Mayra Palacios
Los Angeles,CA
Summary
Enthusiastic Provider Network Account Manager with 29 years extensive experience with network development and building relationship with Management Services Organizations, Participating Physician Groups, Ancillary Groups, Hospitals and Providers. Able to work independently in a fast-paced environment and manage multiple tasks.
Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Overview
1
1
Language
1
1
Certification
35
35
years of professional experience
Work History
PROVIDER NETWORK ACCOUNT MANAGER III
L.A. Care Health Plan
11.2015 - Current
- Implement and oversee multiple areas for the development of L.A. Care Direct Network
- Contracting Primary Care Physicians and Specialty Care Physicians throughout L.A. County, negotiate rates, processing contracts from initiation through implementation and training.
- Determine Network Adequacy of Specialists for L. A. Care Direct Network and focused contracting efforts on provider network deficiencies.
- Conducted onboarding training for new providers to ensure compliance with DMHC, DHCS, CMS, NCQA, and HIPAA regulations.
- Re-serviced existing providers annually to maintain up-to-date knowledge of policies and procedures.
- Collaborated with internal departments and primary care physicians to analyze HEDIS performance and implement improvements.
- Educate oversight and interact with assigned RCAC Regions to ensure providers understand and comply with their contracts, policy and regulatory requirements.
- Coordinate and work effectively with internal departments regarding complex claims and authorization issues.
- Collaborate with internal departments (including Utilization Management, Transhealth, DHS) to secure that members have access to L.A. Care Specialist when standard network options are unavailable.
PROVIDER RELATIONS REPRESENTATIVE
Conifer Value Based Care
01.2006 - 01.2015
- Incorporated solutions to assigned networks under challenging financial circumstances, enhancing network satisfaction.
- Leverage strong claims negotiation skills to consistently achieve optimal and monetary savings for PPG’s.
- Negotiated high dollar claims prior to the health plans. Cap-Deducting the PPG’s.
- Network development for new clients from beginning to end. Including contract negotiation and managing all aspects of implementation.
- Developed and maintained positive relationships with Primary Care Physicians, Specialty Care Physicians and Ancillary Providers.
- Provided education on network policies and procedures to ensure compliance.
- Facilitated physician and office manager forums and delivered in-service and new provider training to meet regulatory requirements.
- Resolved provider issues received from internal and external resources.
- Responsible for maintaining a high RAF and HEDIS Score.
MEMBER SERVICE LEAD
Health Net Health Plan
01.1997 - 01.2005
- Directed daily performance of 25-30 Member Service Representatives.
- Coordinated workflow for staff handling telephone and correspondence inquiries from members, providers, hospitals, and ancillary providers to ensure timely and effective responses.
- Improved business unit responsiveness by identifying areas for enhancement and implementing new customer service practices.
- Created more responsive business unit by identifying areas for improvement and implemented new practices for customer servicing.
- Led Customer Service Department to assist members in Medi-Cal, Healthy Families, and AIM Programs, enhancing service delivery and support.
- Supported the Disenrollment and Grievance Department by managing case files and facilitating communications.
- Reconciles complex issues.
- Assisted with developing guidelines, training manuals and multiple projects.
- Provided accurate and excellent service to internal and external customers.
OFFICE ADMINISTRATOR
United Interpreting Service
01.1992 - 10.1996
- Enhanced staff productivity and performance by implementing operational guidelines.
- Supervised 45 employees and all staff related functions, including processing payroll, hiring and training.
- Oversaw day-to-day office operations, ensuring effective administrative and customer service functions.
- Supervised 45 employees, managing payroll, hiring, and training processes.
Education
High School Diploma - High School
DIVINO CORAZON DE JESUS
Business Administration -
East Los Angeles College
Skills
- Provider engagement expertise
- Effective contract negotiation, evaluation, and execution
- Data analysis tools
- Policy Development
- Execution of best practices strategies
- Leadership
- Effective team leadership
- Regulatory compliance
- Results-driven mindset
- Healthcare billing knowledge
- Dedicated work ethic
- Fluent in English and Spanish languages
Certification
Delivery and Business of Healthcare, Clinical Documentation for Diagnosis Coding, ICD-10 for Non-Coders
Languages
Bilingual – Fluent in English and Spanish
Timeline
PROVIDER NETWORK ACCOUNT MANAGER III
L.A. Care Health Plan
11.2015 - Current
PROVIDER RELATIONS REPRESENTATIVE
Conifer Value Based Care
01.2006 - 01.2015
MEMBER SERVICE LEAD
Health Net Health Plan
01.1997 - 01.2005
OFFICE ADMINISTRATOR
United Interpreting Service
01.1992 - 10.1996
High School Diploma - High School
DIVINO CORAZON DE JESUS
Business Administration -
East Los Angeles College