maximize results
  • Integrity and Compliance: Can be relied upon to act ethically, to safeguard confidential information and to adhere to UnitedHealthcare's Code of Conduct and all legal and regulatory requirements
6

Responsibilities For Healthcare Provider Network Contractor Resume

  • Experience in developing of product pricing and utilizing financial modeling in making rate decisions
  • Experience in managing multi-specialty or primary care practices with 10 or more practices in scope of authority and progressive leadership responsibility
  • Experience in a network management- with accountability for business results
  • Leadership experience (Supervisor, Team Lead)
  • Experience in fee schedule development and methodologies
7

Responsibilities For Healthcare Provider Network Program Management Resume

  • Strong technical and healthcare regulatory knowledge
  • Experience with LTC/LTSS, BHS, LTSS and ID/DD highly desirable
  • Territory: Center City and outskirts of Center City
  • Ability and willingness to travel at least 50% of the time
  • In-depth knowledge of Medicare Resource Based Relative Value System (RBRVS)
  • Proficient in MS office with emphasis on outlook and excel
  • Experience working with a managed care organization or health insurer; or as a consultant in a network/contract management role, such as contracting, provider services, etc
  • Experience with contract submission, validation and maintenance with strong knowledge of business processes that impact facility/ancillary contact loading and auditing
  • In-depth knowledge of Medicare Resource Based Relative Value System (RBRVS), DRGs, Ambulatory Surgery Center Groupers, etc
8

Responsibilities For Provider Network Process Engineer Resume

  • Familiarity with Humana’s provider data systems (PIMS, CAS, MTV)
  • Experience in contracting, provider relations, provider servicing; or any combination of education and experience, which would provide an equivalent background
  • Strategically manage in-force provider contracts, sharing Humana’s value proposition through frequent contact and education and proactively administering the relationship process
  • Educate providers about Humana’s ever-expanding portfolio of products and services, ensuring continually updated knowledge about the company’s offerings
  • One to three years experience in a Provider Services position working with providers and especially provider network contracting
  • Valid driver’s license and current auto insurance
9

Responsibilities For Service Provider Network Software Resume

  • Experience in customer service
  • Experience in the managed care/health insurance industry
  • Substantive Account Executive experience with high impact, high dollar, extremely visible and critical provider group
  • Fice experience
  • Managed care or related experience
  • Hospital claims experience
  • Working knowledge of provider business operations (PRL)
  • Three years in a provider services field work or contracting position; preferably Ancillary Contracting with a strong background in contracting DME & Home Health
10

Responsibilities For Associate Provider Network Recruiting Specialist Resume

  • Experience working with behavioral Health Providers
  • Experience in a Provider Services position working with providers
  • Experince experience in a Provider Services position working with providers
  • Physician contracting experience
  • Five years in the managed care/health insurance industry

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