DENISE D. GRUSSING, CPC
Villa Grove,IL
Summary
Results-driven healthcare professional with extensive experience in fraud detection and provider relations. Proven ability to lead cross-functional teams and implement data-driven strategies, ensuring regulatory compliance and cost savings. Demonstrates strong analytical skills and strategic planning capabilities within the healthcare industry.
Overview
30
30
years of professional experience
1
1
Certification
Work History
Special Investigations Analyst
Health Alliance Medical Plans, Inc.
Champaign, Illinois
03.2022 - Current
- Investigated complex FWA cases in healthcare, utilizing analytical skills, and a deep understanding of medical billing processes.
- Collaborated with cross-functional teams to identify and mitigate fraudulent activities, ensuring compliance with regulations.
- Implemented data-driven strategies to detect and prevent fraudulent activities, resulting in cost savings for Health Alliance Medical Plans, Inc.
Provider Relations Manager
Health Alliance Medical Plans, Inc.
Urbana, Illinois
10.2006 - 03.2022
- Led a team of eleven in the Provider Relations Department, enhancing operational efficiency and staff performance.
- Developed and executed staff performance plans to drive quality and effectiveness, aligning with organizational goals.
- Implemented strategic provider network development initiatives for Commercial, Medicare, and Medicaid business.
- Facilitated cross-departmental communication and collaboration to resolve provider inquiries and improve satisfaction.
- Oversaw hiring processes to ensure recruitment of qualified staff members.
Provider Relations Specialist
Health Alliance Medical Plans, Inc.
06.2003 - 10.2006
- Acted as liaison between healthcare providers and Health Alliance to facilitate effective communication.
- Conducted routine office visits to providers per departmental accountability standards.
- Proofed provider directories, identifying and reporting necessary changes promptly.
- Distributed provider manuals and educational materials to enhance provider knowledge.
- Executed on-site inspections of new providers to ensure compliance with Department of Public Health regulations.
- Ensured understanding of contract language limitations to maintain compliance.
- Delivered superior customer service, addressing inquiries and concerns efficiently.
Senior Contract Analyst
Health Alliance Medical Plans, Inc.
01.1996 - 05.2003
- Served as primary communicator for Commercial and Medicare contracting processes.
- Negotiated legal, operational, and financial terms of contracts to benefit all stakeholders.
- Oversaw compliance with contract regulations, including audit preparations and site visits.
- Collaborated with Compliance Analysts and Legal Counsel to ensure adherence to regulations.
- Partnered with Finance Department to secure favorable payment terms with providers.
- Ensured accuracy of financial contracting information through collaboration with Managers.
- Led development and implementation of Provider Access database system to enhance efficiency.
- Supported provider directories and credentialing processes while managing Health Alliance contract terms.
Education
Some College (No Degree) -
Parkland College
ChampaignHigh School - Accounting, Typing, Computer Classes, General Business Courses
ABL High School
Skills
- Fraud detection
- Provider relations
- Regulatory compliance
- Cross-functional collaboration
- Data-driven strategy implementation
- Medical billing and compliance
- Risk management and assessment
- Contract negotiation
- Performance metrics
- Customer engagement
- Problem solving
- Effective communication
- Team leadership
- Coaching and mentoring
- Strategic planning
- Process enhancement
- Research and analysis
- Root-cause analysis
- Attention to detail
- Project management
- Critical thinking
- Presentation development
Seminars Workshops Continuing Education
- Healthcare Fraud Shield Software Training
- Tapestry/Epic Training
- GeoNetworks - Geographical Computer Software Training - Kansas City, MO
- Quest Analytics - Geographical Computer Software
- Completed Process Management as part of Carle’s TQM Process
- OAO Pricing Module Training, Burbank, CA
- Ken Blanchard – Lessons in Leadership – The High 5
- Negotiation Skills Class
- Professional Presentation Skills Class
- Leadership Development Institute (LDI)
- SalesForce Training and Usage
Certification
- AAPC Certified Professional Coder, July 2024
References
References available upon request.
Timeline
Special Investigations Analyst
Health Alliance Medical Plans, Inc.
03.2022 - Current
Provider Relations Manager
Health Alliance Medical Plans, Inc.
10.2006 - 03.2022
Provider Relations Specialist
Health Alliance Medical Plans, Inc.
06.2003 - 10.2006
Senior Contract Analyst
Health Alliance Medical Plans, Inc.
01.1996 - 05.2003
Some College (No Degree) -
Parkland College
High School - Accounting, Typing, Computer Classes, General Business Courses
ABL High School