Donna McClain
Syracuse,NY
Summary
Interested in using my strong work ethic, strong organizational and analytical skills, consistent longevity, and preparedness to meet an exciting future at a growing and changing company. Determined Provider Partnership Associate with dedication to quality and accuracy. Familiar with handling multiple projects in highly competitive environments. Solid interpersonal and collaboration skills. Enthusiastic Provider Partnership Associate eager to lead a team success through hard work, attention to detail and excellent organizational skills. Clear understanding of QARR/HEDIS, Risk Adjustment, VBP and Appointment Agendas. Motivated to learn, grow and excel in Health Quality Arena.
Overview
37
37
years of professional experience
Work History
Provider Quality Specialist
Fidelis Care
, NY
01.2015 - Current
- Facilitate retrieval of member healthcare records to ensure achievement of optimum QARR and HEDIS scores for both Medicaid and Medicare – achieved 100% of assigned retrievals including behavioral health
- Collaborate with Provider Relations and QHCM so that outreach is coordinated and records are tracked in a consistent manner
- Possess a strong knowledge of quality programs including QARR/HEDIS and related measures
- Strong ability to coordinate projects
- Able to work in a fast paced environment with strong analytical and problem solving skills
- Skilled in communications with technical and business specifications and requirements
- Educate key providers on all aspects of Quality programs including QARR/HEDIS
- Effective in Risk Adjustment retrieval with difficult providers
Provider Relations Representative/Senior Provider Relations Representative
Fidelis Care New York
01.2011 - 01.2015
- Responsible for ensuring all provider orientations, site visits, access and availability studies were completed in a timely manner
- Coordinated project for the Central Region to include record retrievals, access and availability, ICRS requests, Member Complaints, IPRO audits, Directory Reviews
- Provided support to Provider Relations Director in determining assigned territories and coordination of training for Provider Representatives
- Identified staff training needs and provided ongoing training, as well as initial orientation, to ensure the effectiveness of the Provider Services staff to enhance performance
- Investigated and resolved provider/ member complaints to maintain satisfaction
- Monitor provider compliance and work with non-compliant providers to achieve compliance
- Drive to identify root causes and solutions
- Fostered positive relations with all providers with a focus on key providers by training and helping to resolve their issues and decrease open accounts receivable
- Helped to facilitate the launch of Fidelis Care New York in St Lawrence/Jefferson Counties
- Coordinated projects over a staff of ten Provider Representatives and one Provider Services Associate
- Provided support to Marketing and Provider Relations personnel (including upper management) to ensure Departmental and Corporate goals are met
- Assisted Contract Management in identification of network deficiencies and make recommendations on how to address them
- Monitored the provider network and made recommendations to improve the network
- Identified customer needs in more complex situations
- Identified issues and determined potential solutions
- And its implementation / Educated and assisted providers with the Quality Care Management Incentive program to achieve optimum results
- Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
- Contributed to and enhanced audit processes to maximize quality management standards.
- Assisted with physician recruitment by identifying specific providers within designated territories, negotiating rates for new physicians and distributing provider agreements, successfully recruiting [Number] new physicians per [Timeframe].
- Initiated physician and hospital orientations to support ongoing education of health care provider community.
- Educated staff on organizational mission and goals to help employees achieve success.
- Coached staff on daily performance and conducted evaluations to constructively address concerns.
Provider Relations Representative/Project Manager
Excellus BlueCrossBlueShield
01.2005 - 01.2011
- Responsible for maintaining and improving relationships with as many as 300 providers, hospitals and vendors that participate with Excellus BlueCross and BlueShield in various counties
- Assisted large providers in maintaining acceptable open accounts receivable and resolving complex claim issues
- Member of the Operational Improvement Team tasked with identifying quantifiable improvement opportunities, establishing and/or improving controls, and helping prepare the corporation for the transition to a new claim processing system.
Business Analyst/ Claims/Service Representative/Trainer/Quality
Excellus Blue Cross Blue Shield
01.1985 - 01.2005
- Identified training needs and developed new training programs, including national standards and Microsoft Office
- Solely responsibility for development and delivery of various training programs in order to align different plan locations into a single processing system
- Resolved customer inquiries regarding membership enrollment, contract benefits, medical policies and claim payment via telephone, written and personal contact
- Checked documentation for accuracy and validity on updated systems.
- Modified, updated and processed existing policies.
- Communicated effectively with staff members of operations, finance and clinical departments.
- Acted as [Type] subject matter expert, answering internal and external questions and inquiries.
Education
PAHM Certification Professional, Academy for Healthcare Management -
Academy For HealthCare Management
05.2000
B.S - Business Administration
Houghton College
Houghton, NY05.1984
Skills
- QARR/HEDIS Performance Guidance with both facility and privately owned practices
- Provider Relations
- Scheduling and Coordinating
- Customer Relationships
- Meeting Minutes
- Customer Experience
- Administrative Support
- Client Satisfaction
- Business Analysis
- Special Projects
Timeline
Provider Quality Specialist
Fidelis Care
01.2015 - Current
Provider Relations Representative/Senior Provider Relations Representative
Fidelis Care New York
01.2011 - 01.2015
Provider Relations Representative/Project Manager
Excellus BlueCrossBlueShield
01.2005 - 01.2011
Business Analyst/ Claims/Service Representative/Trainer/Quality
Excellus Blue Cross Blue Shield
01.1985 - 01.2005
PAHM Certification Professional, Academy for Healthcare Management -
Academy For HealthCare Management
B.S - Business Administration
Houghton College
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