Silvia Rodriguez

Accountable for maintaining accurate data for assigned providers. This may include path-to-value and value-based contracts. Manages provider audits, provider service and relations, credentialing, and contract management systems. Executes processes for intake and manage provider perceived service failures. Decisions are regarding the daily priorities for an administrative work group and/or external vendors including coordinating work activities and monitoring progress towards schedules/goals, and often oversees work of others and/or is the primary administrative owner of a main process, program, product or technology. Works within broad guidelines with little oversight.

· Works with provider data, provider directories, and/or contract management

· Works with PCP data and membership assignment

· Conducts audits, manages credentialing and a variety of other network management projects

· Works within several complex provider data management systems and maintains proficiency with basic Office, and internal applications required to perform job duties

· Collaborates with contractors, and other functional areas to problem solve and otherwise ensure a positive provider and member experience

· Ensures data integrity and maintenance of the contracts including but not limited to demographics, rates and contract intent

· Ensures contracts are operationalized from contracting through implementation, leveraging standardized tools and quality processes end to end

· Defined point of contact for Contracting and Provider Service (DCAV, PPG, Credentialing, Service Fund) regarding contract administration, data integrity, testing/auditing and maintenance

· Ensures initial credentialing, managing unresponsive providers through re credentialing, and resolves discrepancies

· Manages operations issues related to data integrity with assigned providers

• Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
• Conducted thorough investigations of complex insurance claims, gathering evidence and analyzing relevant documentation.
• Achieved cost savings through successful subrogation efforts, recovering funds from responsible parties in various claims scenarios.
• Contributed to a positive work environment through active participation in team meetings and collaborating on cross-functional projects.
• Achieved high customer satisfaction ratings by providing clear and timely communication throughout the claims process.
• Evaluated coverage accurately by interpreting complex insurance policies and applying them to specific claim scenarios.
• Improved claim resolution times by efficiently managing a caseload of 50+ claims per month.
• Researched claims and incident information to deliver solutions and resolve problems.
• Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.

• Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
• Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
• Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
• Responded to customer requests for products, services, and company information.
• Developed strong product knowledge to provide informed recommendations based on individual customer needs.
• Maintained detailed records of customer interactions, ensuring proper follow-up and resolution of issues.
• Provided coaching and mentoring to new hires, contributing to their successful integration into the team.
• Exceeded performance metrics consistently, earning recognition as a top performer within the team.
• Addressed customer inquiries to ensure satisfaction and foster positive service experience.