Rene Gonzales
Monterey Park,CA
Summary
Healthcare professional with 28 years of experience in provider relations and project management within dynamic environments. Proven track record of enhancing provider satisfaction and streamlining communication between healthcare providers and insurance companies. Expertise in contract interpretation, conflict resolution, and regulatory compliance, supported by strong interpersonal skills. Demonstrated ability to foster collaboration among diverse teams while maintaining professional relationships.
Overview
29
29
years of professional experience
Work History
Provider Relations Representative
Lighthouse Management Associates Organization, LLC
Chino Hills, CA
10.2021 - Current
- Preparing and draft contract agreements, such as MOU/LOA/SSA
- Implement strategies with providers to improve performance
- Coordinate escalated claim disputes and all necessary research timely and effectively
- Coordinate data extracts and data analysis interpretation in preparation of reports aimed to determine necessity of rate increases to retain key providers, with some support and guidance from peers or direct report
- Work closely with assigned IPA/medical group to ensure it is compliant with access and availability requirements
- Ensure direct contracted networks also meet access and availability requirements
Provider Service Representative
RadNet Management Inc
Arcadia, CA
02.2017 - 09.2020
- Conducts one-on-one contact with potential referral sources including physicians, physician groups
- Calls on existing and potential referral sources to provide educational information and materials, as well as company updates
- Maintain effective communication with physicians, referral sources; responds promptly and appropriately to any concerns or issues
- Maintain accurate records of daily and weekly activities and referral profiles within company’s CRM system
- Identifies and targets new and existing services, and updates management regarding activities, opportunities, and market changes and conditions
Associate Analyst, Provider Configuration
Molina Healthcare
Long Beach, CA
07.2015 - 07.2016
- Responsible for accurately entering provider demographics and contract affiliation information into the health plan system
- Load and maintain provider information into LEGACY systems with attention to detail and accurately
- Perform provider audits for quality and financial reports for accuracy
- Audit loaded provider records for quality and financial accuracy and provide documented feedback
Provider Relations Representative
Citizens Choice Health Plan
Orange, CA
11.2010 - 12.2014
- Identified network trends and gaps as it relates to provider questions and concerns
- Facilitated and coordinated meetings with contracted medical groups/hospitals/ancillary providers
- Scheduled on-site training of new and existing physician offices/medical groups
- Establish/maintained effective working relationships with contracted and potential providers
- Created/distributed provider marketing materials to physicians
Lead Eligibility Representative
Citizens Choice Health Plan
Orange, CA
11.2010 - 12.2014
- Supervised & trained Eligibility Unit staff/Ensured goals were achieved/Staff evaluations
- Member/retro disenrollment’s/reported monthly disenrollment’s
- Assisted with creating department policies/procedures according to CMS guidelines
- Generated & submitted monthly E-List & eligibility reports to contracted IPA’s
Provider Relations Representative
LA Care Health Plan
Los Angeles, CA
11.2009 - 11.2010
- Conducted PCP visits and weekly in-services to 7-10 providers daily
- Handled provider and member inquires and resolved operational issues
- Conducted and documented plan partner group annual audits findings according Compliance Department guidelines
- Planned/organized/facilitated plan partner groups Joint Operations meetings biannually
Provider Relations Representative
SynerMed
Monterey Park, CA
08.2001 - 11.2009
- Preparing and draft contract agreements, such as (MOU/LOA/SSA) as directed by Network OPS
- Ensured provider contracts were accurate for internal distribution
- Assist providers with issues related to contracting, capitation, claims, referrals and eligibility
- Distributed informational and educational correspondence to providers and specialists monthly
Eligibility Specialist
SynerMed
Monterey Park, CA
08.2001 - 11.2009
- In-load electronic eligibility files using EZLINK, validates and updates EZCAP databases
- Processes and reconciles electronic eligibility using Eligibility Manager Software on monthly basis
- Update eligibility data on daily basis in all systems, new enrollees, changes, and cancellations
- Responds to all written and telephone eligibility inquiries from assigned health plans
Eligibility Consultant
Aetna US Healthcare
Los Angeles, CA
11.1996 - 08.2001
- Accurate and timely processing of eligibility data into healthcare systems; ensure production of Member ID cards
- Proven ability to collaborate with providers, subscribers, personnel directors, and benefits administrators; adeptly handle eligibility questions and/or concerns via phone or in person
- Interact with team members, associates, departments on a national level; effectively communicate current information regarding employees' and clients' medical and dental plans
Education
Certificate - Business Management
Everest College
Alhambra, CA01-2012
Skills
- Team collaboration
- Attention to detail
- Project management
- Relationship building
- Interpersonal communication
- EZCAP and EZLINK expertise
- LEGACY system proficiency
- CRM software knowledge
- RIS and DR familiarity
- Microsoft Office proficiency
Timeline
Provider Relations Representative
Lighthouse Management Associates Organization, LLC
10.2021 - Current
Provider Service Representative
RadNet Management Inc
02.2017 - 09.2020
Associate Analyst, Provider Configuration
Molina Healthcare
07.2015 - 07.2016
Provider Relations Representative
Citizens Choice Health Plan
11.2010 - 12.2014
Lead Eligibility Representative
Citizens Choice Health Plan
11.2010 - 12.2014
Provider Relations Representative
LA Care Health Plan
11.2009 - 11.2010
Provider Relations Representative
SynerMed
08.2001 - 11.2009
Eligibility Specialist
SynerMed
08.2001 - 11.2009
Eligibility Consultant
Aetna US Healthcare
11.1996 - 08.2001
Certificate - Business Management
Everest College
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