Susan Dzialo Ross
Plymouth,MA
Summary
Seasoned Provider Relations Representative possessing in-depth knowledge of various insurance plans and policies. Expertise in handling high volume of calls, efficiently resolving disputes and identifying ways to improve processes. Proficient in claim resolution and provider communications with detail-oriented individual excellent interpersonal abilities.
Overview
13
13
years of professional experience
Work History
Director of Provider Relations
CeltiCare Health
06.2014 - 12.2018
- Design and implement provider satisfaction programs for MassHealth CarePlus
- Achieved a score 73 points on 2016 Provider Satisfaction Survey (increase of 19 pts
- From previous survey)
- Account Managed large Tier 1 groups with PR Reps
- Train and continue to educate PR Team on provider processes and needs
- Develop and oversee marketing materials used for providers
- Work closely with Network Management on contracting issues
- Credentialing & Recredentialing oversight and provider education
- Chair committee meetings to solve issues with operations/claims
- Created and introduced a new account manager role for PR
- Project Managed reporting criteria for MassHealth
- Hedis criteria presentations and engage providers to improve rates
- Worked closely with the Quality Team on NCQA reporting
- Review and interpret CAHP scores to improve service to providers
- Attend monthly Quality of Care meeting and present data as requested
- Familiar with the Massachusetts provider market including: hospitals, physicians, ancillary and DME
- Assist in resolution of member Appeals and Grievances
- Developed Dashboard to track PR Metrics and State requirements
- Joint Action Committee for Medical Management, Contracting & PR to create better provider and member service
- Familiar with all health insurance software and expert skills with Microsoft products
- Joint collaboration with Contracting regarding new providers and provider issues
- Advisor and member of the Employee Engagement Team.
Territory Supervisor Provider Relations
CeltiCare Health Plan of Massachusetts, Inc.
06.2014 - 06.2015
- Manage provider satisfaction for the CeltiCare MassHealth CarePlus program overseeing 6 provider relations representatives
- Created and supervised a 4 person team that allowed for more efficient updating of addresses, credentialing information, adds, terms, member PCP reassignments, roster reconciliation, and quality checks to allow for accuracy of the provider directory
- Maintain dashboard to track provider visits, orientations, site visits, and provider updates
- Claim research and resolution
- Mentor and train staff on presentation skills and provider education
- Use of CRM, Amysis, Configuration Tracker, Portico, Microsoft Office Suite
- Cross functional interactions to improve operations.
Corporate Operations Consultant
UnitedHealth Community Services
06.2011 - 05.2013
- Responsible for Corporate operational processes for the Medicare/Medicaid Program
- Interaction with all levels of Management advising on the best practices to maintain excellence in the care of members & payment of providers
- Project Manage Projects for Provider Relations, Compliance, Quality, COO, Clinical and Member services
- Liaison with the IT Department to insure quality of program changes and new programs were created to meet the needs of the health plan
- Ensure accurate handling of member and provider Appeals & Grievances per Medicare/Medicaid regulations
- Creation of a State grievance tracking system in conjunction with the Customer Service Center, Compliance & Quality Departments
- Conduct annual of training for Member/Provider call Center to ensure compliance with Medicare/Medicaid regulations
- Maintain Dashboards to track progress of operation projects
- ICD-10 education lead for the plan
- Participate in preparation and planning for CAHPS Survey
- Review Annual CAHPS survey results and create processes to improve any areas of deficiency
- Project Manage Special Operational Services as required
- Encounter Reporting for the State of Massachusetts.
Manager of Member Services & Claims
UnitedHealth AmeriChoice
10.2008 - 06.2011
- Work Collaboratively with Member Call Center to insure member satisfaction
- Submitted monthly member State Report
- Direct Contact with Providers & Members insuring positive experience with State of CT Medicaid Products
- Direct all educational materials to Customer Call Center
- Manage the distribution and completion of ORS issues via PC ORS
- Instruct staff in the integration of IBM COSMOS Platform with State 834 Report
- Coordinate with Vendors to insure their services are compliant with State of CT DSS Contract
- Work with Corporate Claims team to develop a claim system that paid per the DSS Fee Schedule
- Coordinate all State Required member materials with printing vendor to meet DSS requirements
- Request National Queue Reports for Providers & Members
- Handle State DSS Member and Provider Complaints.
Manager of Provider Relations & Operations
Evercare By UnitedHealth Group
09.2005 - 10.2008
- Evercare is a nursing home program that provides Nurse Practicioners in SNFs to care for members and that offered community
Education
Bachelor of Science - Accounting
Central Connecticut State University
New Britain, CT12.2004
Timeline
Director of Provider Relations
CeltiCare Health
06.2014 - 12.2018
Territory Supervisor Provider Relations
CeltiCare Health Plan of Massachusetts, Inc.
06.2014 - 06.2015
Corporate Operations Consultant
UnitedHealth Community Services
06.2011 - 05.2013
Manager of Member Services & Claims
UnitedHealth AmeriChoice
10.2008 - 06.2011
Manager of Provider Relations & Operations
Evercare By UnitedHealth Group
09.2005 - 10.2008
Bachelor of Science - Accounting
Central Connecticut State University
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