Summary
Overview
Work History
Education
Skills
Accomplishments
Timeline
Generic

Diane Dixon

Charlotte,NC

Summary

Strong Customer Service and Strong Provider Relation Skills. Superior Administrative Skills. Recognized for excellent research and responsiveness to providers in need. Strong skills in project preparation and resolution. Excellent Claims Remediation skills 10 + years experience in claims payment, research for both Medicaid and Medicare LOB. Superior trouble shooting skills. Exceptional knowledge of pricing and provider payment methodologies to include CPT, ICD9, HCPC coding, stop loss, Rev Code, DRG pricing, lab and radiology pricing. Recognized for efficiency, accuracy and service excellence. Service Hero Award

Overview

23
23
years of professional experience

Work History

Provider Advocate Managment

United Healthcare
02.2020 - 02.2024
  • Provide and maintain excellent customer care.
  • Maintain and preserve relationships with physicians and facilities through scheduled and unscheduled conference calls and face to face meetings when necessary
  • Educate affiliates on healthcare systems, portals, and all tools made available to enhance service to our members. Concentrate on reaching a successful goal of financial and business practices
  • Open door policy with providers amd facilities to resolve claim, contract, and appeal issues. Created and maintained projects end to end for positive results
  • Connect and maintain relationships with internal and external partners to resolve differences and difficult issues
  • Report analytics on negative and positive trends to improve the overall scope of the provider relations experience.

Provider Advocate

United Healthcare
06.2015 - 02.2020
  • Provide excellent customer service as the Ancillary Provider Advocate. Responsible for a wide range of provider relations service including working on end-to-end provider claim and call quality
  • Build and maintain positive relationships between the health plan and Radiology, Lab and ASC providers
  • Responsible for coordinating and implementing strategies that assist in developing a provider network
  • Identify gaps in network services to assist with claims remediation and contracting issues
  • Educate providers on policies and procedures, reconsiderations, appeals, contracts, and notifications
  • Educate and train providers on the physician portal and all service enhancements.

Supervisor, Appeals and Grievances

United Healthcare
07.2011 - 06.2015
  • Responsible for providing excellent customer service. Support teams in reviewing, researching, investigating, negotiating and resolving various appeals and grievances
  • Communicates with appropriate parties regarding appeals and grievance issues, implications and decisions
  • Analyzes and identifies trends for all appeals and grievances
  • Responsible for reporting on team metrics
  • Coordinates and supervises 25 direct reports
  • Accountable for the daily activities of business support, technical or production team or unit.

Claims Project Manager

United HealthCare
10.2005 - 01.2011
  • Interact directly with market specific providers in resolution of claims issues
  • Resolve Complex issues and support fellow Claims Project Managers
  • Work diligently with providers to gather info, prepare and submit claims projects
  • Resolve reimbursement issues in collaboration with other operational units within the company
  • Point of escalation for Network Management
  • Accountable for accurate documentation and routing of issues to appropriate resolution partners.

Claims Analyst

United Health Care/ Americhoice
12.2000 - 10.2005
  • Provide excellent customer service care
  • Research, analyze and report on a variety of problems associated with Provider and facility payments
  • Assess reasons for problems and formulate/recommend solutions
  • Process/monitor adjustments
  • Coordinate projects/adjustments with Claims team leads
  • Handle Special projects for Executive staff
  • Resolve Provider Complaints/Inquires from Call Center
  • Answer State Complaints in a timely manner
  • Process and adjust 1st and 2nd level appeals
  • Document and prepare Stop loss and High dollar claims for payment
  • Check authorizations and image original claims
  • Research contracts and pricing to assure claims are paid correctly
  • Work diligently with Ancillary Providers, pricing and contracting.

Education

Bachelor Of Science - Health Administration And Information Systems

University of Phoenix
Remote
11.2010

Skills

  • Excellent Customer Service Skills
  • Claims remediation
  • Provider appeal and disputes
  • Review contracting issues
  • Project management
  • Regulatory requirements
  • Diamond Claims Processing System
  • FACETS, Claims system
  • Care One
  • Knowlegeant
  • Citrix Macess Imaging System
  • Lotus Notes
  • Windows
  • Microsoft Word
  • Microsoft Excel
  • Microsoft PowerPoint
  • Microsoft Access
  • Netscape Communicator
  • MS Outlook
  • Internet
  • COSMOS
  • UNET
  • ISET
  • Emptoris
  • NDB
  • IMPACT
  • PEGA
  • Evicore
  • ETS
  • Team Track
  • CCI Navigator
  • ICUE
  • DCT
  • ODAR
  • PECOS
  • Oxford AYS
  • LINK
  • Exceptional organizational and communication skills
  • Analytical skills and attention to detail skills
  • Exceptional resolution skills
  • Excellent root cause analysis skills

Accomplishments

Received several bonuses for customer care. Resolved complicated complaints. Received Service hero award for which 200 employees were chosen out of 4000.

Timeline

Provider Advocate Managment

United Healthcare
02.2020 - 02.2024

Provider Advocate

United Healthcare
06.2015 - 02.2020

Supervisor, Appeals and Grievances

United Healthcare
07.2011 - 06.2015

Claims Project Manager

United HealthCare
10.2005 - 01.2011

Claims Analyst

United Health Care/ Americhoice
12.2000 - 10.2005

Bachelor Of Science - Health Administration And Information Systems

University of Phoenix

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Diane Dixon