TIESHA WILLIAMS
Coward,SC
Summary
Accomplished Provider Network Manager with extensive experience at WELLPOINT/AMERIGROUP CORPORATION, specializing in network development and enhancing provider relations. Demonstrated success in contract negotiations and provider training, leveraging strong leadership skills and SQL/DB2 relational expertise. Recognized for exceptional service delivery and efficiency in expanding provider networks, with an emphasis on strategic growth and stakeholder education.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Provider Network Manager I (Manager, Network Development)
WELLPOINT/AMERIGROUP CORPORATION
11.2011 - Current
- A member of the National Contracts Team
- Responsible for Health Plan start-ups, territory expansion; contract negotiations; provider education and training; mentoring and management of consultant staff
Network Contractor
PALMETTO PHYSICIAN CONNECTIONS
12.2010 - 11.2011
- Company Overview: New Medicaid Medical Homes Network to the state of SC
- Currently in the process of receiving all required CMS approvals in preparation for Go Live
- Cold call, recruit, contract providers into the Medical Homes Network
- Provider education and training on the Policies and Procedures of the program and differences between MHN’s vs
- MCO’s
- Currently assigned to the Midlands region of the state (11 of 46 counties); liaison for FQHC IPA contract, Dual Eligible Initiative, Senior Citizens Association, and Gov’s Office on Aging
- New Medicaid Medical Homes Network to the state of SC
- Currently in the process of receiving all required CMS approvals in preparation for Go Live
Provider Relations Field Representative
UNIVERSAL AMERICAN
10.2009 - 08.2011
- Company Overview: Fortune 500 company specializing in affordable healthcare products and programs, including traditional health insurance, Medicare managed care plans, and Medicare prescription drug benefits
- Recruited to grow expansion counties/market for CMS approval and licensing
- Accountable for identifying, recruiting, and capturing key accounts to establish a competitive market advantage
- Also required to strengthen and enhance the role of provider relations within the community
- Currently servicing SC (PPO and NPFFS); Asheville, NC; Augusta, GA; Savannah, GA; AL PFFS, and FL PFFS markets
- Educate and train providers in licensed counties
- Recruit and contract providers in expansion market
- Service and assist PFFS and PPO providers in SC
- Mentor and role model for team mates
- Conducted database training for staff
- Liaison with state sales agents working to grow MA membership
- Adhere to all CMS policies and procedures for Medicare Advantage product
- Assist and troubleshoot claims, recoupments, appeals, etc as required
- Established reputation and rapport with providers in the state
- Experience with facets database navigation, Netsuite/Salesforce CRM-based products/applications
- Fortune 500 company specializing in affordable healthcare products and programs, including traditional health insurance, Medicare managed care plans, and Medicare prescription drug benefits
Hospital Relations Representative
UNISON HEALTH PLAN
04.2009 - 10.2009
- Company Overview: Americhoice Division of United Health Group, providing high quality, cost-effective health care and responsive customer service that empowers its members and providers to work together for better health
- Recruited to managed and maintain hospital and ancillary relationships throughout approval areas of the state
- Manage and maintain statewide facility network (35 PAR facilities and 41 state approved counties), DHEC, anesthesia, neonatology, and ancillary accounts
- Troubleshoot and assist with claims disputes, denials, appeals, and discrepancies
- Educate and train on web accessibility, tools, and functions
- Conduct onsite orientations/training, quarterly visitations/servicing as required
- Adhere to Health Plan PNP and state contractual guidelines for Managed Care Medicaid
- Americhoice Division of United Health Group, providing high quality, cost-effective health care and responsive customer service that empowers its members and providers to work together for better health
Provider Relations Representative II
AMERIGROUP CORPORATION
09.2007 - 03.2009
- Experienced subject matter expert and back up to AVP of Provider Relations
- Selected by CEO/Plan President as 2007 Performance Champion for SC Market for outstanding service and strong leadership ability within first 6 months of employment
- Management of large-scale IPA and multi-specialty contracts
- Managed SC Hospital and Ancillary accounts management initiative as assigned by AVP and CEO
- Maintained and successfully serviced providers in 13 of 30 DHHS approved counties
- Assisted Case Management team to ensure authorizations obtained as needed for providers
- Assisted QM/RCCO/Compliance dept with education/resolution for appeals and grievances as assigned
- Supervised and trained consultants and lower level staff
- Designated SC point of contact for Credentialing/Re-credentialing initiative
- Project Management of assigned specialty projects by AVP
- Verification of provider credentials through national database resources
- Conduct required site inspections
- Coordinate and work directly with Credentialing Coordinator and Provider Data Management area to ensure accurate provider data is on file and populate in printed directories and web files
Provider Relations Representative II
BLUE CROSS BLUE SHIELD OF SC/GOV. CONTRACTS DIVISION
03.2006 - 08.2007
- Recruited as highest-level customer service representative and moved into well-respected management and support staff position
- Recruit and maintain a civilian network of health care providers to augment the services available at the Military Treatment Facility (MTF)
- Contract Negotiations
- Maintain effective communications in accordance with DOD policies and procedures
- Telephonic and on-site visits to providers as needed/required
- Educate/ train on Electronic Data Interchange (EDI) and Electronic Media Claims (EMC) features
- Conduct web training for regarding claims submissions, status checks, etc
- As required
- Establish effective relationships with medical societies, medical and hospital associations
- Ensure that providers adhere to regulations and guidelines established by the DOD, TRICARE Management Activity (TMA), contractors and subcontractors
- Ensure that medical services provided to military population with integrity
- Report any/all suspicion of fraudulent practices by providers and beneficiaries
WIA Youth Case Manager
Florence County School Dist III/Lake City Once Stop Ctr
07.2005 - 03.2006
- Recruit and case manage eligible applicants
- Interview/evaluation to identify applicant barriers
- Maintain, review, and prepare case files by federal, state, and local requirements
- Service/assist applicants in areas of education and employment
- Develop detailed Individual Education Plans (IEPs)
Provider Relations Rep/Management Support Staff
BLUE CROSS BLUE SHIELD OF SC/GOV. CONTRACTS DIVISION
06.2001 - 09.2004
- Provide on-site visits upon request by the provider, contractor’s office, or in-house staff
- Conduct semi-annual provider seminars in 7 SE states (35 TRICARE Service Centers)
- Provide presentations to provider, beneficiary, or other health service groups as needed
- Conduct web training
- Assist in the certification of providers as needed
- Provide feedback to management of any claims processing trends
- Extensive travel throughout the 7 southeast states (35 TRICARE Service Centers)
- Educate provider community on efficiency and submission of claims
- Perform website demonstrations
Claims Associate III/Customer Service Rep
BLUE CROSS BLUE SHIELD OF SC/GOV. CONTRACTS DIVISION
08.1996 - 05.2001
- Research and respond accurately and professionally to 85% of all correspondence received
- Coordination with Judge Advocate Generals’ (JAG) offices in regards to Third Party Liability
- Respond to telephonic inquiries with an average talk time of four minutes or less
- Identify and resolve all incorrectly processed claims for auditing purposes
- Ensure accuracy of all files processed
- Possess vast knowledge of governmental as well as medical policies, procedures, and guidelines
- Knowledge and experience with medical claims coding and keying by use of ICD-9, CPT-4, and HCPCS procedures
Education
MBA - Business Admin- Healthcare Mgt
Webster University
St. Louis, MO05-2025
B.A. - Business Admin-Mgt
Saint Leo University
Saint Leo05-2011
Associate of Arts -
Florence Darlington Technical College
Florence, SC05.2000
Skills
- Microsoft PowerPoint '97 Level I
- Microsoft PowerPoint '00 Level II
- Microsoft PowerPoint '00 Level III
- Microsoft Access '00 Level I
- Microsoft Access '00 Level II
- Microsoft Excel '00 Level I
- SQL/DB2 Relational Training Levels I & II (Systems Applications & Queries)
References
Available Upon Request
Managementstrengths
- Contract Negotiations
- Key Relationships
- Branding and Positioning
- New Market Penetration
- Client Satisfaction
- Dynamic Leader and Team Builder
- Key Account Management
- Client Advocate
- Computer Proficient
Certification
Insurance Producer
Timeline
Provider Network Manager I (Manager, Network Development)
WELLPOINT/AMERIGROUP CORPORATION
11.2011 - Current
Network Contractor
PALMETTO PHYSICIAN CONNECTIONS
12.2010 - 11.2011
Provider Relations Field Representative
UNIVERSAL AMERICAN
10.2009 - 08.2011
Hospital Relations Representative
UNISON HEALTH PLAN
04.2009 - 10.2009
Provider Relations Representative II
AMERIGROUP CORPORATION
09.2007 - 03.2009
Provider Relations Representative II
BLUE CROSS BLUE SHIELD OF SC/GOV. CONTRACTS DIVISION
03.2006 - 08.2007
WIA Youth Case Manager
Florence County School Dist III/Lake City Once Stop Ctr
07.2005 - 03.2006
Provider Relations Rep/Management Support Staff
BLUE CROSS BLUE SHIELD OF SC/GOV. CONTRACTS DIVISION
06.2001 - 09.2004
Claims Associate III/Customer Service Rep
BLUE CROSS BLUE SHIELD OF SC/GOV. CONTRACTS DIVISION
08.1996 - 05.2001
Insurance Producer
MBA - Business Admin- Healthcare Mgt
Webster University
B.A. - Business Admin-Mgt
Saint Leo University
Associate of Arts -
Florence Darlington Technical College
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