Summary
Work History
Education
Skills
Interests
Additional Information
Quote
Timeline
48
Nancy Vasquez

Nancy Vasquez

Stockton,CA

Summary

Results-oriented Provider Relations Representative with extensive experience in the healthcare industry. Adept at building and maintaining strong relationships with healthcare providers and managing complex provider networks. Proven track record in acting as an effective liaison, resolving escalated claims, and ensuring compliance with health plan policies. Expertise in client service, administration, and communication, with a focus on improving provider relations and operational efficiency. Skilled in large group installations, renewals, and provider changes, demonstrating strong time management and critical thinking abilities. Proficient in Microsoft 365 and other relevant software tools.

Work History

Provider Relations Representative I

Gold Coast Health Plan
02.2023 - 06.2024
  • Remotely managed provider delegated lists and performed provider data entry for all incoming and terminating providers, maintaining 100% accuracy across 50+ provider groups
  • Reviewed and addressed 200+ daily incoming emails, resolving claim complaints, appeals, and grievances, achieving a 95% resolution rate
  • Acted as liaison to assigned providers/vendors, ensuring timely communication and updates for over 40 provider groups, resulting in improved provider satisfaction
  • Analyzed and resolved complex provider relations issues and escalated claims, leading to a 20% reduction in nonpayment and underpayment disputes
  • Conducted timely data entry for new providers across large groups, ensuring all records were updated within 24 hours to maintain compliance with health plan standards

Provider Relations Representative

Blue Shield of California
09.2019 - 01.2023
  • Collaborated with department management to evaluate, plan, and maintain HMO networks of 50+ primary care physicians, IPAs, multi-site groups, specialist physicians, and ancillary service providers, ensuring 100% compliance with health plan standards
  • Acted as liaison to assigned providers/vendors, keeping over 40 groups informed and updated, leading to a 15% increase in provider satisfaction
  • Developed and managed relationships with large and complex provider groups, including IPAs and PHOs, achieving a 98% provider retention rate
  • Analyzed and resolved complex provider issues, including contract discrepancies in claims, reducing disputes by 25%
  • Conducted monthly, quarterly, and annual provider reviews, ensuring adherence to company policies and improving overall provider performance metrics by 10%

Customer Service Representative

Aerotek for Blue Shield of California
08.2018 - 04.2020
  • Managed intermediate large group installations and renewals, ensuring seamless transitions for over 100 clients annually
  • Processed new and renewal applications for large groups during open enrollment, achieving 98% accuracy and on-time completion
  • Conducted outreach to employers to resolve application errors, reducing processing delays by 30%
  • Collaborated with internal teams to streamline workflows, improving application processing efficiency by 15%

Intermediate Member Level Processor

Volt Workforce for Blue Shield of California
09.2017 - 03.2018
  • Assisted in the assignment of Primary Care Physicians for Individual Family Plans during open enrollment, ensuring timely and accurate updates for over 1,000 members
  • Reviewed and processed employer applications, verifying the correct update of member information to prevent coverage lapses, achieving a 98% accuracy rate
  • Conducted outreach to employers to resolve discrepancies in applications, improving data accuracy by 15%
  • Updated member profiles upon identifying system errors, reducing processing time by 20%
  • Collaborated with internal teams to troubleshoot and resolve system issues, resulting in a 25% reduction in coverage errors

Intermediate Correspondence/Phone Support Medicare Supplement

Volt Workforce for Blue Shield of California
09.2016 - 08.2017
  • Resolved customer inquiries and processed claims accurately, adhering to production and quality standards, achieving a 95% issue resolution rate within specified timeframes
  • Collaborated with cross-functional teams to ensure timely and appropriate responses, reducing response times by 20%
  • Expedited and resolved complex claim issues, initiating claim adjustments and reducing escalation rates by 15%
  • Educated clients on Blue Shield products, policies, and procedures, increasing overall customer satisfaction by 30%
  • Navigated multiple platforms and applications efficiently to complete processing tasks, maintaining a 98% accuracy rate in data retrieval and task completion

Senior Customer Care Representative

Blue Shield of California
04.2012 - 03.2016
  • Delivered telephone and online customer service for Medicare Supplement and Individual Family Plan members, managing over 100+ calls daily in a high-volume call center with an average first-call resolution rate of 90%
  • Resolved customer concerns in a timely manner, consistently meeting or exceeding call center benchmarks for customer satisfaction and response time
  • Promoted to the Correspondence Processing team, handling premium email correspondence, reinstatements, and refunds across all business lines, processing an average of 50+ requests daily with 98% accuracy
  • Collaborated with the Business Readiness team to perform User Acceptance Testing (UAT) for letter server access, ensuring seamless integration and functionality for system upgrades

Education

Bachelor of Science (BS) - Criminal Justice Administration

University of Phoenix
Phoenix, AZ

POST Basic Police Academy -

Monterey Peninsula College
Monterey, CA

Reserve Fire Academy -

College of San Mateo
San Mateo, CA

Reserve Police Officer Academy -

Canada College
Redwood City, CA

Skills

  • Claims Resolution and Analysis
  • Large Group Install and Renewal Processing
  • Compliance with Health Plan Policies
  • Microsoft 365 Proficiency (Word, PowerPoint)
  • Customer Service in High-Volume Environments
  • Health Plan Network Evaluation and Management
  • Relationship Building and Management
  • Effective Communication
  • Problem-Solving and Critical Thinking
  • Time Management and Organization
  • Provider Relations Management
  • Data Entry and Database Maintenance
  • Administrative and Office Support
  • Data Collection
  • Clerical and Filing Support
  • HIPAA Compliance
  • Provider support

Interests

Renaissance Faires

Additional Information

Previous employment includes:

Automotive Service Advisor, 12 years

Banking Operations, 20 years

Law Enforcement, 17 years P/T

Quote

Everybody gets so much information all day long that they lose their common sense.
Gertrude Stein

Timeline

Provider Relations Representative I

Gold Coast Health Plan
02.2023 - 06.2024

Provider Relations Representative

Blue Shield of California
09.2019 - 01.2023

Customer Service Representative

Aerotek for Blue Shield of California
08.2018 - 04.2020

Intermediate Member Level Processor

Volt Workforce for Blue Shield of California
09.2017 - 03.2018

Intermediate Correspondence/Phone Support Medicare Supplement

Volt Workforce for Blue Shield of California
09.2016 - 08.2017

Senior Customer Care Representative

Blue Shield of California
04.2012 - 03.2016

POST Basic Police Academy -

Monterey Peninsula College

Reserve Fire Academy -

College of San Mateo

Reserve Police Officer Academy -

Canada College

Bachelor of Science (BS) - Criminal Justice Administration

University of Phoenix

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Nancy Vasquez