Orlando Gonzalez
Manager/Supervisor
El Paso,Tx
Summary
To obtain a challenging position that will utilize my broad skills in management, training, guidance, establishing performance goals, customer service, retention, multitasking, and problem-solving skills. I can also balance time management, oversee daily operational needs of the business, and am very career oriented.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Executive
03.2016 - 06.2016
- Collaborate and maintain relationships with providers and staff throughout Presbyterian to ensure an exceptional provider experience. Develop and maintain cooperative working relationships between Presbyterian Health Plan, institutional providers and individual providers. Provide education on quality initiatives, managed care, capitation, products, policies and procedures, reimbursement issues, referral/authorization process, etc.
- Responsible for ensuring provider data integrity and accuracy by ensuring PIF’s are completed timely accurately and through a comprehensive review and validation of provider directory data.
- Responsible for post payment validation of assigned providers to ensure accuracy of payment to the contract and corresponding fee schedules.
- Resolve provider issues - claims, health services, finance, etc.
- Stimulate and foster professional development of the Network Relations Service Associates.
- Support Network contracting strategies to preserve a robust provider network.
- Serve as primary liaison between the provider and the health plan.
- Maintain general knowledge of health plan reimbursement methodologies.
- Conduct provider visits based on established departmental goals, which requires 50-65 percent field contact.
- Engage and support leadership and peers by promoting and participating in department initiatives and being accountable for achieving business objectives.
- Provide consulting and educational support to providers regarding appropriate health care access and navigation of the healthcare system to improve provider satisfaction.
- Follow appropriate confidentiality requirements.
- Collaborative solutions in recommending healthcare resources.
Associate
10.2014 - 06.2016
- I am responsible for supporting the network relations service executive with limited supervision. I respond to and resolve complex issues related to daily operations. The network relations service associate assists with data collection and distribution of clinical quality measures to the provider network in accordance with Presbyterian Health Plan’s quality and incentive programs.
- I run a territory for Long Term Care of about fifty facilities. We assist in claims, hospice, home health, personal care options, respite, and nursing facilities. Our main goal is to make sure each facility runs smoothly and assist them with any barriers they may have.
- Assignment List: Bernalillo, Sandoval, Torrance, & Valencia County
Supervisor
Presbyterian Health Plan
Albuquerque, NM
08.2022 - 03.2026
- Supervising 12 to 30 staff members for multiple specialties. I managed My Time, PTO, FMLA, HR Documents, Authorizations process to meet state regulations for PCS, INF, ERS, EDMO’s, ESPDT, and Respite for all staff including helping other Supervisors Teams when needed. I support on yearly training needed, work on day-to-day discrepancies, do monthly audits for efficiency, yearly evaluations, work closely with HR, attend monthly HSD meetings, appeals and grievances, and will assist with anything else that may arise from running claim reports, assist with reporting for upper leadership, customer service, performance goals, esnures compliance of agencies processes and policies and procedures, assist as a mentor to staff by providing guidance in all areas as needed to ensure we meet company standars. This includes assisting with daily work that needs to be completed, assigning work to over 30 HSA’s biweekly and working closely with Clin Ops, Appeals, Provider Relations, Contracting, Care Coordination, Distribute approved Health Education materials, translate benefits, Medicaid LOB, Clear verbal and written communication skills, Basic Clinical Knowledge, Health Risk Assessment, Claims, Authorizations, Calculations, HRP, Facets, Authenticare, Assist patients and families, Jiva, My Time, Manage Goals, IT Dept, Supplies Memorandum of Records and work with HR with all aspects of employees evaluations.
- I now assist with process improvements, monthly power points to staff, assist with denied claims reports, prior authorizations for all long-term care, assist providers in ensuring their claims get paid timely along with receiving the right care at the right time and having authorizations in place.
- We also check claims for correct ICD, NPI, Tax Identification, contracts include codes billed, timely filing, and appeals and grievance’s etc.
Executive
12.2019 - 08.2022
- Managing Long Term Care services throughout New Mexico for over 95 Facilities. My job duties include monthly visits with providers, Skype phone calls, assisting with contracts, managing rosters, claims projects, reporting deliverables for HSD, service request, verify ED visits for correct claims processing, configuration, Mobile device approvals, and assisting with all billing aspects for a system called Authenticare.
- Projects are supported in detail by having meetings as needed, providing reports with detailed data, and ensuring that we are moving forward in rectifying any Facility issues.
Executive
07.2016 - 12.2018
- Electronic Visit Verification and Manage Personal Care Services for about 150 facilities, nine nursing facilities, and three emergency response agencies. My job duties consist of providing education on EVV functions, provider conferences, Attorney General Request, state escalations, reports, scheduling, provider visits, Excel spreadsheets, travel within New Mexico, provider education/resolutions, book travel, Enterprise rental, mileage, tablet monitoring, general escalations, trainings, service request, Monitor Mobility Exchange, AuthentiCare, manuals, Verizon, Utilization Management, Care Coordination, appeals, customer service, sales, contracting, credentialing, provide training to the other executives on EVV, and monitor any changes.
Team Lead
10.2013 - 10.2014
- Coaching & Claims Training for about 14 individuals, Communications with individuals, groups, and facilities, Mentoring, Escalations, Leadership skills, Delegation, HMO PPO, Centennial Care
- Team building, PowerPoint and coordinating activities
- Certified in Spanish medical terminology to assist Spanish callers
Navigator
11.2011 - 10.2013
- Summary of Major Duties: Coordinate and administer services for patients seeking emergent care within the emergency department in situations where other avenues of care are more appropriate to affect optimal patient outcomes, achieve continuity and quality of care and reduce costs.
- Educating customers, providers, transferring knowledge
- Diagnosing and resolving problems
- Mentoring and developing fellow peers
- Coordinating activities, anticipating and addressing customer’s needs
- Acquiring and applying superior skills to achieve quality outcomes
Certification
03.2010 - 10.2010
- The following are surgeries and DME in which we reviewed criteria for:
- Bariatric surgery, breast reduction, DME
- DME, orthotics and prosthetics
- Rehabilitation services
- Hysterectomy, implantable devices
- Leadership skills
- Delegation
- Team building
- Certified in Spanish medical terminology to assist Spanish callers
Representative
07.2007 - 02.2010
- Educating customers and transferring knowledge
- Resolving problems with claims, enrollment, pharmacy and billing
- Anticipating and addressing customer needs
- Functioning as an effective team member
- Acquiring and applying superior skills to achieve quality outcomes
- Responding to a changing circumstance
- Travel & lodging scheduling
- Certified with the following lines of business:
- Centennial Care, Medicare-HMO/PPO, Commercial, HMO
Education
High School Diploma - TVI, Crucial Confrontations, Emerging Leader, EME, Professional Contributor and Joining Toast Masters
TVI
Albuquerque, NM07-2003
Skills
- Proficient in Windows 10, XP, Word Perfect, 10 key touches, PowerPoint, Internet Explorer, Outlook, Facets, Dart, Epic, Scheduling, SXC, ECT Viewer, Travel, Care Manager, HRA, Claim Adjustments, CFIS, NPI Registry, NM Portal, McKesson, UMI, Business Objects, Document Manager, EVV AuthentiCare, School Based, PIF Log, Partner, Document Manager, InstaMed, Zelis, ECT Viewer, C4C, Service Request, UMI’s, Magellan, NM Medicaid Portal, Contract Tracking, Mobility Exchange, Jiva, Teams, Presentations, etc
Accomplishments
- Collaborated with team of 12 in the development of any projects.
Certification
Crucial Confrontation's and Emerging Leadership trainings to better lead my staff.
Interests
Road Runner Food Bank, United Blood Drive, foster parenting, manage SOS team on feeding people in need, CPR Certified, reading, home improvement, biking, gym and self-improvement
Summary of Primary Functions
- -Manage administrative functions for self, providers and facilities
- -Type reports, special projects and any related materials for Provider Network Management. This is including utilizing policies, procedures, flowcharts and spreadsheets
- -Maintain projects for enrollment, over payments, underpayment, configuration, contracting and interpretation of benefits
- -Assist other departments in resolving member’s issues in a timely manner
- -Schedule and coordinate appointments and meetings with facilities
- -Receive member information, handles phone calls, takes messages and assign workloads by territory
- -Process correspondence and complaints in a timely manner
- -Maintain internal monitoring systems for ongoing provider issues
- -Process payments to member’s accounts and assist with plan exclusions and limitations
- -Participate in education programs for growth and development; attend department meetings and other meetings as required
- Physical, Occupational, or Rehab Therapists with a minimum of one year of relevant experience.
- Prefer 1 year of experience in MCO, health plan insurance environment , with expertise performing utilization management or experience working in long term care services
- Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records.
- Analytical skills as applicable to interpret provider communication and medical records.
- Attention to detail and organizational skills.
- Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best representing the organization professionally.
- Ability to work cooperatively with other employees and departments.
- Efficient and comfortable with computer electronic data entry and documentation
- Ability to succinctly document using correct spelling and grammar.
- Able to summarize from medical clinical notes, progress notes, needs assessments, functional assessments, progress notes, history and physicals, care plans and other state required documentation.
- Able to meet timelines and deadlines associated with work load.
Languages
Spanish
Full Professional
Timeline
Supervisor
Presbyterian Health Plan
08.2022 - 03.2026
Executive
12.2019 - 08.2022
Executive
07.2016 - 12.2018
Executive
03.2016 - 06.2016
Associate
10.2014 - 06.2016
Team Lead
10.2013 - 10.2014
Navigator
11.2011 - 10.2013
Certification
03.2010 - 10.2010
Representative
07.2007 - 02.2010
High School Diploma - TVI, Crucial Confrontations, Emerging Leader, EME, Professional Contributor and Joining Toast Masters
TVI