Jeanne Taylor
Edgewater Park,NJ
Summary
Highly skilled Provider Relations Representative with relevant experience in managing relationships between healthcare providers and insurance companies. Strengths include strong communication, problem-solving capabilities, and the ability to maintain professional relationships. Previous work has made significant strides in improving provider satisfaction and resolving conflicts efficiently. Skilled at interpreting contract terms and conditions, fostering cooperative interactions among diverse teams, all while ensuring regulatory compliance within the organization.
Overview
21
21
years of professional experience
Work History
Provider Relations Representative
Elderplan
New York, NY
04.2008 - 03.2025
- Facilitated communication between assigned, contracted providers and the health plan.
- Ensured compliance with health plans policies and procedures among providers and staff.
- Monitored adherence to contractual obligations within the network by providers and their staff.
- Assist providers with any contract, claims issues, and demographic updates.
- Ensured that the provider and key administrative staff are educated on any changes to the members' plans.
- Collaborated with the Credentialing department to ensure the completion of applications that were overdue for re-credentialing or had lost their privileges to delegated hospitals.
- Collaborated with the Quality Management Department in retrieving medical records for HEDIS, and ensured providers completed Gaps in Care to better star ratings.
- Collaborated with the Pharmacy Department to ensure providers complied with CMS measures for prescriptions for chronic members. Verified compliance through the CVS Mart application.
- Collaborated with Sales and Marketing in campaigning for members for providers.
- Assisted ancillary staff with conducting annual site inspections for Social Adult Day Care with the Department of Health.
In-House Provider Service Representative
Healthcare Partners, IPA/MSO
Garden City, NY
02.2006 - 04.2008
- Serve as a liaison to the IPA and administrators.
- Assisted the physician with any contract issues. Resolve demographic, claims issues, and track utilization, compliance trends, and all reimbursement issues.
- Assist with the recruitment of physicians.
- Handle termination reports for physicians, and also the Quality Improvement/Utilization Management reports.
- Create and update monthly reports for physicians' incentive programs.
Customer/Clinical Service Representative
Healthcare Partner, IPA/MSO
Garden City, NY
10.2003 - 02.2006
- Initiated phone calls to physicians and members in a call center environment. Handle and resolve issues in a prompt and courteous manner through high call volume.
- Responsible for documenting and forwarding claims inquiries and medical reviews to the appropriate department.
- Managed each call by applying suitable actions to rectify issues, which involved claims reconsideration, referrals, and provision of explanations of benefits.
- Initiated authorization referrals if deemed necessary.
- Responded to any calls or correspondence in regard to billing, eligibility, benefits, claims, and medical policies.
Education
Some College (No Degree) - Opthalmic Dispensing
New York City College of Technology
Brooklyn, NYSkills
- Regulatory compliance
- Network management
- Managed Care Operations
- Microsoft Office Suites
- Communication skills
- Health plan operations
- Data analysis
- Team collaboration
References
References available upon request.
Timeline
Provider Relations Representative
Elderplan
04.2008 - 03.2025
In-House Provider Service Representative
Healthcare Partners, IPA/MSO
02.2006 - 04.2008
Customer/Clinical Service Representative
Healthcare Partner, IPA/MSO
10.2003 - 02.2006
Some College (No Degree) - Opthalmic Dispensing
New York City College of Technology
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