Jeffrey Perez
Rogers,AR
Summary
Healthcare professional with extensive experience in complex contract negotiations, health plan operations, quality initiatives, and leading performance improvement projects service delivery. provider education, analytics, and customer service. Strong professional with demonstrated experience developing innovative solutions, process improvement, and management.
Overview
11
11
years of professional experience
Work History
Market Contract Manager
CareSource Management Services
04.2021 - 10.2023
- Lead statewide contacting efforts with large systems, provider organizations, and complex health providers for health plan implementation resulting in achieving statewide network adequacy.
- Collaborated across cross-functional teams to review and counter contract redlines reviews and reimbursement terms in accordance to regulatory and business requirements.
- Conducted gap analysis to identify network deficiencies and develop contracting strategy to meet regulatory network guidelines.
- Supported network contracting functions related to credentialing and provider loading to ensure applications and configuration completed with in regulatory on company guidelines.
- Support strategies to create a value-based reimbursement strategy according to corporate guidelines.
- Cultivate strong, positive relationships with key providers by coordinating, facilitating, and leading partnership meetings and conducting in-service trainings and education.
- Contribute to and enhance audit and validation processes to maximize quality management standards and network integrity.
- Provider support for team as Subject Matter Expert for contracting and provider service models.
Provider Network Manager
Summit Community Care (Anthem)
09.2018 - 04.2021
- Lead statewide contacting efforts with large systems, provider organizations, and complex health providers for health plan implementation resulting in achieving statewide network adequacy.
- Work with hospital physician advocates, legal team and healthcare economics on complex and / or critical issues.
- Conducted gap analysis to identify network deficiencies and develop contracting strategy to meet regulatory network guidelines.
- Research and resolve provider related contract issues.
Collect and review provider enrollment information to determine providers eligibility to participate in Medicaid, through screening the providers' credentials. - Cultivate strong, positive relationships with key providers by coordinating, facilitating, and leading partnership meetings and conducting in-service trainings and education.
- Experience in a network management-related role, such as provider data management, contracting, installation, enrollment, or provider services.
Grievance and Appeals Analyst
Anthem
05.2017 - 09.2018
- Contact and respond to members and providers within required timeframes as required by contracts, regulations, and standards.
- Prepare written materials following policies and procedures for notification and tracking purposes of appeals and provider disputes.
- Consult with manager on problem cases and interfaces with unit staff in data obtainment and resolution.
- Prepare and present information on non-authorizations, appeals and provider disputes to external review organizations and customers.
- Assist in data gathering and reporting of non-authorizations, appeals and provider disputes.
Customer Care Representative
Anthem Blue Cross
08.2013 - 05.2017
- Respond to telephone and written inquiries regarding claims, adjustments, plan benefits, policies and eligibility.
- Resolve issues presented both internally and externally in a timely matter.
- Process claims and adjustments to meet production standard set for the unit. Audit claims in question to determine if adjustments are needed.
- Explain in detail plan benefits for both retirees and active employees.
- Train new employees on how to use review benefits on multiple platforms.
Customer Service Operations
Coventry Health Care
01.2013 - 08.2013
- Process basic/moderately complicated claims, enrollments, and/or adjustments in accordance with company policies.
- Met or exceeded productivity and quality goals.
- Research and respond to customer inquiries; interface with customers via telephone, written correspondence, fax, web, and/or electronic mail. Investigate, analyze, and resolve outstanding issues to achieve customer satisfaction.
Education
Bachelor of Science - Accounting
University of Phoenix
Online05.2024
Skills
- Managed Care Contracting
- Medicaid and Medicare
- Policy Development
- Innovative Strategies
- Service Optimization
- Quality & Affordability Initiatives
- Account Management
- Health Plan Operations
Accomplishments
Implementated healthplans for Summit Community Care and CareSource for the Arkansas Medicaid.
Timeline
Market Contract Manager
CareSource Management Services
04.2021 - 10.2023
Provider Network Manager
Summit Community Care (Anthem)
09.2018 - 04.2021
Grievance and Appeals Analyst
Anthem
05.2017 - 09.2018
Customer Care Representative
Anthem Blue Cross
08.2013 - 05.2017
Customer Service Operations
Coventry Health Care
01.2013 - 08.2013
Bachelor of Science - Accounting
University of Phoenix
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