Tanisha Amway-Bailey
Harrisburg,PA
Summary
Experienced senior manager with over 10 years in credentialing and network compliance, seeking to leverage expertise in regulatory compliance, provider credentialing, and network development to drive organizational excellence and operational efficiency.
Overview
16
16
years of professional experience
Work History
Provider Account Executive
UPMC HEALTH PLAN
HARRISBURG, PA
11.2021 - Current
- Cultivate and manage relationships with healthcare providers, including hospitals, physicians, and ancillary service providers, to ensure alignment with UPMC Health Plan's strategic objectives
- Negotiate provider contracts, fee schedules, and reimbursement rates, resulting in improved network adequacy and financial performance
- Lead provider education and training initiatives to enhance understanding of UPMC Health Plan policies, procedures, and quality improvement initiatives
- Collaborate with internal stakeholders to streamline provider credentialing and enrollment processes, reducing administrative burdens and improving provider satisfaction
- Develop and implement quality improvement initiatives and care management programs in collaboration with providers to achieve clinical and financial goals
- Monitor provider performance metrics, identify areas for improvement, and implement corrective actions to address performance gaps
- Serve as the primary point of contact for provider inquiries, issue resolution, and all aspects of the credentialing/recredentialing process, ensuring compliance and efficiency
Network Contract and Provider Enrollment Coordinator
AMERIHEALTH CARITAS
HARRISBURG, PA
01.2021 - 11.2021
- Coordinated provider enrollment and contracting processes, including credentialing, contracting, and onboarding activities, to expand and maintain the AmeriHealth Caritas provider network including Medicare and Medicaid
- Managed communication with providers regarding enrollment requirements, credentialing status, and contract negotiations, ensuring compliance with organizational policies and regulatory standards
- Collaborated with internal stakeholders, including network management, provider relations, and legal teams, to facilitate timely execution of provider contracts and agreements
- Reviewed provider credentialing applications, verifying credentials, licenses, and certifications, and ensuring adherence to AmeriHealth Caritas credentialing criteria
- Monitored provider enrollment data and maintained accurate records in compliance with state and federal regulations and NCQA accreditation standards
- Responded to provider inquiries and resolved issues related to enrollment status, credentialing documentation, and contract terms in a timely and professional manner
- Assisted in the development and implementation of process improvements to enhance efficiency and effectiveness of provider enrollment and contracting operations.
Dental Network Service Rep
UNITED CONCORDIA
HARRISBURG, PA
01.2013 - 07.2020
- Managed relationships with dental providers, including dentists, dental specialists, and ancillary service providers, to ensure network adequacy and provider satisfaction
- Acted as the primary point of contact for provider inquiries, issue resolution, and escalation management, ensuring timely and accurate resolution of issues
- Conducted provider outreach and education initiatives to promote understanding of United Concordia policies, procedures, and reimbursement processes
- Facilitated provider contracting and credentialing processes, including contract negotiations, fee schedule management, and provider enrollment activities
- Committed to ensuring the highest levels of compliance and integrity through NCQA standards
- Collaborated with internal stakeholders, including network development, claims, and customer service teams, to address provider needs and enhance operational efficiency
- Monitored provider performance metrics, identified opportunities for improvement, and implemented strategies to enhance provider engagement and satisfaction
- Assisted in the development and implementation of provider network expansion strategies to improve access to care and meet the needs of United Concordia members.
Credentialing Representative
UNITED CONCORDIA
HARRISBURG, PA
01.2009 - 01.2013
- Managed the credentialing and recredentialing processes for dental and vision providers, ensuring adherence to United Concordia's credentialing standards, state and federal regulatory requirements along with NCQA standards
- Reviewed provider credentialing applications, verifying credentials, licenses, certifications, and malpractice history to assess provider qualifications
- Conducted primary source verification of provider credentials, including education, training, work experience, and professional references
- Communicated credentialing decisions to providers and facilitated the resolution of credentialing-related inquiries and issues in a timely and professional manner
- Maintained accurate provider credentialing data in the credentialing system and ensured compliance with data integrity standards and confidentiality requirements
- Collaborated with internal stakeholders, including network management, provider relations, and legal teams, to facilitate credentialing-related activities and resolve complex issues
- Assisted in the development and implementation of process improvements to enhance the efficiency and effectiveness of the credentialing process.
Education
Certification in Leadership and Organizational Change -
ROBERT MORRIS UNIVERSITY
05.2023
Bachelor of Science in Public Policy -
PENN STATE UNIVERSITY
12.2013
Associates in Arts of General Studies -
HARRISBURG AREA COMMUNITY COLLEGE
12.2002
Skills
- Policy Development
- Analytical Skills
- Regulatory Standards
- Oral & Written Communication Skills
- NCQA
- Problem Solving
- Data Analysis
- Cross-Functional Collaboration
Timeline
Provider Account Executive
UPMC HEALTH PLAN
11.2021 - Current
Network Contract and Provider Enrollment Coordinator
AMERIHEALTH CARITAS
01.2021 - 11.2021
Dental Network Service Rep
UNITED CONCORDIA
01.2013 - 07.2020
Credentialing Representative
UNITED CONCORDIA
01.2009 - 01.2013
Certification in Leadership and Organizational Change -
ROBERT MORRIS UNIVERSITY
Bachelor of Science in Public Policy -
PENN STATE UNIVERSITY
Associates in Arts of General Studies -
HARRISBURG AREA COMMUNITY COLLEGE
Similar Profiles
Brenda PalmaBrenda Palma
Administrative Coordinator at Department of Health Economics, UPMC Health Plan (remote)Administrative Coordinator at Department of Health Economics, UPMC Health Plan (remote)
Lori (Loraine) M HartmanLori (Loraine) M Hartman
Senior Product Manager at UPMC Health PlanSenior Product Manager at UPMC Health Plan
Bailey PrellBailey Prell
Health Care Concierge at UPMC Health PlanHealth Care Concierge at UPMC Health Plan