Hi, I’m
April Fox
Gilbert,USA
Summary
Experience Provider Relations Manager adept at driving strategic initiatives, optimizing processes and delivering actionable insights. Skilled in data analysis, project management, and able to deliver organizational objectives. Proven track records of success in translating business needs into effective solutions. 17 Years of Experience in Health Insurance Industry from Customer Service, Claims Processing and Grievance and Appeals.
Overview
8
years of professional experience
Work History
Cigna Healthcare
Provider Relations Manager
07.2023 - Current
Job overview
- Maintained relationship with Provider’s assigned from a Book of Business as assigned based on territory. Met with Providers in person to go over, target matrix, and outline goals. Assisted in HEDIS Measures, bonus structure and financial performance for my Book of Business. Collaborated with Provider’s to achieve clinical and operational goals. Handled dating sharing and worked with managing patient demographics. Handled day-to-day workflow of Provider Relations Department. Maintained compliance with Health Plan, Corporate and State Policies and Procedures. Ensure internal and external standards for excellence are met and maintained. Plan, Coordinate, and participate in scheduled meetings and unscheduled meetings. Conducted Orientations and trained on policies and procedures of the Health Plan. Review Policy Changes for accuracy, assist in resolution of claims payment and provider set up issues. Assisted with upselling health line products and generating fee for service contracts. Worked with Medicare Programs, and benefits. Handled Long Term and Assisted Living Claims processing and prior authorizations. Worked with providers to have those claims processed and advised on billing issues.
Centene Corporation
Provider Relations Manager/Appeals and Grievances
05.2018 - 07.2023
Job overview
- Maintained relationship with Provider’s assigned from a Book of Business as assigned based on territory. Assisted in HEDIS Measures, bonus structure and financial performance for my Book of Business. Collaborated with Provider’s to achieve clinical and operational goals. Handled dating sharing and worked with managing patient demographics. Handling day-to-day workflow of Provider Relations Department. Maintained compliance with Health Plan, Corporate and State Policies and Procedures. Ensure internal and external standards for excellence are met and maintained. Plan, Coordinate, and participate in scheduled meetings and unscheduled meetings. Assisted in underwriting fee schedules and yearly contract increases. Assisted with hands on training, and provider feedback on growth and development. I worked with the State of Arizona AHCCCS Program and benefits administrator. Prior to Network position was in Grievance and Appeals. Researched and resolved written complaints submitted by both members and providers. Categorize complaints, review supporting documentation. Forwarded to clinical team for review if needed for medical necessity review. Send letter to the party who initiated Grievance and Appeals. Reviewed in compliance with local and state guidelines. Participated in State Fair Hearings, as needed as alternate. Worked Long Term Care and Assisted Living Claims and assisted with contracts.
State of Arizona
Eligibility Worker
11.2017 - 05.2018
Job overview
- Handled day to day applications and made determinations of eligibility for people applying for Medical, Food Stamps and Cash Assistance. Additionally, Conducted in person interviews for benefits and eligibility. Worked within State Guidelines for approval.
Education
Central Valley High School
Diploma from General Education
06.1998
Ozark Technical College
from General Education
Skills
- Health plan operations
- Strategic business relationships
- Healthcare industry
- Member enrollment
- Claim Processing End to End
Accomplishments
- Supervised team of 10 staff members.
- Documented and resolved Long Term Care Claims Issues which led to better Customer Satisfaction.
- Collaborated with team of Network Operations in the development of SOP'S Standard Operating Procedures.
Languages
English
Native or Bilingual
Timeline
Provider Relations Manager
Cigna Healthcare
07.2023 - Current
Provider Relations Manager/Appeals and Grievances
Centene Corporation
05.2018 - 07.2023
Eligibility Worker
State of Arizona
11.2017 - 05.2018
Ozark Technical College
from General Education
Central Valley High School
Diploma from General Education
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