Loudgy Gilles
Hockessin,DE
Summary
Experienced healthcare operations leader with 15+ years in managed care. Specializing in provider networks, data management, and compliance with ACA and HIPAA regulations. I have a strong history of streamlining workflows and managing vendors to boost sales and maintain data accuracy. As a dedicated team player with a fixation for efficiency, I’m passionate about driving efficiency in healthcare.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Senior Vendor Management
Emblem Health Insurance
New York, NY
12.2019 - 02.2025
- Oversaw end-to-end contract management for provider network vendors, ensuring accurate provider information in claims databases.
- Coordinated data synchronization among multiple claims systems, applying business rules across databases.
- Collaborated with IT, Business Systems, Claims, and Provider Services to enhance systems and improve processes.
- Developed and monitored contract performance standards, conducting root cause analysis and implementing corrective action plans.
- Implementation of new programs coordinating EPMO and IT projects related to vendor contracts.
- Reviewed vendor performance and provided feedback for service improvement.
- Coordinated vendor contracts and negotiated terms for service agreements.
- Facilitated communication between vendors and internal departments for seamless operations.
- Supported training sessions for staff on effective vendor management practices.
Behavioral Health Case Manager
North Shore LIJ
Manhasset, NY
12.2016 - 11.2019
- Coordinated with healthcare providers to ensure comprehensive treatment for clients.
- Assessed client needs and developed tailored care plans for diverse populations.
- Documented case notes and maintained accurate client records in electronic systems.
- Assessed patients to identify individual needs and created care plans to address objectives and goals as identified during evaluation.
- Coordinated counseling efforts with mental health professionals, doctors, nurses and social workers.
- Managed comprehensive care coordination for members with complex health conditions, ensuring optimal utilization management, and provider network coordination.
- Database Management: Maintained accurate member and provider information across care management systems.
- Followed up with previous clients after discharge from program to monitor progress over time.
- Advised family members about available resources for providing support to their loved ones with mental illness.
Outreach Marketing & Provider Relations
North Shore Care Connect
Great Neck, NY
11.2012 - 11.2016
- Developed and implemented provider network strategies for a startup managed care organization, building comprehensive provider databases, and establishing key relationships.
- Conducted comprehensive research and data analysis to support strategic planning and informed decision-making.
- Provider Network Development: Led a direct outreach campaign connecting with community-based organizations and providers, resulting in a 200% increase in network participation.
- Database Creation: Established foundational provider databases and data management processes for a startup organization.
- Account Management: Served as the primary contact for providers and vendors, ensuring accurate provider data and contract compliance.
Appeals Management & Insurance Verification
North Shore Lij Hospital
New Hyde Park, NY
04.2005 - 11.2012
- Managed complex provider data verification, claims processing, and appeals management across multiple healthcare systems.
- Provider Data Accuracy: Coordinated electronic billing transfers and maintained accurate provider information across multiple systems.
- Claims System Management: Resolved claim payments based on provider status, benefit coordination, and regulatory requirements.
- Process Improvement: Developed a comprehensive knowledge base for government regulations, benefit coordination, and healthcare terminology.
- Vendor Relations: Served as the chief liaison between the organization and providers.
Education
MBA - Health Care Management
American InterContinental University
Schaumburg, IL06-2009
Bachelor of Science - Business Administration
Monroe College
Bronx, NY06-2003
Skills
- Provider network management and data configuration
- Database management and system integration
- Regulatory compliance and audit support
- Healthcare claims processing and provider relations
- Project management and implementation
- Issue resolution
- Provider relations
- Contract management
- Vendor negotiation
- Data analysis
Certification
- Affordable Care Act (ACA) Compliance
- HIPAA Privacy Laws
- Provider Credentialing Standards
- Healthcare Claims Management
- Vendor Contract Management
Custom
TECHNICAL PROFICIENCIES
- Healthcare Database Management Systems
- Claims Processing Platforms
- Microsoft Office Suite (Advanced)
- Provider Network Management Software
- Regulatory Compliance Systems
- Project Management Tools
Timeline
Senior Vendor Management
Emblem Health Insurance
12.2019 - 02.2025
Behavioral Health Case Manager
North Shore LIJ
12.2016 - 11.2019
Outreach Marketing & Provider Relations
North Shore Care Connect
11.2012 - 11.2016
Appeals Management & Insurance Verification
North Shore Lij Hospital
04.2005 - 11.2012
MBA - Health Care Management
American InterContinental University
Bachelor of Science - Business Administration
Monroe College
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