Sylvia Machado-Petry
Richmond,Texas
Summary
Detail-oriented individual with exceptional communication and project management skills. Proven ability to handle multiple tasks effectively and efficiently in fast-paced environments. Recognized for taking proactive approach to identifying and addressing issues, with focus on optimizing processes and supporting team objectives.
Overview
24
24
years of professional experience
Work History
Network Operations Consultant
Aetna, a CVS company
03.2019 - Current
- Oversee the provider onboarding process (POR) for Texas and support other markets when there is a high volume of inventory.
- Negotiate, execute, review, and analyze standard contracts for medical and behavioral health providers.
- Verify and ensure provider contract data is accurately loaded into EPDB before the go-live date.
- Create and manage cases using PRMS and NAF systems.
- Handle HRP cap office reports and member movement tasks.
- Work collaboratively with local market teams to resolve contracting issues and participate in initiatives beyond the POR.
- Educate providers and address complex inquiries related to policies, procedures, plan design, and contract terms.
- Assist with additional team projects as assigned by supervisor.
Care Management Coordinator
Harris Health
07.2016 - 03.2019
- Conducted outreach calls for the Care Management Program (High Risk Perinatal, Congestive Health Failure (CHF), Asthma & Diabetes).
- Handled incoming faxes and physician referrals for newly identified members to the program.
- Assist appeals department with inquiries, and verification of receipt of handling certified mail.
- Completed weekly analytic reports for eligible members of mental health services through Beacon Health Strategies.
Member Services Rep II
Harris Health
11.2015 - 07.2016
- Fast-paced inbound call center handling calls for benefits, authorizations and eligibility for plan types: STAR, CHIP and CHIP Perinatal programs.
- Completed PCP changes, newborn requests and scheduling of newborn and postpartum visits.
- Arranged Medicaid Transportation (MTP) for members.
- Provided member education for state compliance.
- Processed member and provider dissatisfaction calls.
Manager Quality Ops
Amerigroup/Anthem Inc.
04.2009 - 06.2015
- Designed, analyzed, and produced monthly ad hoc reports.
- Provided coaching/feedback to team members.
- Coordinated training and coaching of new hires.
- Assisted with new program implementation
- Review claims process for state compliance.
- Completed call audits using Avaya systems.
- Prepared quarterly state FREW reports for Children of Migrant Farm-Workers (CMFW) and THSTEPS initiatives in coordination with HEDIS measures.
- Primary contact handling ESRD membership applications.
- Completed Quality Assurance (QA) for phone idle times.
Intake Coordinator
United HealthCare
11.2007 - 04.2009
- Handled incoming calls from providers/members regarding benefit services.
- Handled prior-authorization requests for outpatient and DME requests.
- Handled mail outs such as: Advance Directives/Plan of Care and Unable to reach letters.
Medical Assistant
Memorial Neurological Associates
11.2002 - 11.2007
- Fully trained experience performing front office clerical and back office clinical work.
- Multi task responsibilities included: pre-certifications, referrals, verification of medical insurance (phone/online), reception, scheduling, assisting the physicians and working the nurse’s station, taking vitals, charting, filing, phone operator, testing technician and Spanish Interpreter.
Medical Assistant
Dr. Raina Patel, MD
10.2001 - 11.2002
- Performed back office work such as blood draws, injections, vitals, assistant to the physician, UA, EKG, pre-op preparing, referrals, verifying medical insurance, reception and scheduling.
Education
MHA - Healthcare Administration
Capella University
TX12-2024
Bachelor of Science - Psychology
University of Houston- Victoria
Victoria, TX08-2017
Skills
- Analytical problem solving
- Organizational planning
- Strong communication skills
- Results-oriented professional
- Proficient in medical terminology
- Bilingual communication in Spanish
- Proficient in Word, Excel and Powerpoint
Timeline
Network Operations Consultant
Aetna, a CVS company
03.2019 - Current
Care Management Coordinator
Harris Health
07.2016 - 03.2019
Member Services Rep II
Harris Health
11.2015 - 07.2016
Manager Quality Ops
Amerigroup/Anthem Inc.
04.2009 - 06.2015
Intake Coordinator
United HealthCare
11.2007 - 04.2009
Medical Assistant
Memorial Neurological Associates
11.2002 - 11.2007
Medical Assistant
Dr. Raina Patel, MD
10.2001 - 11.2002
MHA - Healthcare Administration
Capella University
Bachelor of Science - Psychology
University of Houston- Victoria
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