MYKA L. TURNER

• Review of new contracts, determining if there are Agreements built to support the Compensation language within contract or if new agreements need to be built by Configuration. Once this is determined, work with appropriate Teams to get correct Agreement loaded on record or work with correct Teams to get Agreement built, get Agreements placed in Agreement Tool for future use and communicate new Agreement details to Teams so it placed on records as warranted. Main responsibility is running and maintaining the Anomaly Report, identifying where incorrect Agreements have recently been placed on records and work through resolution to prevent Provider abrasion later.
• Achievements: Worked with Leadership on build and processes of the Anomaly Report.

Served as the primary contact for Providers in Northeast Georgia. Meetings, calls and/or emails take place with Provider Representatives and any issues/concerns communicated are addressed to ensure performance improvement within the Practices. Assistance is provided in array of areas, from completing contracts, system loading, claim issues, portal inquiries, Policy and Procedures updates, EDI set up, etc. The issues/concerns reported by Providers are routed to appropriate internal Teams for resolution via one of the many tools used by the Teams.

Achievements: Built new, lasting relationships for CareSource through building of the Medicaid, Marketplace and DSNP Networks within my Region, North Georgia. Assisted many Therapy Groups with claim issues, through resolution, when multiple systemic issues were identified. Worked with internal Teams to resolve multiple load and claim issues under every Plan.

• Developed strategic partnerships to enhance member engagement and improve health outcomes.
• Provided outstanding service to all individuals, promoting effective, and lasting business relationships.
• Stayed informed on industry developments and market trends to gain competitive advantage.
• Achieved successful client outcomes by identifying and addressing their unique needs and goals.

• Serve as primary contact for contracted Providers. Conduct monthly meetings with Provider Account Representatives, documenting attendees, discussions, action items related to Credentialing and Contracting and research claim issues. All issues are then routed to appropriate departments within UHC or are entered in tracking system for research and Provider follow up. Submit claim projects as needed where rate loads occurred or incorrect fee schedule loads occurred. Provide education on Policy and Procedure changes and/or updates, claim submissions, web site usage, EDI set up, and related topics for performance improvement within Practices. Liaison between Provider and Networking when there are questions, issues and/or concerns relating to data entry of Provider demographic information changes. Travel for Meetings, Townhalls, Expos and/or Training Sessions.
• Achievements: Building relationships for UHC as there has been no company representation in the area prior. Cleaning up load and/or claim issues for Groups that have been trying for months on their own to resolve. Personal outreach is 40+ Providers a month plus contacts made via email or phone.

• Serve as primary contact for Providers, being liaison between the Providers and PSHP. Conduct monthly meetings with Provider Account Representatives, documenting attendees, discussions, action items related to Credentialing and Contracting and research claim issues and then route all to appropriate departments within PSHP. Receive and respond to external Provider related issues. Provide education on Policy and Procedure changes and/or updates, claim submissions, web site usage, EDI set up, and related topics for performance improvement within Practices. Initiate data entry of Provider related demographic information changes and oversee completion of these requests. Travel.
• Achievements: Achieved goal of outreaching to 90%+ Providers in assigned territory. Providers in assigned territory never had a Provider Representative to reach out to, rebuilt many relationships, resolved many aged issues, and strengthened Provider opinions about PSHP. Territory working was largest area opened up for participation under Ambetter. Educated providers, assisted through set up hurdles and initial claim issues.

• As Credentialing Specialist: Obtained, researched and prepared all documents needed for a Providers file to be presented to the Credentialing Committee. Set up meetings, maintained files, ran monthly monitoring items as required, ran rosters when requested by each Payor, handled chart preparation for all Payor audits as well as providing Payors all other items needed to complete the audits other than Provider files. Made all changes in database from TIN additions/changes, name and location changes to entering all new Provider data. Maintained Policy and Procedures to ensure they follow NCQA Guidelines. Working with a couple of Payors on obtaining delegated credentialing. Working to get CAAP accredited under NCQA.
• As Managed Care Contract Specialist: Primary contact person for Providers staff to come to with claim issues, underpayments, billing questions, or wanting to become a participating Provider under a Payor that CAAP has contracts with. Worked directly with Payor Representatives in getting Providers loaded with correct information and effective dates under CAAPs contracts and fee schedules. Maintained database with all issue and loading details. Set up and attended meetings with Providers and staff when needed, presenting agenda, answering questions on open issues, etc.
• Achievements: Re-built Provider and staff relationships, ensuring CAAP is stable and works for them. Built new relationships with Payor Representatives, working to resolve issues Providers were having. Claim resolution, resulting in Additional reimbursement to several Providers.

• Held several positions at STMH as advancement opportunities were presented.
• Patient Financial Services (PFS): 03/2005 to 05/2007 Customer Service: Answered phones, worked with other departments within Hospital to clear up issues with accounts, opened and distributed mail, reviewed statements and prepared for mailing, worked return mail Back-Up Cashier: Answered phones, assisted patients with account issues, collected payments from all departments within the facility, balanced and closed drawers at close of business day. Government Collection Analyst: Primary focus was Medicaid. Worked remits to ensure correct payments were received and worked denials. Kept up with updates daily and kept manuals updated. If any changes was needed in billing or forms, was responsible for communicating this to Management and any Departments the changed affected. Was primary contact for WellCare, Amerigroup and PeachState. Worked remits and denials for these Payors as well as TriCare.
• Managed Care: 06/2007 to 06/2012 Performed audits on Managed Care payor accounts in order to ensure payments were correct. Continuous monitoring of specific items, contract related (i.e., Stop Loss, HCD, implants, bilateral procedures, carve outs and any other complex payment methodology that had a tendency to be processed incorrectly by Payors). Assist in review and analysis of Managed Care contracts in order to assist in negotiations of new contracts and/or amendments. Communicated directly with the Payor Provider Reps with contract issues. Follow up behind new contracts and/or amendments to ensure payments are correct. Primary contact with PFS when incorrect payment trends occur or any other department is affected. Maintained Managed Care contract books. Worked directly with Payors when there were rate increases at the Hospital, new services were going to be performed, etc. Worked directly with the Payor Reps on single case agreements, got LOA’s in place and monitored these accounts to ensure payments were correct.
• Achievements: Audits resulted in finding $1M+ annually that was not paid to STMH due to claims not being adjudicated correctly under contracted terms. Goal met, securing 70% of audit amounts found not paid.
• Chiropractic and Dental Experience prior to employment at St. Mary’s HealthCare System. Details available upon request.