Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Sherri L. Baker

Jacksonville,Florida

Summary

Dynamic and results-driven claims review expert with extensive experience at Centene Corporation. Proven track record in enhancing provider relations and streamlining processes through strong leadership and analytical research skills. Successfully achieved significant improvements in provider engagement and customer satisfaction by leveraging a detail-oriented approach and proficiency in medical terminology. Career aspirations include further optimizing healthcare operations to drive impactful results.

Overview

41
41
years of professional experience
1
1
Certification

Work History

Provider Engagement Administrator II

Centene Corporation (Sunshine Health Plan)
Jacksonville, Florida
01.2017 - 02.2024
  • Role required fieldwork and telecommuting to support provider engagement.
  • Conducted initial provider orientations and ongoing educational outreach.
  • Acted as liaison between provider and health plan to enhance financial and quality performance.
  • Assisted providers and members using expertise in Managed Care, Governmental, and Commercial claims.
  • Delivered outstanding customer service to internal and external stakeholders, reviewing all relevant documentation to support decision-making.
  • Reviewed and analyzed claims in accordance with medical policies, guidelines, and supplementary documents for decision-making.
  • Engage with customers using precise and clear information.
  • Analyze and track patterns in claims problems, record details and communicate them to responsible department.

Provider Relations Specialist I

Centene Corporation (Sunshine Health Plan)
Jacksonville, Florida
01.2016 - 01.2017
  • Supported providers through remote operations and on-site visits.
  • Explained credentialing documentation, website education updates, and Electronic Health Records processes to providers.
  • Investigated, documented, and resolved provider issues to enhance account relationships.

Generate detailed reports for providers.

  • Evaluated provider performance using quantitative and qualitative metrics.

Delivered updates on status of incentive agreements to providers.

  • Responded promptly to inquiries from both internal staff members and external customers regarding provider relations matters.
  • Developed and maintained relationships with providers to ensure quality of care for patients.
  • Analyzed data from various sources to identify trends in utilization patterns among providers.
  • Researched and resolved issues related to provider contracts, credentialing requirements, and reimbursement claims.

Member Connections Representative II/Community Health Worker

Centene Corporation (Sunshine Health Plan)
Jacksonville, Florida
01.2015 - 01.2016
  • Conducted home visits for Sunshine Health Members in a remote role.
  • Led training sessions for new Member Connections Representatives.
  • Conducted home visits for evaluation of needs to guide care.
  • Conveyed specific health and social information to the case management team for care pathway development.
  • Assisted members in accessing essential services.
  • Provided guidance to members, families, and representatives on health care benefits.
  • Facilitated connections between clients and social support services.
  • Coordinated member care through joint efforts with community outreach and member advocates.
  • Executed targeted phone calls for compliance.

Member Connections Representative I

Centene Corporation (Sunshine Health Plan)
Jacksonville, Florida
01.2010 - 01.2015
  • Educated members on available health plan services and assisted in utilization.
  • Engaged in local community events.
  • Organized and executed Start Smart Baby Showers and Diaper Days.
  • Facilitated identification of hard-to-reach members.
  • Conducted home visits for non-compliance issues.
  • Coordinated delivery and instruction of Connections Plus cell phones for members.
  • Communicated detailed health and social data to case management team for care pathway development.
  • Identified serious issues to avert negative health and social effects.

Affiliated Computer Services, Inc.
Tallahassee, Florida
01.2006 - 01.2010
  • Company Overview: Certified Medicaid Choice Counselor
  • Educated beneficiaries on Medicaid reforms and health plan options via group/individual sessions, and telephone and home visits for a leading provider of business solutions
  • Conducted group visits to Behavioral Health facilities to conduct individual sessions with Medicaid members
  • Enrolled beneficiaries in plan of their choice and contact hard to reach beneficiaries via field visits
  • Followed up with beneficiaries who have received a mandatory plan assignment to ensure they are aware of their options
  • Certified Medicaid Choice Counselor

Shands Jacksonville
Jacksonville, Florida
01.2003 - 01.2006
  • Company Overview: Managed Care Coordinator
  • Conducted onsite provider visits and provided medical record-keeping reviews for all PCP, OB/GYN, and high-volume specialist providers for an academic medical center specializing in cardiac, neurological, orthopedic, and critical care
  • Reviewed the physical accessibility and appearance of sites, the adequacy of the waiting room and exam room space, and reviewed the provider's procedures for medical record keeping, including confidentiality, and the availability of appointments
  • Analyzed sample medical records and office policies and procedures and resolved managed care operational issues, such as authorization for services, billing, and claims payment
  • Maintain provider database
  • Managed Care Coordinator

Business Analyst I

Blue Cross Blue Shield of Florida
Jacksonville, Florida
01.2001 - 01.2003
  • Functioned as a liaison to support and educate providers, ensuring the successful electronic transmission of claims to Blue Cross Blue Shield of Florida
  • Investigated technical and connectivity issues from vendors and end users and coordinated with IT department to develop remedies
  • Conducted regional training for providers and billing services using PC-ACE Pro32 billing software

Help Desk Associate

Blue Cross Blue Shield of Florida
Jacksonville, Florida
01.1999 - 01.2001
  • Provided support to providers and practice management system vendors
  • Reviewed test files and transmitted via Electronic Data Interchange (EDI) trading partners
  • Provided feedback to senders testing new tools and software

Subrogation Analyst

Blue Cross Blue Shield of Florida
Jacksonville, Florida
01.1996 - 01.1999
  • Provided exceptional customer service by resolving coordination of benefits issues
  • Negotiated settlements with attorneys and risk management staff on subrogation claims and aided in the development of Standard Operating Procedures (SOP) used by COB analysts and claims examiners

Customer Service Representative

Blue Cross Blue Shield of Florida
Jacksonville, Florida
01.1993 - 01.1996
  • Educated customers on benefits and services in a correct and professional manner and provided continuing education for team members on contract specifics, policies, and procedures

Claims Examiner / Written Analyst

Blue Cross Blue Shield of Florida
Jacksonville, Florida
01.1983 - 01.1993
  • Analyzed code and used knowledge of medical terminology to process medical claims promptly
  • Determined coverage of services made based upon proven corporate guidelines and medical policies

Education

Bachelor of Science - Business Administration

Edwards Waters College
Jacksonville, Florida

Skills

  • Proficient Written Communication
  • Effective verbal communication
  • Analytical Research Skills
  • Claims Review Expertise
  • Problem-Solving Expertise
  • Detail-Oriented Approach
  • Analytical Reporting
  • Conflict resolution
  • Leadership Skills
  • Detail-Oriented Approach
  • Data Gathering
  • Proficient in Medical Terminology
  • Earned Credential Specialist Certificate

Certification

  • Medical Coding, Certificate Florida Community College, Jacksonville, Florida
  • Certified Medicaid Choice Counselor, Florida Community College, Jacksonville, Florida
  • Certified Professional Biller, AAPC
  • Provider Credentialing Certificate of Completion, AAPC

Timeline

Provider Engagement Administrator II

Centene Corporation (Sunshine Health Plan)
01.2017 - 02.2024

Provider Relations Specialist I

Centene Corporation (Sunshine Health Plan)
01.2016 - 01.2017

Member Connections Representative II/Community Health Worker

Centene Corporation (Sunshine Health Plan)
01.2015 - 01.2016

Member Connections Representative I

Centene Corporation (Sunshine Health Plan)
01.2010 - 01.2015

Affiliated Computer Services, Inc.
01.2006 - 01.2010

Shands Jacksonville
01.2003 - 01.2006

Business Analyst I

Blue Cross Blue Shield of Florida
01.2001 - 01.2003

Help Desk Associate

Blue Cross Blue Shield of Florida
01.1999 - 01.2001

Subrogation Analyst

Blue Cross Blue Shield of Florida
01.1996 - 01.1999

Customer Service Representative

Blue Cross Blue Shield of Florida
01.1993 - 01.1996

Claims Examiner / Written Analyst

Blue Cross Blue Shield of Florida
01.1983 - 01.1993
  • Medical Coding, Florida Community College, Jacksonville, Florida
  • Life, Health, and Variable Annuities 2-16, Florida Community College, Jacksonville, Florida
  • Certified Medication Choice Counselor, Florida Community College, Jacksonville, Florida
  • Certified Professional Biller, AAPC
  • Provider Credentialing Certificate of Completion, AAPC

Bachelor of Science - Business Administration

Edwards Waters College
Sherri L. Baker