Esther N. Hamilton
DeSoto,TX
Summary
Results-driven healthcare professional with over 18 years of expertise in provider data analytics, claims processing, and contract issue resolution at United Healthcare. Extensive experience in the healthcare industry includes a deep understanding of professional and facility claims processing, as well as reimbursement methodologies for facilities, ancillary services, and physicians. Proven track record of streamlining processes and enhancing efficiency while ensuring compliance with industry standards demonstrates a commitment to excellence. Recognized as a valued team player, consistently achieving results through effective collaboration and adaptability, ready to contribute significantly to a health plan or medical institution.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Provider Data Consultant
United Healthcare
11.2022 - Current
- Collaborate with care providers and medical groups to manage their rosters, provide maintain demographic information, ensure credentialing compliance, and update network status for rostered providers in our systems.
- Perform comprehensive data and contract reconciliations across all platforms.
- Partner with Contract Managers, the Health Plans, and medical groups to sign off on the accuracy of network profiles.
- Ensuring that new contract provisions are successfully executed across all platforms and processes.
- Coach, provide feedback to, and guide provider contacts and Network Management staff, while also serving as a resource for less experienced team members.
Network Program Consultant
United Healthcare
09.2016 - 11.2022
- Managed FQHC/RHC contracts across both Commercial and Government products. Responsibilities included validating demographics, credentialing, and ensuring system accuracy prior to installation in applicable systems.
- Manage rate escalator and chargemaster maintenance including tracking, calculation of adjustments, creation of payment appendices to support the change, working directly with Network Pricing and Network Management for review and approval, and submission of the contract for installation to systems.
- Manage service code maintenance for assigned contracts to ensure contracts are updated within Emptoris/CLM as well as working with CCI to ensure appropriate systems are updated to reflect the changes.
Business Analyst
United Healthcare
03.2015 - 09.2016
- Conduct deep-dive analyses to identify root causes of failures and develop remediation action plans for escalated provider issues.
- Collaborate with internal and external business partners to resolve and close out escalated provider issues, communicating the final resolution actions back to the provider.
- Track and monitor multiple ongoing projects for status and resolution.
- Function as the point of contact for escalated provider claim issues, providing end-to-end provider service, including incident identification, and understanding, and following up with remediating action plans.
Provider & Group Contract Installation Specialist– SME
United Healthcare
01.2011 - 03.2015
- Installed and maintained assigned contracts, including structure and billing set up, eligibility collection, database loading, and the preparation of plan materials such as administrative documents and provider education materials.
- Audit contract loads for adherence to quality measures and reporting standards.
Provider Claim Resolution Specialist - SME
United Healthcare
10.2008 - 01.2011
- Provide feedback to staff in person and through SharePoint inquires within 24 hours.
- Conduct observations of adjusters and assist with coaching when needed.
- Assist supervisor with the handling of and responding to escalated emails from internal business partners and management.
- Communicate information to adjusters regarding processing updates and changes.
- Process claims adjustments for a minimum of 4 hours each day to maintain knowledge and proficiency in all technical applications.
Provider Claims Service Lead
United Healthcare
07.2007 - 10.2008
- Answer and diffuse incoming escalated claim and benefit calls from domestic and global Provider Phone Representatives.
- Research United Healthcare Reimbursement Polices and submit claims to adjustments for reconsideration when necessary.
- Adhere to all call metrics and quality requirements.
Patient Access Representative
UT Southwestern Medical Center
02.2001 - 09.2007
- Data enter patient demographic/health insurance information for accurate billing in EPIC.
- Assist with Bed control, collections of co-payment and deductibles.
- Register patients for scheduled admissions and outpatient procedures; Verify patient insurance coverage for scheduled admissions.
- Utilize OnBase software to image patient records.
Collections/Underpayment Analyst/Clinical Appeals
HCA Patient Account Services
05.2003 - 07.2007
- Perform second validation on contract discrepancies and ensure contract compliance, utilizing detailed contract knowledge.
- Contact health plans and initiate request for payment.
- Monitor Insurance claims by running appropriate reports and contacting insurance companies to resolve claims not paid according to Texas Prompt Pay Guidelines.
- Identify coding or billing problems from EOBs and work to correct the errors promptly.
Education
BS - Health Care Administration, Health Information Management
Capella University
Minneapolis, MN06.2028
Skills
- Claims Processing
- Contract Administration
- Contract Opportunity Execution
- Credentialing (Non Delegated and Delegated Providers)
- Data Analysis
- Data Quality Assurance
- Data Reconciliation
- Data Reporting
- Database Management
- Demographic Data Validation
- Feedback and advice
- Health Authority Regulations
- Healthcare Collaboration
- Network Management
- Problem Solving
- Project Coordination
- Provider Data Load
- Provider Data Management
- Provider Network Experience
- Provider Relations
- Rigorous Attention to Detail
- Stakeholder Communication
- Time Management
Certification
- Revenue Cycle Management Specialist, Currently Pursuing
- CPC, Currently Pursuing
Timeline
Provider Data Consultant
United Healthcare
11.2022 - Current
Network Program Consultant
United Healthcare
09.2016 - 11.2022
Business Analyst
United Healthcare
03.2015 - 09.2016
Provider & Group Contract Installation Specialist– SME
United Healthcare
01.2011 - 03.2015
Provider Claim Resolution Specialist - SME
United Healthcare
10.2008 - 01.2011
Provider Claims Service Lead
United Healthcare
07.2007 - 10.2008
Collections/Underpayment Analyst/Clinical Appeals
HCA Patient Account Services
05.2003 - 07.2007
Patient Access Representative
UT Southwestern Medical Center
02.2001 - 09.2007
BS - Health Care Administration, Health Information Management
Capella University
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