Gerald Reynolds

This job is responsible for provider file maintenance. The incumbent ensures compliance with National Committee on Quality Assurance (NCQA), CMS, DOH regulations, BCBS, internal and private business audits. The incumbent is responsible for contract administration, inclusive of, but not limited to, contract generation, reviewing signed contracts, updating provider file and executing contract. The incumbent encompasses Provider Customer Service on a rotated schedule. This provider line is specific to the file maintenance and credentialing processes.

• Communicate effectively and professionally. This position will display communications with varied sources which are not limited to, State licensing agencies, Provider offices, billing agents, provider representatives, management and internal staff.
• Position is responsible to review the contract to ensure there are no changes, secure and execute standard provider contracts, materials, and information as required for the development of provider networks. Ensure compliance with terms of the provider contracts. Ensure compliance with the file maintenance and credentialing guidelines.
• Ensure compliance with the following agencies, Federal Government, NCQA and CMS standards are met, American Healthcare Commissions URAC standards within the scope of WV contracts. Department of Labor (DOL), Department of Health (DOH) and/or the Insurance Department. Other agencies include, HIPAA, HEDIS and Highmark Health Services and all its affiliates’ operational and Corporate policies.
• Provide quality customer service to ensure all telephone or written inquiries received are handled promptly, accurately and consistent with department standards, documenting information accurately using internal inquiry tracking systems or credentialing database.
• Data Integrity. Contact external sources to collect or clarify information or documentation which in turn must be reviewed and evaluated against the established guidelines, policies and procedures to ensure the file meets all policy and procedures in conjunctions with regulations. This specialist must maintain accurate data in corporate provider file repository (CPR) and credentialing database (HC3).
• Provider Credentialing and File Maintenance Analysis.
• Quality Control. This individual will participate in corrective updates from various quality control reports to ensure provider data accurately reflects current data. Follow guidelines in support of BCBS requirements and maintain strict confidentiality of all information, requires the utmost integrity in the discreet and proper handling of all confidential materials.

Scheduled medical appointments for all provider specialties at Allegheny Health Network patients as an Elite Call Center Rep at Care Connect.

Managed high call volumes while providing exceptional customer support and maintaining professional composure.

Received many "kudos" from supervisors that received calls from patients stating they received excellent customer service from me.

• Developed rapport with customers through empathetic listening skills, creating positive experiences even during difficult conversations.

Built and maintained relationships with Network providers. Duties included provider recruitment, contracting, orientation, claims analysis, and issue resolution for Ancillary Network providers. Communicated with providers via phone, email, and personal on site visits. Managed Special Projects and traveled extensively in Western Pennsylvania , maintaining strong and lasting relationships.

Configured, tested, audited, and implemented transactional claims systems. Identified areas of concern that may compromise client satisfaction through data analysis, and came up with solutions based on research analysis, and expertise.

Answered provider inquiries in a fast-paced call center. Provided information and issue resolution.

Worked as an EMT for Lifestar Ambulance then as a Paramedic for TransCare. Delivered compassionate care to patients in emergency and non-emergency situations.

Transferred patients safely and securely to medical facilities for continued care.

Participated in ongoing professional development opportunities such as conferences or workshops to stay current on best practices in pre-hospital emergency medicine.

Evaluated patient vital signs and status to determine care needs using pulse oximeters and electronic vital sign machines.

Administered fluid replacement via IV, IO, and IM to replace fluid volumes and correct electrolyte imbalances.

Administered continuous 12-lead electrocardiogram monitoring to record heart rhythms in patients with acute coronary syndrome.