Raquel Dillon

Working as a contract employee at Molina Healthcare for the state of Iowa. Negotiates assigned contracts and letters of agreements with physician groups and ancillary providers ensuring the contract process is understood by the provider. Daily meetings and conference calls with the providers to assist in completing the provider enrollment and contract agreements for Medicaid, Medicare, LTSS and Market place plans. Maintains tracking system and publish reports according to departmental procedures.
Initiates, negotiates, generates, and tracks provider Letters of Agreement, contracts and amendments from initial draft to full execution utilizing approved standardized contract templates/amendments.
Supports network development throughout state to including researching, recruiting, and negotiating with providers.
Participates in the evaluation of provider network and implementation of strategic plans.
Clearly and professionally communicates contract terms, payment structures, and reimbursement rates to physician, hospital, and ancillary providers.
Assists in analysis and coordination of amendments, reimbursement, and language changes. Requests information of billing codes, services provided and other information needed to complete the contract profile.
Coordinates preparation and routing distribution of documents to complete the contracting process in a timely and thorough manner according to standardized processes.

• Self-motivated, with a strong sense of personal responsibility.
• Uses strong analytical and problem-solving skills to develop effective solutions for challenging situations.
• Have the ability to learn and adapt quickly to new technology and software applications.
• Work's effectively in fast-paced environments.
• Excellent communication skills, both verbal and written.
• Complete paperwork, recognizing discrepancies and promptly addressing for resolution.
• Used critical thinking to break down problems, evaluate solutions and make decisions.
• Proven ability to develop and implement creative solutions to complex problems.
• Passionate about learning and committed to continual improvement.
• Has developed and maintained courteous and effective working relationships.
• Exercise leadership capabilities by successfully motivating and inspiring others.
• Pays close attention to detail while completing assignments.
• Cultivated interpersonal skills by building positive relationships with others.
• Demonstrated respect, friendliness and willingness to help wherever needed.
• Strengthened communication skills through regular interactions with others.
• Skilled at working independently and collaboratively in a team environment.
• Demonstrated a high level of initiative and creativity while tackling difficult tasks.
• Managed time efficiently in order to complete all tasks within deadlines.
• Demonstrated creativity and resourcefulness through the development of innovative solutions.
• Identified issues, analyzed information and provided solutions to problems.

The Provider Data Management Specialist perform a variety of data entry, auditing and editing functions including but not limited to: perform research to obtain accurate provider data. Includes researching by accessing a variety of websites and other sources to update and ensure the provider information is accurate.

Oversees and manages assigned projects and departments data, ensuring it meets predetermined contractual or policy requirements. I recreated the terms policy and procedures to increase the efficiency and exceed the state's requirements. Serves as the point person for data-related tasks on assigned projects. Coordinates the production of data by the assigned departments.

Provider Data Management Specialist I Understanding database design concepts and being able to participate both short and long-term planning database projects. Developed the ability to effectively manage and use information. Many promotions and awards given due to the changes and being team player.

Heavy contact with Medicare member via telephone, internet and written correspondence. Responsible for irate customer resolution and supervisor call backs. Assist with escalated issues involving healthcare benefits, claims, pharmacy and eligibility questions. Responsible for customer retention and growth. Subject Matter Expert (SME) Floor Mentor responsible for answering questions via IM for at home employees and help representatives within the office regarding member call issues. Also, assist with side-by-side coaching with representatives to ensure good quality results and manage tasks. Awarded the Aetna Silver Award in 12/2011.

Learned and maintained in-depth understanding of product and service information to offer knowledgeable and educated responses to diverse customer questions.

Processed, scheduled and executed customer orders for new and established customers.

Researched and rapidly resolved client conflicts to maintain key accounts.

Engaged clients in person and over phone to answer questions and address complaints.

Series 6 Licensed in June, 2005. Assisted participants with their questions regarding 401k, 401 {a} and 457 plans. Entered exchanges, deferrals and allocation changes. Also assisted participants with loan modeling online. Provided investment education on the investment options available for the State of California employees. Helped the participants complete plan forms. Responsible for contacting participants when additional information is needed to complete their requests. I was the liaison between the Call Center and Processing teams regarding the Unforeseeable Emergency and Hardship application requests. Provided the monthly reports to upper management. Involved in many projects to make the online process and forms more user friendly for the participants. Named Employee of the Month in April 2006.

Responsible for taking incoming and making outbound calls in reference to dedicated insurance accounts to assist in the resolution of escalated issues. Heavy call volume resolving claim issues and benefit questions. Assisted in the processing of of medical claims. Also, responsible for the resolution of provider issues. Named CIGNA Team CSA in January 2001, which involved traveling to resolve call center issues at the main office in Connecticut. In 2002, responsibilities increased to Technical Coach/Floor Supervisor responsible for side-by-side coaching to ensure the quality of service provided by the customer service associates and to answer any questions the associates had regarding member calls. Specialized in resolving irate and complex customer issues. Promoted to Team Lead/Supervisor in 2002, responsible for 20/30 employees.