Brenda Valle: Redeployment 2024
Idaho Falls,ID
Summary
Seasoned Provider Relations Representative possessing in-depth knowledge Medicaid state plans and policies. Expertise in handling high volume of calls and emails to efficiently resolving disputes and identifying ways to improve processes. Proficient in Microsoft Word and Powerpoint. Communicative and detail-oriented individual with excellent interpersonal abilities. Disciplined and energetic professional well-versed in clinical relations, level of care guidelines and contractual regulations. Reliable business professional with experience in process improvement, cross team collaboration and project management. Adept to analyzing data to identify trends and developing strategies to improve efficiency. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
15
15
years of professional experience
Work History
Provider Relations Advocate
Optum
07.2013 - Current
- Improved operational efficiency with thorough analysis, identifying areas of improvement in provider performance metrics.
- Conducted ongoing evaluations of provider performance, implementing corrective action plans when necessary to maintain high-quality care delivery.
- Enhanced network quality and accessibility by recruiting new providers and expanding existing partnerships.
- Strengthened provider relations by organizing and conducting regular meetings to address concerns and discuss improvements.
- Developed strong working relationships both internally across departments as well as externally among contracted providers to ensure seamless coordination of services.
- Monitored trends in healthcare delivery systems, recommending adjustments to contracts or network strategies as needed.
- Effectively negotiated contracts with Rural Health Centers, Federally Qualified Health Care and other healthcare providers within established guidelines.
- Achieved provider satisfaction due to prompt resolutions of escalated grievances involving in-network services or billing disputes.
- Maintained up-to-date information about industry trends in order to better inform decision-making processes within the organization.
- Optimized provider recruitment process by collaborating with various departments, ensuring mutually beneficial background to address provider questions.
- Oversaw the successful transition of new or acquired provider groups into our network systems and processes.
- Assisted in the design and execution of targeted provider education programs to improve compliance with policies and procedures.
- Supported overall network growth through the identification and recruitment of new specialty service providers based on member needs.
- Managed strategic initiatives with Idaho Tribes for the development of long-term relationships with key providers, ensuring consistent high-quality care for members.
- Reduced administrative costs by streamlining processes related to utilization management, credentialing, and service request forms.
- Optimize healthcare coverage for IOP/PHP expansion by recruiting supportive providers.
- Educated providers on contractual terms and policy limitations for in-network participation and outpatient mental health, health plans.
- Participated in high risk audit outcomes to ensure provider meet quality of care and service.
- Assist in training implementation and development to network providers through one-on-one interface
- Identified operational and performance issues and worked with managers to resolve concerns.
- Analyzed operational performance to identify pain points and provide actionable solutions to management.
- Served as liaison between certain departments to implement new improvement plans and changes.
- Competent knowledge and enforced contractual guidelines and regulations to providers
Regional Care Coordinator
OptumHealth
03.2009 - 06.2013
- Used company software and databases to maintain records of services performed and member conditions.
- Managed patient caseloads effectively, ensuring timely follow-up and appropriate interventions.
- Developed strong relationships with community partners, facilitating referrals and collaboration on behalf of patients.
- Conducted regular evaluations of care plan effectiveness, making necessary adjustments based on feedback from patients and providers.
- Built strong relationships with members to deliver emotional support and companionship during their inpatient stays.
- Monitored treatment progress towards members goals, adjusting clinical care plans as needed to achieve desired results.
- Advocated for patients'' rights within the healthcare system, working diligently to address family involvement or barriers to care.
- Improved communication among healthcare providers, streamlining the coordination of services for patients and attending care plan reviews.
- Promoted the utilization of evidence-based interventions that improved overall patient satisfaction with the care process.
Education
Master of Science - Medical Social Work
University of Utah
Salt Lake City, UT05.2008
Bachelor in Elementary Education
Utah State University
Logan, UT05.2005
Skills
- Insurance Regulations Understanding
- Healthcare Industry Knowledge
- Policy Interpretation
- Provider network management
- Project Management
- Conflict Management
- Strategic Business Relationships
- Provider support
- Quality Assurance
- Service Optimization
- Provider orientations
- On-site visits
- Analytical Thinking
- Data Analysis
- Project Planning
- Process Improvement
- Idea Development and Brainstorming
- Dispute Resolution
- Provider relationship management
- Outpatient BH plan operations
Timeline
Provider Relations Advocate
Optum
07.2013 - Current
Regional Care Coordinator
OptumHealth
03.2009 - 06.2013
Master of Science - Medical Social Work
University of Utah
Bachelor in Elementary Education
Utah State University
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