CLAUDIA BARBOUR
San Antonio,TX
Summary
Dynamic professional specializing in health insurance with a focus on provider relations, data analytics, and contracting. Achieved a 90% satisfaction rating through effective issue resolution and quality assurance initiatives. Bilingual in English and Spanish, proficient in advanced analytics tools to improve reporting and operational efficiencies. Demonstrated ability to build strong partnerships and deliver outstanding customer care.
Overview
11
11
years of professional experience
Work History
Sr Provider Relations Advocate
UNITEDHEALTHCARE
San Antonio, TX
04.2024 - 05.2025
- Ensured contract SLAs were met by meeting with PCPs and specialists on a monthly, quarterly, or annual basis to address provider panels, after-hours availability, and EMR meaningful use.
- Conducted regular site visits to service providers to provide education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information, and review HEDIS information.
- Researched and resolved disputes, billing discrepancies, and claims efficiently within 72 hours, boosting satisfaction ratings by 90%.
- Answered assigned provider group inquiries within 24 hours via email, telephone, and written correspondence.
- Developed, reviewed, and prepared financial statistical reports, and presented educational material, increasing efficiencies in processes by 80%.
- Performed quality reviews of translated documents to ensure accuracy and compliance.
- Utilized internal software to generate reports to support credentialing, contract negotiating, and provider services activities.
- Served as a liaison between the health plan and contracted network providers to provide orientation training, ongoing education, and to research and resolve complex claim issues within the San Antonio area.
- Facilitated and participated in provider education fairs, webinars, town halls, and monthly provider in-services with contracted physicians, hospitals, and ancillary groups via face-to-face, written correspondence, and telephone contact.
- Developed and fostered strong relationships with internal and external partners.
- Interfaced proactively with all health plan departments.
- Assisted with special projects and additional duties as assigned, which were consistent with company and department goals.
- Managed provider relations in SharePoint by triaging inquiries, facilitating the resolution of incoming requests, and forwarding requests to appropriate parties.
Sr. Provider Data Analyst
UNITEDHEALTHCARE
San Antonio, TX
05.2019 - 04.2024
- Analyzed provider data to ensure accuracy and compliance with regulatory standards.
- Executed queries, extracts, and validations to efficiently fulfill provider requests.
- Imported, cleaned, and transformed provider data to ensure accuracy.
- Utilized advanced analytics tools to enhance reporting capabilities and insights.
- Researched complex issues related to provider eligibility verification, credentialing, contracts.
- Conducted audits of provider records to maintain data integrity and quality.
- Managed contract amendments and executions from initiation to completion through CLM.
- Maintained current loading protocols for provider groups and markets.
- Engaged regularly with providers and network management to resolve data-related inquiries and issues.
- Generated reports to identify errors, ensuring accurate and complete provider information.
- Verified credentials through NPPES to uphold provider integrity.
Appeals and Grievances Analyst
UNITEDHEALTHCARE
San Antonio, TX
03.2016 - 05.2019
- Reduced processing errors by meticulously reviewing claim documentation, and ensuring adherence to company policies and guidelines.
- Expedited resolution times for appeals cases by efficiently managing workload and prioritizing urgent requests.
- Maintained a strong knowledge of basic medical terminology to better understand services and procedures.
- Demonstrated exceptional attention to detail when evaluating medical records in order to identify discrepancies or inconsistencies that could impact an appeal outcome, positively or negatively.
- Consistently met or exceeded performance metrics, demonstrating a strong understanding of the claims review process, and an unwavering commitment to achieving positive results.
- Managed high-stress situations with professionalism, ensuring that appeals were handled promptly and accurately, even under tight deadlines or heavy volumes.
- Proved successful at working within tight deadlines and a fast-paced environment.
- Skilled at working independently and collaboratively in a team environment.
Claims Analyst
UNITEDHEALTHCARE
San Antonio, TX
02.2014 - 03.2016
- Ensured compliance with industry regulations by following established claims handling procedures.
- Conducted thorough assessments of claims documents for accuracy and completeness prior to submission.
- Examined reports and evidence to verify integrity and accuracy of information.
- Analyzed escalated claims to resolve issues efficiently and effectively.
- Reduced claim settlement turnaround time by prioritizing tasks and managing deadlines.
- Processed large volumes of claims in a fast-paced work environment.
- Researched complex claims to determine next steps and potential outcomes.
- Maintained confidentiality of claimant information in line with privacy laws.
Education
Bachelor's - Organizational Communication/Public Relations
UNIVERSITY OF TEXAS AT EL PASO (UTEP)
El Paso, TXSkills
- Building rapport and credibility
- Quality assurance and protocols
- Issue and complaint resolution
- Professional telephone demeanor and etiquette
- Attention to detail
- Data and analytics
- Customer care
- Microsoft Office proficiency
- Database systems
- Relationship building
- Bilingual English and Spanish
Languages
English
Full Professional
Spanish
Native/ Bilingual
References
References available upon request.
Timeline
Sr Provider Relations Advocate
UNITEDHEALTHCARE
04.2024 - 05.2025
Sr. Provider Data Analyst
UNITEDHEALTHCARE
05.2019 - 04.2024
Appeals and Grievances Analyst
UNITEDHEALTHCARE
03.2016 - 05.2019
Claims Analyst
UNITEDHEALTHCARE
02.2014 - 03.2016
Bachelor's - Organizational Communication/Public Relations
UNIVERSITY OF TEXAS AT EL PASO (UTEP)
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