Thomas M. Balades
Phoenix
Summary
I am a healthcare professional of 25+ years’ experience with a strong background including Leadership as a Senior and Associate Manager in Provider Relations, and Contract Management. I have strong leadership and employee development in Provider Network Management. I am highly experienced prioritizing and organizing multiple high profile projects simultaneously working collaboratively across multiple divisions in an organization. My goal is to maintain CORE Values of any organization and develop trust maintaining business relationships.
Overview
26
26
years of professional experience
Work History
Regional Contract Manager
OPTUM SERVE
02.2022 - Current
- Served as Manager of the Day when needed or asked to fill in during high level projects.
- Successfully developed and mentored Jr. Contract Managers with recruitment and retainment of physician groups
- Analyze reports to make decisions of network adequacy, financial planning, and identifying intended targets of provider recruitment. Creating queries utilizing technology such as Tableau, SQL, and BI Power Reporting.
- Maintain and build customer relationships providing complex solutions, and excellent provider services
- Proven track record of complex issue resolution and deliverables that met KPI deadlines.
Associate Insurance Sales Manager
Independently Employed
01.2019 - 02.2022
- Developed and executed sales strategies to enhance market penetration and revenue growth.
- Trained and mentored sales team to improve product knowledge and customer engagement techniques.
- Analyzed market trends to identify new business opportunities and adjust sales tactics accordingly.
- Established strong relationships with key clients, fostering trust and long-term partnerships.
Senior Contracts Specialist
HEALTH NET OF ARIZONA
11.2013 - 11.2018
- Designated subject matter expert contract negotiations and servicing within the Commercial, Medicare, Medicaid, and Affordable Care Act lines of business.
- Established and maintained provider network relationships with education, problem solving and delivering results.
- Developed and implemented strategic sourcing strategies enhancing supplier performance and cost-efficiency.
- High experienced various payment fee schedules using payment methodologies such as DRG, ASC Groups, FFS, RBRVS, and Pay for Performance with both hospital facility and physician offices.
- Responsible for training and developing new associates with processes and guidelines of complex issue resolution.
- Negotiated and finalized complex contract terms to ensure compliance and mitigate risks.
Senior Provider Advocate
UNITED HEALTHCARE NEW YORK AND ARIZONA
03.2010 - 11.2013
- Responsible for servicing, hosting Joint Operation Committee meetings regarding State Sponsored Programs.
- In charge of servicing all FQHC providers in the New York Metropolitan area.
- Implemented Value Based Performance incentive programs based on HEDIS requirements and structuring achievement metrics.
- Conducted Quarterly Provider Forums for State Medicaid, State Children’s Health Insurance Program and Medicare/Medicaid Dual-Special Needs Program contracted in-network clinics.
- Handled projects pertaining to claims, roster audits, and changes in contracted payment conditions.
Senior Network Consultant
Anthem Healthcare
08.1999 - 11.2008
- Resolved escalated issues pertaining to subscriber medical needs, claims adjustments, and provider appeals.
- Spearheaded client engagement initiatives, fostering long-term relationships and satisfaction.
- Supervised a Claims and Customer Service unit of 15 associates. Responsible for meeting metrics of claims adjudication, wait times of call center queue, and regulatory guidelines for CMS Appeals.
- Managed multiple Medicaid States with complex issue resolution and subject matter expert legal resolution.
- Led network architecture design and implementation for complex enterprise solutions.
- Mentored junior consultants, enhancing team capabilities and knowledge base.
Education
Associates of Science - Business Administration
Phoenix Community College
Associate of Science - Culinary Arts (Major), Hospitality Management (Minor)
Oxnard Community College
Oxnard, CA05-1995
Skills
- Data Reporting Platforms: SQL, BI Power Reporting, Tableau
- Microsoft Office Suite: Word, Excel, Access, PowerPoint, Visio (Certified)
- Contracting Systems: MEDNET, Emptoris
- Cross-functional coordination
- Dispute resolution
- Contract administration
EXPERIENCE SUMMARY
- Technology Databases: Currently utilizing technology such as BI Reporting, Tableau Data Management, and various other programs to generate, manipulate and retrieve data.
- Communication: Excellent written and verbal communication with both internal and external business partners.
- Leadership: Exceptional employee leadership and development of teams in areas of complex issue resolution, high level presentations, and decision making.
Timeline
Regional Contract Manager
OPTUM SERVE
02.2022 - Current
Associate Insurance Sales Manager
Independently Employed
01.2019 - 02.2022
Senior Contracts Specialist
HEALTH NET OF ARIZONA
11.2013 - 11.2018
Senior Provider Advocate
UNITED HEALTHCARE NEW YORK AND ARIZONA
03.2010 - 11.2013
Senior Network Consultant
Anthem Healthcare
08.1999 - 11.2008
Associates of Science - Business Administration
Phoenix Community College
Associate of Science - Culinary Arts (Major), Hospitality Management (Minor)
Oxnard Community College
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