Carolyn Acosta
Lake Forest,CA
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Over 25 years of Provider contracting experience in a managed care, IPA, Medical Group & Hospital settings. Exercises independent judgment and decision-making abilities with a high level of confidentiality. Comfortable in fast paced corporate settings, superior written and verbal communication skills, team-oriented mentality and highly professional demeanor, excellent project management skills and meticulous attention to detail.
Overview
28
28
years of professional experience
Work History
Network/Contracts Manager
Memorial Care
02.2022 - Current
- Oversee contracting and provider relations team for all services in the development of provider networks, which includes physician, ancillary and hospital contracting and growth of networks
- Identify potential providers and recruit providers when necessary to assure geographic and specialty coverage
- Assist with negotiations for simple and complex contracts for all MCMG networks
- Working knowledge and understanding of different reimbursement methodologies such as fee-for-service, capitation, case rates, ASA, and able to document methodology within a contract
- Assist in resolving contract disputes related to claims payments
- Communicate professionally with all levels of management
- Oversee various projects for capitated groups in amending contracts as well as implementing updates with all collaborating departments
- Ensures that direct reports are meeting expectations with the use of tools including one on one's, coaching and auditing of work performed
- Responsible for supervising and working closely with the Provider Relations Representatives to set direction, resolve problems, provide guidance and develop staff including periodic provider visits with the representatives
- Assists management with all aspects of staff management, including but not limited to monitoring and approving time sheets, providing input for evaluations, coaching, counseling, training, distribution of work and team building activities.
Provider Contracting Administrator
Memorial Care
12.2019 - Current
- Primary point of communication for all provider contracts and network changes, negotiations and database workflows
- Accountable for the contracts database implementation from paper files
- Review, negotiate, amend, and complete provider contract proposals, which include rates, payment methodologies and scope of services for new and existing providers
- Monitor out of network utilization and expense to pinpoint services for future provider contracts
- Function as a liaison between the Provider Contracting Department and other internal departments to determine network needs and identify provider contracts needing to be modified due to operational issues
- Serve as a liaison for contracted providers and/or internal departments to interpret contract language and payment methodologies.
Contracts Coordinator
Memorial Care
08.2018 - Current
- Assist Contracting Manager and Director in preparing contract documents
- Secure signature from all parties including Provider, Director and Senior Management
- Negotiate, process, track provider Letter of Agreements
- Ensure that provider contract files are completed and updated as needed
- Inform internal departments of new contract terms as they are implemented.
Contracting & Billing Specialist
Wirth Plastic Surgery
03.2017 - 08.2018
- Assures that all contracts and credentialing documents comply and are submitted in a timely manner
- Prepares and submits transactions or adjustments to patient claims
- Processes corrected claims to third party insurance carriers, electronically or by hard copy billing
- Secures medical documentation required by third party insurances
- Places outbound calls to patients, physician clients and third-party insurance companies to resolve any outstanding billing issues and inquiries
- Understands and communicates claims' status to appropriate party.
Contracts & Claims Review Specialist
Vantari GENETICS
03.2017 - 01.2018
- Created and maintained contracts and credentialing for various health plans
- Maintained working relationship with various health plan counterparts
- Assured that all contracts and credentialing documents were in compliance and submitted in a timely manner
- Managed incoming calls from patients, providers related to billing issues resulting from testing services
- Communicated with patients, physician clients and third-party insurance companies to resolve any outstanding billing issues and inquiries.
Contracts Manager
UC Irvine Medical Center (UCIMC)
02.2006 - 11.2016
- Contracting for External Service Agreements, Memorandums of Understanding on behalf of UC Irvine Physicians and Surgeons, clinical departments
- Contracting for Referral Lab Agreements and Patients
- Prepare, process, monitor and distribution of all Agreements per guidelines in conjunction with department chairs, administrators, the office of risk management, the School of Medicine Dean's office and community facilities or providers
- Responsible for collection and organizing required data for monthly and annual review of all Service Agreement and Memorandums of Understanding for presentation at monthly committee meetings
- Development and maintenance of departmental database on regular basis, as well as monthly updates to various administration and faculty throughout the organization.
Physician Development Liaison
UC Irvine Medical Center (UCIMC)
10.2003 - 02.2006
- Acted as contact person for the external providers including Medical Directors, Utilization Management and Provider Relations staff
- Developed various reports for tracking referral activity, responsible for logging and tracking all encounters with clients and the progress of all actions taken
- Collaborated in resolving concerns or complaints from various referrals groups related to Referrals, appointment access as well as physician medical reports.
Referral Center Manager
UC Irvine Medical Center (UCIMC)
06.1999 - 10.2003
- Managed staff of thirteen agents and two supervisors in a 24/7 day a week setting included but not limited to: training, hiring, scheduling and orientation of all new staff
- Maintain department reports, staff schedules, call monitoring as well as employee evaluations
- Supervised the maintenance of several systems for call processing, codes, overhead paging and on-call schedules.
Customer Service Representative/Grievance Coordinator
05.1996 - 06.1999
- Tracked, resolved and reported all customer complaints, appeals and grievances for the specific health plans
- Verify eligibility with the various Health Plans as well as PCP changes within Medical Group.
Skills
- Excellent Communication
- Self Motivation
- Attention to Detail
- Multitasking Abilities
- Multitasking
- Problem-solving abilities
- Relationship Building
- Team Collaboration
- Adaptability and Flexibility
Accomplishments
Project lead on organization and implementation on the transition of contract paper files to electronic database.
Collaborator in the implementation of various contract amendment update to multiple capitated specialties.
Created tracking workflow and working provider matrix to be used by multiple teams for implementation of PCP bi-annual updates.
Languages
Spanish
Native or Bilingual
Timeline
Network/Contracts Manager
Memorial Care
02.2022 - Current
Provider Contracting Administrator
Memorial Care
12.2019 - Current
Contracts Coordinator
Memorial Care
08.2018 - Current
Contracting & Billing Specialist
Wirth Plastic Surgery
03.2017 - 08.2018
Contracts & Claims Review Specialist
Vantari GENETICS
03.2017 - 01.2018
Contracts Manager
UC Irvine Medical Center (UCIMC)
02.2006 - 11.2016
Physician Development Liaison
UC Irvine Medical Center (UCIMC)
10.2003 - 02.2006
Referral Center Manager
UC Irvine Medical Center (UCIMC)
06.1999 - 10.2003
Customer Service Representative/Grievance Coordinator
05.1996 - 06.1999
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