Kimberly Elam
Houston,TX
Summary
Adaptable healthcare professional with more than 20 years of progressive experience in contract negotiations, project management, process implementation, and relationship management. Exceptional at identifying opportunities to meet changing business needs, drive revenue growth, and improve capabilities. Solid record of consistently exceeding institution goals by providing knowledge to support the direction of large healthcare facilities, physician organizations, and health plans.
Overview
16
16
years of professional experience
Work History
Senior Contracts Administrator
TEXAS CHILDRENS HEALTH PLAN
02.2023 - 07.2024
- Negotiates hospital contract language and rates using established parameters/guidelines
- Makes recommendations to management regarding contracting strategy when contract proposals are not within Network Development established parameters/guidelines
- Conducts financial analysis of claims data to develop rate proposals and to evaluate reasonableness of all assumptions
- Evaluates hospital claims data to determine service lines which influence medical expenses
- Monitors hospital claims data to identify opportunities for re-negotiation
- Develops and maintains successful business relationships with participating hospitals
- Documents visits with hospitals in call tracking system
- Submits hospital visit reports in accordance with departmental policies and procedures
- Demonstrates proficiency with Texas Department of Insurance regulations relating to hospital contracting
- Demonstrates proficiency with product requirements relating to provider contracting
- Recommends amendments to policies and procedures as needed to maintain compliance
- Assists in the development of contracting strategy for high volume, strategic providers
- Receives and reviews completed contracting documents from providers and forwards to credentialing department
- Communicates provider trends to management and other parties as appropriate in a timely manner.
Senior Contract and Provider Relations Manager
FRIDAY HEALTH PLANS
06.2022 - 11.2022
- Negotiated, contracted, and credentialed all physician, hospital, ambulatory surgical centers, and ancillary provider types
- Directed the day-to-day activities of all Contract/Provider Relations Managers
- Developed and ensured execution of a market-wide provider network plan that aligned growth, network performance, and other market activities, as appropriate, considering direction and input from organizational leadership
- Worked to negotiate provider contracts and rates in support of the overall strategy and direction of the health plan
- Developed, managed, and sustained strategic relationships with network providers in an assigned territory
- Performed face-to-face visits with key providers and practice managers for network maintenance
- Maintained large facility and group practice relationships
- Lead negotiations, rate modeling, and implementation of new and existing contracts.
- Fostered strong, positive relationships with key providers by coordinating, facilitating, and leading partnership meetings.
Provider Relations Account Lead
TEXAS CHILDREN'S HEALTH PLAN
10.2020 - 06.2022
- Oversaw assigned TCHP network provider contract relationships to promote communication, excellent service, process improvement, education, and development
- Planned, directed, and maintained strategies that assure harmonious relationships are established and maintained with physicians and other providers
- Management of provider issues related to continuity of care, system configuration, contracting, authorization, billing, and HHSC and TDI complaints
- Managed complex provider contract relationships involving regular engagement and collaboration under continuous regulatory change
- Created community outreach opportunities for marketing and educational purposes
- Investigated complaints, documented findings, and made recommendations that adjudicate the complaints so that the health plan is compliant with TDI, HHSC and any other regulatory agencies as appropriate.
Provider Relations Manager
TEXAS CHILDREN'S HEALTH PLAN
02.2017 - 10.2020
- Established and maintained relationships with physicians within a discreet assigned territory to provide efficient, effective care to TCHP membership
- Promoted continuing education classes and other educational programs that supported the goals and objectives of the health plan
- Routine decisions included resolving managed-care, claims, and medical management issues independently, serving as a second level resource to providers and peers
- Determined the educational needs of provider network and team members; initiating appropriate training programs for each group; and serving as mentor for team members
- Assured compliance with TDI rules and regulations as they relate to network accessibility & provider credentials.
Senior Revenue Cycle Liaison
TEXAS CHILDREN'S PHYSICIAN SERVICES ORGANIZATION
07.2011 - 02.2017
- Managed and coordinated all aspects of the day-to-day activities relating to the revenue cycle process which included, physician education, coding, charge capture, professional fee billing, denial trending, EPIC EMR functionality, compliance, and general analytics
- Served as a physician advocate through the optimization of physician revenue cycle processes, ensuring compliance with coding rules and regulations, and searching for potential revenue enhancement by interacting with third party payers
- Implemented and maintained strategies to increase physician reimbursement for both the public and private sector
- Met routinely with TCPSO colleagues, physicians, and hospital management to present departmental progress and challenges to improve operational effectiveness
- Analyzed project goals, prepared a timeline for project completion, and developed action plans for project completion from inception to evaluation
- Maintained maximum knowledge related to commercial and government billing regulations, while continually communicating billing requirements and updates to appropriate staff and physicians.
Lead Ambulatory Services Representative
TEXAS CHILDREN'S HOSPITAL
09.2009 - 07.2011
- Supervised insurance verification team, managed patient complaints, processed insurance verification/pre-certifications
- Processed clinic billing and reconciliation of outpatient and inpatient charges
- Processed reports of outstanding charges to physicians and clinic manager
- Setup financial arrangements for clinic visits
- Researched insurance denials and provided documentation to TCPSO during monthly meetings
- Trained new employees, provided back-up coverage for scheduling and front desk areas, maintained staffing index, audited accounts of insurance verifiers, addressed problems/issues in the pre-admit area
- Developed/organized workflows, assisted providers with insurance issues
- Collaborated with clinic's liaison from TCPSO on billing and insurance matters.
Financial Counselor
TEXAS CHILDREN'S HOSPITAL
12.2008 - 09.2009
- Communicated with families or guarantors to screen for financial assistance using government assistance guidelines if the patient is self-pay or if insurance benefits do not cover the entire cost of clinic visit
- Verified insurance eligibility and benefits
- Obtained authorization or precertification as needed
- Maximized front-end collections by quoting and collecting deposit amounts for patients with an unsecured funding source
- Managed unique billing and customer service questions and issues with families in a sensitive manner.
Education
Bachelor of Science in Psychology -
University of Houston – Main Campus
Houston, Texas05.2025
Skills
- Contract Administration
- Contract Management
- Contract Negotiation
- Network Management
- Project Management
- Process Improvement
- Revenue Cycle Management
- Customer Relationship Management
- Data Analysis
- Policy Interpretation
- Regulatory Compliance
- Contract terms negotiation
- Regulatory knowledge
- Legal Compliance
- Dispute Resolution
- EPIC
- PeopleSoft
- Microsoft Office Suite
- QNXT
- Macess
- WebEx
- Adobe PDF/PDF Creator
- Salesforce
- DocuSign
Timeline
Senior Contracts Administrator
TEXAS CHILDRENS HEALTH PLAN
02.2023 - 07.2024
Senior Contract and Provider Relations Manager
FRIDAY HEALTH PLANS
06.2022 - 11.2022
Provider Relations Account Lead
TEXAS CHILDREN'S HEALTH PLAN
10.2020 - 06.2022
Provider Relations Manager
TEXAS CHILDREN'S HEALTH PLAN
02.2017 - 10.2020
Senior Revenue Cycle Liaison
TEXAS CHILDREN'S PHYSICIAN SERVICES ORGANIZATION
07.2011 - 02.2017
Lead Ambulatory Services Representative
TEXAS CHILDREN'S HOSPITAL
09.2009 - 07.2011
Financial Counselor
TEXAS CHILDREN'S HOSPITAL
12.2008 - 09.2009
Bachelor of Science in Psychology -
University of Houston – Main Campus
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