Summary
Overview
Work History
Education
Skills
Accomplishments
Certification
Timeline
Generic

Frances A. Linford

Adelphi,MD

Summary

Insightful Manager with experience directing and improving operations through effective employee motivational strategies and strong policy enforcement. Proficient in best practices, market trends and regulatory requirements of industry operations. Talented leader with analytical approach to business planning and day-to-day problem-solving.

Overview

42
42
years of professional experience
1
1
Certification

Work History

Senior Provider Network Analyst

Adventist HealthCare
07.2020 - Current
  • Manage and oversee credentialing and re-credentialing employed provider groups and facilities with commercial and government payers
  • Enroll new service lines and service locations of all AHC entities with payers
  • Track agreement participation for AHC’s clinically integrated network, One Health Quality Alliance, and oversee delegated credentialing rosters and audits
  • Oversee work of Provider Network Analyst Credentialing Team Manage the process of Network Management Credentialing Tool
  • Maintain a strong working relationship with AHC entities and Patient Financial Services regarding group credentialing and service location payer issues
  • Maintain system for tracking facility credentialing and enrollment deadlines
  • Load new providers and update data in the online credentialing system in order to streamline delegated credentialing process
  • Manage Payer Contracting and Enrollment for all new service lines
  • Manage Credentialing and Recredentialing for all Facilities
  • Collaborate with AHC Medical Staff Offices to ensure credentialing policies and procedures meet the overall payer requirements under NCQA guidelines for continued participation under delegated credentialing agreements
  • Oversee work of and serve as a resource to Provider Network Analyst
  • Generate and prepare monthly provider reports of new, updated, and terminated providers for delegated payers
  • Maintain and apply for National Provider Identification (NPI) numbers for entities
  • Manage and oversee payer credentialing and recredentialing for All of AHC Entities
  • Manage payer credentialing and recredentialing of facilities and ancillaries
  • Work collaboratively with AHC Medical Staff Offices to obtain provider staff privileges
  • Create workflows within Morrisey Credentialing database to process new provider applications
  • Maintain extensive communication with providers to establish and maintain positive relationships throughout Adventist HealthCare
  • Manage the Council for Affordable Quality Healthcare (CAQH) database for all employed physicians and clinical staff
  • Collaborate with third-party administrators, payers, and AHC Medical Staff Offices to ensure network accuracy of physician data
  • Maintain and update monthly rosters to send to the delegated payers for credentialing
  • Add providers to and delete providers from payer contracts for Physician Networks
  • Build and maintain professional relationship with all payers
  • Manage all Medical Group providers database and update as needed
  • Collaborate with Adventist HealthCare’s Legal Department to ensure all correspondence is submitted to obtain malpractice insurance
  • Provide guidance and support to all providers and office staff
  • Establish and maintain effective working relationships with employees and payers
  • Collaborate with AHC entities to ensure efficient and effective operations
  • Work with entity leadership to identify operational issues and develop resolutions
  • Review and process credentialing invoices for payments, refunds and reimbursement
  • Manage process with billing company to identify and correct provider credentialing claims denial and timely claim submission
  • Provide project management support for the Clinically Integrated Network
  • Conduct provider onboarding meetings
  • Guard confidential information
  • Organize and integrate organizational objectives in order to meet deadlines
  • Assume responsibility and exercise authority over assigned work functions
  • Analyze situations and taking effective action Manage all Delegated and Pre-Delegated Audits

Business Operations Manager, Managed Care Department

Adventist Healthcare
06.2009 - 07.2020
  • Adventist Medical Group, Managed Care and Physicians Network
  • Physician Contracting
  • Collaborate with third party Administrators, Managed Care plans, and AHC Medical Staff to ensure network accuracy of Physician data
  • Prepare and submit group contracts with new payers
  • Negotiate single case agreements for non-contracted payers
  • Assist with Physician onboarding
  • Manage employee outcome by training, coaching and counseling
  • Insurance Credentialing / Liaison
  • Create and Manage CAQH (Council for Affordable Quality Healthcare) database for all employed Physicians and clinical staff
  • Assist AHC Entities with obtaining Provider information for facility credentialing
  • Prepare and submit all Credentialing and Re-credentialing applications for all Employed Providers and Contracted Providers
  • Maintain current Licensure to include License, CDS, DEA and Mal-Practice
  • Responsible for sending monthly updated Rosters to Delegated Insurance Carriers
  • Responsible for adding Providers to and deleting Providers from Insurance Contracts
  • Build and maintain professional relationship with all payers
  • Follow up with payers as needed
  • Maintain Provider database and update as needed
  • Facility Credentialing
  • Review Payer Contracts Work collaboratively
  • Work collaboratively with the Morrisey Program within AHC's MSO's
  • Create workflow within MSOW to process applications
  • Maintain updates for AMG Providers
  • Run provider reports for Managed Care
  • Insurance Contracting / Managed Care
  • Assist Managed Care Department on Insurance Contract review and Negotiations
  • Work collaboratively with the Managed Care Department on third party contracts
  • Negotiate single case agreements for non-contracted health plans
  • Practice Operations
  • Build and maintain strong relationship throughout AHC
  • Provide Guidance and Support to all AMG Providers and Office Staff
  • Work collaboratively with all AMG practices to ensure efficient and effective operations
  • Participate in creating operational plans for all outpatient clinics
  • Oversee Multi-Specialty Medical Practices
  • Provide office assistance as needed
  • Ensure that all employees follow Policy and Procedure Guidelines
  • Conduct monthly staff meetings to discuss administrative issues
  • Coordinate with site Manager to provide appropriate training and education to staff
  • Work with Treasury to coordinate Lockbox, Virtual Merchant (credit cards), Deposits slips, etc
  • For all Practices and ensure that all payees are kept current
  • Work collaboratively with Risk Management / Legal Department to ensure that Employment Contracts and Mal-Practice is kept current
  • Collaborate with Site Managers to problem solve and manage non-clinical staff
  • Review and process all invoices and reimbursement
  • Maintain patient confidentiality and comply with HIPAA policies
  • Revenue Cycle / Financial Management
  • Oversee Provider billing for all AMG practices
  • Coordinate with office site managers to ensure timely receipt of charges and resolve billing issues
  • Prepare accurate daily reports on data entry and submission of charges
  • Work collaboratively with PFS on denials and Insurance appeals
  • Run monthly credit balance reports and process refund requests
  • Research and resolve claim issues
  • Work collaboratively with and outside Collection Agency and review all accounts prior to Collection
  • Process
  • Oversee Cerner Registration and Billing for Providers and Facility for Outpatient Services at ABH
  • Work collaboratively with Site Managers to ensure proper authorizations are obtained
  • Maintain monthly access reports for all ABH Outpatient Facilities

Practice Administrator

David K
02.1982 - 06.2009
  • Assessed processes and procedures, complying with OSHA, and HIPAA regulations.
  • Developed close working relationships with front office and back office staff.
  • Boosted staff morale by offering constructive feedback and specific direction.
  • Provided outstanding support to entire staff which helped improve process flow and boosted efficiency.

Education

High School Diploma -

High Point High School
Beltsville, MD

Skills

  • Qualifications Include:
  • Proficiency in
  • Microsoft Office (Excel, Word, Outlook
  • Ability to work independently, prioritize, and manage a multi-task environment
  • Working knowledge of payer credentialing, CAQH, ePREP, PECOS, etc
  • SKILLS:
  • Morrisey – Medical Staff Office Credentialing System
  • Medics Elite – Practice Management System
  • SMS
  • Microsoft Office Outlook, Word, Excel
  • CAQH (Council for Affordable Healthcare) Provider Credentialing Database
  • Virtual Merchant – Web based Credit Card payment system
  • Aurora – PFS EOB lookup
  • Peoplesoft for Account Payable
  • Cerner – Registration and Billing
  • EcW EMR
  • Metrix (Patient Financial Services)
  • Staff Management
  • Strategic planning
  • Policies and procedures
  • Schedule optimization
  • Operations management
  • Coaching and mentoring
  • Key Performance Indicators
  • Verbal and written communication
  • Contract Management
  • Business administration

Accomplishments

  • MSOW (Medical Staff Office) Excellent critical thinking skills Strong customer service, professional demeanor and interpersonal and communication skills Strong stewardship of confidential data Understand and willing to work with project development, planning and execution Possess and continuously demonstrate good/sound professional judgment
  • Effectively manage business process flow from individual to individual and department to department
  • Knowledge with Medicare and Medicaid products
  • Strong Analytics, research and Organization skills
  • Willingness to grow and develop skills required to perform his/her job duties and assist in the training and education of other team members
  • Seek education and training in the field of managed care and population health risk management to incorporate best practices for the organization

Certification

MGMA/ACMPE Medical Group Management Association /American College for Medical Practice Executives MCMS Montgomery County Medical Society AAPC American Academy of Professional Coders CPR & AED Certification NAMSS National Association Medical Staff Services

Timeline

Senior Provider Network Analyst

Adventist HealthCare
07.2020 - Current

Business Operations Manager, Managed Care Department

Adventist Healthcare
06.2009 - 07.2020

Practice Administrator

David K
02.1982 - 06.2009

High School Diploma -

High Point High School

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Frances A. Linford