Philana Cluse

• Conduct research to gather and analyze healthcare Provider/Group data to enter from the Workforce system to the Symplr (Payer) system.
• Make sure to add Reimbursement networks per contract agreement.
• Collaborate with cross-functional teams to ensure accurate dissemination of policy information.
• Streamline documentation processes to enhance accessibility.
• Train staff on effective use of information systems and tools for improved efficiency.
• Implement quality control measures for accuracy of data reporting and compliance.
• Use database to research, gather, analyze and present data.
• Research and analyze information into briefing papers, reports and project papers.
• Maintain and document system changes and revisions.
• Achieve Provider confidence and protected operations by keeping information confidential.
• Streamlined data retrieval processes for faster response times and increased Provider/Group satisfaction.
• Resolve Provider/Group problems and complaints.
• Answer general questions and resolve issues.
• Track important information in Workflow and Symplr (Payer), run reports and generate spreadsheets using data.

• Continued role with the Vantage Health Plan brand for Louisiana Providers until it completely phases out at the end of 2024. Resolve Provider issues and send them to correct outlets for resolve, Manage delegated groups for the Mississippi, Arkansas and bordering Louisiana Providers for the Primewell Health brand until brand phases out end of 2025. Audit Provider group rosters and submit contract receive records for prescreen to send to credentialing, submit provider update records to Provider Service for updates. Create Provider Records through QNXT and submit CMP records for audit, collaborate with team members and management, manage delegate questions and resolves. Manage delegated groups. Process delegated rosters. Run reports as needed. Research and critical thinking. Create excel spreadsheet reports.

Position is the same job duties as the Provider Relations Network Representative position. BCBS of Louisiana acquired Vantage Health Plan in 2023 and prepared for the 2024 transition. Restructuring and renaming our positions.

• The Provider Relations Representative’s overall goal is to optimize the Vantage experience for participating providers, facilities, and the Vantage members they treat. The Provider Relations Representative is responsible for growing and maintaining Vantage’s provider network and Shared Savings Program in their assigned parishes/counties, serving as the primary point of contact for questions, issues, claims status, etc. Essential Duties & Responsibilities:
• Consistently operate with high level of integrity and display excellent example of company culture, values, and policies
• Facilitate and build lasting relationships with participating providers, facilities, and the members they treat
• Locate and contract new providers in assigned parishes/counties to obtain network adequacy
• Visit each participating primary care physician (PCP), specialist, Dentist, Shared Savings Program provider, and DeSiard Pharmacy Network Pharmacy, in assigned parishes/counties quarterly
• Visit hospitals in assigned parishes/counties every 6 months to obtain updated rosters and educate on any Vantage updates
• Develop and administer education and training to providers and office staff
• Educate providers on incentive program
• Verify provider information to ensure accuracy as required by CMS
• In-service and complete site reviews on new providers in assigned parishes/counties
• Act as point of contact for providers, facilities, and the members they treat to answer questions and resolve issues regarding enrollment, coverage, benefits, premiums, etc. in a timely manner
• Research and respond to provider appeals, complaints, and grievances
• Research and respond to member bills, copays, prescription drug issues, etc.
• Provide on-going technical assistance to providers and their staff
• Follow up daily with potential Medicare members after retrieving proper documentation
• Schedule appointments to meet potential Medicare members in their home if needed
• Assist members with enrolling in extra benefits associated with the Medicare Advantage plans 2 This description is not intended to be a comprehensive list of the duties and requirements associated with this job, and Vantage reserves the right to revise the description at any time.
• Assist members with qualifying for dual eligible enrollment (Medicare and Medicaid)
• Assist small groups with quotes and enrollment
• May recruit large groups; must work with the Marketing department to obtain quotes and enroll members of large groups
• Document detailed visit logs daily/weekly
• Participate in civic organizations on behalf of VHP
• Provide feedback and make recommendations regarding health management services that are needed within communities of assigned parishes/counties
• Collaborate interdepartmentally to improve overall healthcare needs of Vantage members
• Work with Population Health to plan health fairs and other community events
• Assist in scheduling home visits and/or provider office visits for Population Health Nurse Practitioners as needed
• Assist in facilitating completion of HEDIS measures and submission of applicable diagnosis codes on provider star reports
• Work with Pharmacists to distribute educational materials and increase generic drug utilization rates Marginal Duties:
• Manage mailings, faxes, and other general correspondence to providers
• Facilitate Affordable Care Act enrollments as needed
• Schedule and attend both internal and external meetings
• Assist with special projects as needed
• Other duties as assigned

• I collaborated with both regional Operations personnel as well as Providers directly to secure provider enrollment applications in a timely manner. I processed, completed and submitted provider enrollment applications to the Insurance Carrier within specified time frame to avoid write off charges and maximize reimbursement. I participated on bi-weekly conference calls with Division and Regional personnel to address and strategize on outstanding enrollment issues. I was the Provider’s Liaison to Billing Company on enrollment and claims related issues. I followed-up with the insurance plans to secure the provider’s approval through the provider’s number (PIN) assignment. I entered approval information into Sales Force, and Verity, so the billing company could be notified to release the provider’s claims. I worked with Managed Care personnel to ensure timely enrollment with managed care plans to maximize reimbursement and minimize patient complaints related to participation status. As a Provider Enrollment Specialist I had access to confidential and protected patient information and handled sensitive information in accordance with company protocol and HIPAA rules and regulations. I monitored the Insurance carrier websites for forms revision and update master provider enrollment packets as needed. I answered incoming calls in a professional manner. I maintained a high degree of ethics, integrity, and confidentiality in dealing with my co-workers, providers and external customers. I researched and resolved provider-related claim denials by contacting payors and communicated results to the appropriate Provider Enrollment Managers. I managed multiple priorities and possessed strong organizational skills. I had the ability to analyze data, make recommendations and implement plans. I had strong interpersonal and communication skills and the ability to work effectively.

• Worked through the Home Care Home Base system - Obtained authorization from Humana for multiple Home Health Agencies by sending an authorization request along with the patient’s Physician orders and clinical to support the visits being requested, Worked multiple workflows such as Obtain Re-Authorization, Obtain Initials, Determine Authorization, Obtain Bypass, to make sure that the agencies have enough budget to make their visits to their patients and to put a reminder to request from Humana, worked Review Coordination notes to request authorization from Humana, worked urgent emails daily from the agency for any emergency visits needed within a 24-hour period, open multiple Humana correspondence via email that will either provide approved, denied or pending authorization information, attach this information to the patient’s files as well as add a note and add authorization if provided, constant phone communication with Humana regarding authorization as well as constant contact with the agencies to notify and communicate, provide positive and professional customer service to the agency as well as to the patients that call in, involves research and resolve of issues almost daily.

• Verify Humana and Medicare, add the correct correspondence and insurance information to the patient’s account and then obtain authorization.

• Collector (Biller) Humana – Make sure Accounts Receivable for assigned states are under 120 days. Research and resolve claims that are outstanding whether denied, partially paid or recovered.
• Negotiate a quicker reprocessing time with Humana. Create and run reports to keep track of outstanding invoices. Month-end Bill (close) - to bring in revenue each month for each assigned state by running necessary reports on excel spreadsheets, emailing necessary agencies for verifications for patients that are not ready for billing on the Client Schedule Report, run Pre-post on excel and correct any visit programs that are not setup correctly for billing, check to make sure the charge amount, contractual amounts and expected rates are correct for each visit on each patient, make sure the hours are correct on each visit for each patient, re-run pre-post once corrections are made, re-check 2nd pre-post report, combine any biller/audit notes to the pre-post spreadsheet to see if any invoices need to be held and not billed out for any reason, generate claims in the system to be billed out, upload each batch into our billing system to be sent out to the clearinghouse, so it can get transmitted to Humana for payment. Mid-month bill – To catch any claims that were not billed out in month-end bill for previous month. Work any rejected and denied claims in our billing system.
• Correspond with Humana’s Claims department regarding any claims issues. Correspond with Humana’s Provider Payment Integrity Dept (PPI) regarding the reason for any recovery of monies. I work diligently and resolve most all issues that needs to be resolved including negotiating a quicker claim reprocessing time.

• Transport one patient at a time from one hospital to the next hospital anywhere in Louisiana.

• Bill VA Claims, research and resolve claims (Accounts Receivable), work remits, generate reports for the VP, Manager, supervisor and Financial Person and much more.

• Traveled a widespread area of the Louisiana areas educating and selling insurance to the teachers at the schools.

• Verify Patient demographic & health information. Obtain Accident Reports, call Auto Insurance co and verify whether a claim was setup to set up a lien for patient's bill, verify representation by attorney to lien attorney for patient's bill. VA Billing (assisted someone) – Managed VA accounts w/reports and filing claims.
• Hired Permanently: January 2012 – August 2012

• Billing/Verifying/Benefits/Run and work Reports - everything - Research, resolve and file Medicare, Medicaid and Commercial Insurance claims, File secondary medical claims, Work Claim Tracking reports (Accounts Receivable), Resolve Patient problems in person, Go over OB benefits with patients, Resolve patient problem over phone, Research & execute new insurance policies, Take patient payments, Balance payment reports at end of the day, Business office decision making, Consult with 11 Physicians, Verify Insurance Benefits, due to my skills, I was asked to put safety nets in place to manage the loss of money to the company.

• Account Manager - Phone patients, File Medicare, Medicaid and Commercial Insurance in Payer Path and Misys Tiger. Research and follow up on accounts (Accounts Receivable), Work remittance advice, work month end reports with accounts 90 days or over, help patients with their accounts when they call in, contact Insurance Companies to find out why claims are not getting paid or processed and keep following up until they are paid, daily deposits for each Physician (Dr. Mccarron, Dr. Verma and Scott Family Clinic), help my manager with any projects.

• Billing Medicare/Medicaid, extensive medical data entry for Lafayette and Houston Office (admit/recertification and oasis), file on patient’s charts, chart audit patient’s charts to prepare for State audit, Review and work Unysis Remittance Advice, answer phones. Was in process of being Office Manager of Sunset office. (Power Point, Excel and Access Training Class).

• Managed store and cut and style men’s hair

• PRN in evening. (Allowed me to attend school).

• Billed Medicaid claims electronically for the. hospital in EC2000, worked failed claims in Star, worked daily reports on paper and in Excel (Accounts Receivable), worked Unysis Remittance Advice (Medicaid’s approval or denials of claims), Attended Unysis workshops, Helped patients in person and on phone, worked with doctor’s offices when they felt that I could help to get their claims paid, did research to make sure Medicaid properly processed our claims, made sure to go over any pending claims and filed them to buy timely filing status.

• I worked as a Clinical Processor/Receptionist. Later I became Team Leader/Clinical Processor. My duties were billing for Medicare/Medicaid patients, answering phones, filing on patient’s charts, extensive data entry (admits and recertifications), verified Medicare/Medicaid, ICD-9 codes, payroll, dispensed medical supplies, and basic office duties.