Summary
Overview
Work History
Education
Skills
References
Timeline
Generic

Paulina Jaymes

Newport News,VA

Summary

Dedicated Provider Network specialist with expertise in contracting, data management, and credentialing. Proven track record of optimizing processes and negotiating favorable terms with providers. Skilled in auditing procedures and maintaining high levels of customer service. Strong interpersonal communication and teamwork abilities to drive successful outcomes. Dependable professional with track record of success in field, attention to detail and proactive mindset. Seeks opportunities to improve processes and workflows for team benefit. Conscientious, hardworking and excels at multitasking in fast-paced environments.

Overview

13
13
years of professional experience

Work History

Provider Contracting Specialist 2

Humana
Newport News, VA
03.2021 - 02.2025
  • Implementation of policies to maximize efficiency of contract and credentialing process
  • Reviewed and revised sustainability proposals or policies
  • Investigated markets to determine areas for opportunity
  • Negotiated favorable terms with providers while maintaining a high level of customer service
  • Processed incoming requests from Providers to become In Network with TRICARE
  • Performed audits on contracts and credentialing.
  • Received and processed documents for credentialing.
  • Oversaw contracts for over 7 different departments using both manual and automated strategies
  • Reviewed contracts and other legal documents in order to ensure compliance with applicable laws and regulations.
  • Maintained comprehensive records of all contracts, amendments, and modifications.
  • Checked information in company's database for accuracy and updated data with current information to maintain records.

Network Contracting Specialist

Logistics Health INC
04.2019 - 03.2021
  • In my role as a Network Contracting Specialist with LHI, I recruited and contracted specialty practices to provide consults for military applicants in the MEPCOM II program
  • Performed fee negotiations with existing providers as well as expanding current contracted providers to additional contracts and processed documentation for credentialing practitioners
  • Made recommendations for best-fit contractual guidelines, developed and executed sound contract administration negotiation of contract modifications, Support activities for finalizing a contract and credentialing, manage workloads utilizing a variety of acquisition management information systems
  • Resolved any discrepancies between contract requirements and actual performance or services rendered.
  • Prepared detailed reports related to contracting activities including cost analysis, performance reviews, and project status updates.
  • Conducted research projects related to specific topics as assigned by supervisor.
  • Updated existing data records and deleted unnecessary files.
  • Entered customer and account data from source documents within time limits.
  • Reviewed and verified data for accuracy and completeness before entering into the database.

Provider Relations Specialist

Logistics Health INC
Newport News, VA
01.2019 - 04.2019
  • Served as a Provider Relations Specialist maintaining a successful working relationship between LHI and network providers through a full range of provider relations and service interactions to ensure provider retention
  • Identify and remediate operational short-falls, respond to customer complaints, customer satisfaction surveys and provider questions, and research and resolve accounts payable issues
  • Routinely negotiate cost effective fees for single services, confirm service capability and educate providers on contract expectations, processes and paperwork
  • Comprehend detailed knowledge of customer requirements in order to translate subcontractor agreements, contractual requirements and fee agreements to the providers

Provider Network Specialist

Health Net Federal Services
Newport News, VA
01.2012 - 01.2019
  • I've performed in several positions, such as a Supervisor to more than 10 customer service agents supporting United Military West, a lead supporting more than 20 PC3 (Patient Centered Community Care) agents scheduling veterans for VA-appointed healthcare, a Provider Network Coordinator where I provided contracts to providers requesting to join the Tricare and PC3 network, a PROS (Provider Relations Outreach Specialist) verifying all information for contracted network providers, I credentialed practitioners and conducted webinars for providers on various Tricare/PC3 topics, and assisted with recruiting providers for the new VA Choice program, and as a Provider Network Management Specialist handling multiple providers in a span of five states, resolving contract, credentialing, and claims-related issues with the Department of Veteran Affairs programs.nt of Veteran Affairs programs

Education

High School Diploma -

Phoebus High School
Hampton, VA
06-1989

Skills

  • Auditing procedures
  • Contract Administration
  • Workflow Management
  • Interpersonal and written communication
  • Contract Negotiation
  • Teamwork and Collaboration
  • Attention to Detail
  • Time Management
  • Problem-solving abilities
  • Organizational Skills
  • Credentialing
  • Data analysis
  • Database management
  • Process improvement

References

References available upon request

Timeline

Provider Contracting Specialist 2

Humana
03.2021 - 02.2025

Network Contracting Specialist

Logistics Health INC
04.2019 - 03.2021

Provider Relations Specialist

Logistics Health INC
01.2019 - 04.2019

Provider Network Specialist

Health Net Federal Services
01.2012 - 01.2019

High School Diploma -

Phoebus High School

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