Joshua Villarreal
Miramar,FL
Summary
I am an experienced and accomplished professional with a proven track record in healthcare, specializing in customer service, claims management and the strategic development of provider networks. Effective communicator and excellent eye for detail enabling quick identification of areas for improvement. My unwavering passion in delivering unparalleled service to the Health plans, members and community providers.
Overview
12
12
years of professional experience
Work History
Sr Network Management Consultant
Independent Contractor Consultant / Self Employed
12.2019 - Current
- Evaluate and negotiate contracts in compliance with the health plan's contract templates, reimbursement structure standards and regulatory process controls.
- Expert in performing network adequacy and network gap analysis
- Execute fee schedule development using actuarial models
- Build and establish adequate provider networks across various counties in Florida, Illinois, Kentucky, Georgia, North Carolina Texas, California, and Tennessee.
- Negotiate and contract independent physicians, small and large physician groups, IPA's and ancillary providers for various product lines, Commercial, Medicare, Medicaid, ACA and D-SNP
- Responsible for the collection of credentialing documents from providers
- Cultivated positive relationships with physicians, office managers, compliance officer and staff
- Conduct meetings to review monthly reports with Quality and Clinical care teams
- Ensure provider education and training in the referral process, claims submissions and customer service.
- Assist medical staff to navigate provider portals
- Gathered, organized and input information into digital database.
- Developed and updated tracking spreadsheets for process monitoring and reporting.
- Improved operational efficiency with thorough analysis, identifying areas of improvement in provider performance metrics.
- Managed strategic initiatives for the development of long-term relationships with key providers, ensuring consistent high-quality care for members.
- Conducted comprehensive on-site reviews to evaluate service quality, adhering to regulatory requirements and company standards.
- Facilitated resolution of complex claims disputes between providers, members, and insurance carriers in a timely manner.
Senior Provider Relations Advocate
Preferred Medical Plan
07.2014 - 10.2019
- Streamlined provider relations by developing effective communication strategies and addressing concerns promptly.
- Enhanced network performance by evaluating provider contracts and negotiating favorable terms.
- Identified areas for improvement in provider satisfaction through regular surveys and feedback sessions.
- Improved claims processing efficiency by implementing standardized procedures and providing ongoing training to providers.
- Research, analyze and develop new provider leads in Miami-Dade
- Assisted and facilitated provider's claims and appeal process.
- Review internal data and analytic reports with providers, to identify quality and financial performance improvements.
- Ensured compliance with industry regulations by monitoring changes in legislation and updating policies accordingly.
- Developed targeted education initiatives for providers to improve understanding of processes, guidelines, and best practices.
- Optimized reporting processes to track key metrics related to provider relations activities more efficiently.
- Cultivated long-lasting relationships with influential providers, fostering trust and loyalty towards the organization.
- Acted as a liaison between the company and providers, maintaining open channels of communication to ensure smooth collaboration.
- Answered provider inquiries via email, telephone and written correspondence.
- Identified network gaps and collaborated with recruiters to fill deficiencies.
- Assisted with physician recruitment by identifying specific providers within designated territories, negotiating rates for new physicians and distributing provider agreements.
- Optimized customer experience by delivering superior services and effectively troubleshooting issues.
- Evaluated staff performance and provided coaching to address inefficiencies.
Transaction Analyst
Automated Health Care Solutions
01.2012 - 06.2014
- Responsible for handling 35-50 billing inquiries daily and processing transactions for payment
- Managed collections of past-due balances for Workers' Compensation claims.
- Knowledgeable of Workers' Compensation regulations for each state throughout United States to ensure we are billing per state guideline
- Disputed past-due claims and appealed for payments.
- I updated patient information, verified accuracy, and ensured HIPPA compliance.
- Communicated with insurance adjusters, reconciliation claims payment
- Streamlined transaction processing by implementing efficient verification procedures.
- Enhanced transaction accuracy by diligently reviewing financial documents and records.
- Improved system efficiency, performing regular audits on financial data and transactions.
- Collaborated with team members to resolve complex transaction issues promptly and accurately.
- Demonstrated strong attention to detail while validating critical information contained within each transaction.
- Supported successfully integrating new systems or technologies to improve overall transaction analysis capabilities.
- Actively collaborated with colleagues across various departments to develop innovative strategies for addressing complex financial challenges related to transaction management.
- Researched billing and invoice problems and resolved issues in compliance with established standards.
Education
Bachelor of Arts - Business
Florida International University
Miami, FL05.2012
Skills
- Employee Management
- Management Coaching
- Failure Analysis
- Quality Assurance
- Healthcare Customer Service Expertise
- Bilingual fluency English/Spanish
- Advanced Skills in Microsoft (Outlook, word Excel, Teams, PowerPoint)
- Claims, provider management, and CRM platforms; Emptoris, MedNet, Availity, -SalesForce, ZoHo HubSpot, Slack, Compass and Visitar
- Exceptional Interpersoanl skills, managing multiple projects simultaneously
- Excellent verbal and written communications skills, ability to prioritize effectively and work independently, ability to gather and analyze information and communicate to others
- Time management and organizations kills, ability to work well with others and communicate effectively
- Attention to detail, resourceful and dependable
Timeline
Sr Network Management Consultant
Independent Contractor Consultant / Self Employed
12.2019 - Current
Senior Provider Relations Advocate
Preferred Medical Plan
07.2014 - 10.2019
Transaction Analyst
Automated Health Care Solutions
01.2012 - 06.2014
Bachelor of Arts - Business
Florida International University
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