TONYA D. HUTSON
Washington
Summary
Dynamic healthcare professional with extensive experience at AmeriHealth Caritas, excelling in provider network management and contract negotiation. Proven track record in enhancing provider satisfaction and compliance monitoring. Skilled in data analysis and fostering client relationships, driving operational improvements and achieving departmental goals through effective leadership and strategic planning.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Manager, Provider Network Management
AmeriHealth Caritas
01.2024 - Current
- Manage the day-to-day activities of the Network Management department and staff.
- Assist the Director with departmental activities related to provider satisfaction, education, and communication.
- Ensures that the department and staff remain current in all aspects of Federal and State rules, regulations, policies, and procedures and creates or modifies departmental policies to reflect changes.
- Ensures department achieves annual goals and objectives.
- Research claims issues in FACETS by interpreting provider contracts.
- Responsible for hospital and physician network development and management.
- Develop and recommend policy changes related to provider recruitment and contracting.
- Recruits and negotiate contracts with specific providers to meet company requirements.
- Oversee training and communication for network providers and acts as a liaison with the provider community.
- Ensures compliance with pricing guidelines established by DHCF and Plan.
- Ensures provider contracting is consistent with claim payment methodologies.
- Maintains familiarity with State Medicaid fee schedules and analyzes comparable Plan pricing guidelines.
- Resolves difficult complex contract issues to ensure that provider contracts follow state, federal, national accrediting agencies and Plan contracting guidelines.
- Ensures that non-standard contract elements are communicated to appropriate departments and obtains DHCF and Plan approval prior to submission to provider.
- Responsible for the accuracy and timely management of all provider contracts.
- Responsible for implementation of electronic strategies for provider network to include increasing electronic claims submission and implementation of improved processes that result in increased auto-adjudication of claims.
- Responsible for compliance with State and accrediting agencies’ network adequacy standards.
- Ensures the provider network meets the health care needs of Plan members.
- Establish a recruitment plan, conduct recruiting activities and oversee the recruitment efforts of staff.
- Establishes a priority list of new types of providers to be added to the Plan network in concert with Plan departments.
- Works with Plan departments to retain network providers at risk for termination.
- Augments and modifies the existing provider network to accommodate new products or clients as necessary.
- Responsible for departmental staffing decisions and provide supervision to assigned staff, writes and performs annual reviews and monitors performance issues as they arise.
- Coach team members in the use of data and appropriate analytical tools that support improved quality.
- Support team members in the identification and creative problem resolution for improved processes and expanded use of technology.
- Lead value based discussions on measures and care gaps, and deliver scorecards to providers.
- Systematically keep staff informed of policy and procedural changes affecting program and administrative operations.
- Create and maintain standard operating procedures (SOPs) to reduce training gaps and ensure process compliance.
- Resolves individual provider complaints in a timely manner to ensure minimal disruption of the Plan’s network.
- Analyze and monitors provider claim compliance with Plan policies and procedures and recommend solutions when problems occur.
- Responsible for facilitating the department on system upgrades, regulatory directives (i.e., Medicaid Bulletins, etc.) and assigned corporate initiatives.
- Monitors capitation, provider rosters, and RHC/FQHC reports and develop and implement strategies to address outliers.
- Conduct and prepare reports on annual provider satisfaction surveys; develop plans to improve identified areas of concern; work with other departments to develop quality assurance initiatives based on survey results.
- Supports the Quality Management Department and Company-wide Quality Initiatives such as HEDIS, CAHPS and NCQA/URAC.
Manager, Client Success
HealthEdge/Burgess Group
04.2021 - 12.2023
- Managed high level relationships with assigned accounts while maintaining oversight and adherence to all Client SLAs.
- Tracked client usage metrics and responded to any escalated client product issues.
- Trained client staff and relevant partners on pricing/editing tool.
- Created and maintained standard operating procedures for the client support team.
- Created best practices documents for clients to assist client staff with business practices.
- Created and managed team KPIs/KPs.
- Collaborated with our technical support team to develop onboarding plans for new customers, led and facilitated transition discussions, and appropriately set and managed expectations.
- Facilitated a seamless client experience from implementation to production support.
- Deeply understood customer goals and helped them meet their objectives by providing strategic guidance on our platform's best practices, use cases and organizational workflow.
- Managed assigned technical resources to execute implementation/success plans and provided client support for all account implementation needs.
- Generated and submitted Service Level Agreement (SLAs) reports to all clients monthly and/or quarterly, during client quarterly business review (QBR) meetings.
- Assisted client support consultants with escalated items from an internal and external standpoint.
- Managed the client success team by interviewing, hiring, training, planning, assigning clients, directing work, appraising performance, rewarding, and disciplining employees, addressing complaints, and resolved problems.
- Worked with clients to educate and establish critical goals, or other key performance indicators.
- Review and update Client Support documentation as assigned.
- Built and enhanced positive working relationships with key clients and internal stakeholders.
- Proactively measured, monitored, and reported on client behavior maintaining optimal customer health.
Senior Client Success Manager
HealthEdge/Burgess Group
03.2019 - 04.2021
- Executed and managed daily support activities related to Burgess client questions, issues, and communications to optimize value from the Burgess solution.
- Created, scheduled, and delivered webinars for clients and Burgess staff on current pricing methodologies.
- Identified, researched, and resolved complex business and technical problems as they relate to the use and functionality of the Burgess products and platforms, and communicating with clients and internal Burgess stakeholders throughout problem inception, definition, resolution, documentation, and feedback.
- Provided the highest level of product, technical, and methodology support to our end-users that utilized Burgess products.
- Created and tested use case for sprint planning activities.
- Worked actively with customers to identify reported problems and gathered appropriate information to assist with research efforts.
- Provided problem resolution on a wide variety of issues ranging from general policy and functionality questions to in-depth technical issues relating to integration workflow.
- Proficient in addressing Tier 1, Tier 2, and Tier 3 level needs autonomously.
- Escalated reported client issues as required following Customer Support procedures and use advanced troubleshooting skills to gather appropriate data and convey concise problem information for internal personnel.
- Maintained demeanor as a calming influence during pressure situations, mixing in the correct degree of professional assertiveness without becoming aggressive.
- Maintained communication with customers during the problem resolution process, utilizing superior customer service skills.
- Provided accurate logging of problems and resolution in call tracking system.
- Maintained in-depth knowledge of company supported products.
- Reviewed and updated Customer Support documentation as assigned.
- Leveraged capabilities and tools (knowledge libraries, workflow, issue identification and documentation, function processes).
- Contributed to capability and tool development under direction of Senior Staff and Client Services Leadership.
- Assisted customers in understanding and utilizing the full capabilities of BRS and collaborated on integrating BRS into daily workflow.
- Acted as a liaison between customers and internal support staff (research, development, and product teams) to assure accurate problem interpretation and resolution.
- Captured and solicited issues/feedback from clients and internal stakeholders and document issues and client impacts.
- Trained and mentored junior staff members in all aspects of support activities.
Provider Relations Manager
Conduent
03.2016 - 03.2019
- Responsible for providing management and team leadership to a customer-focused unit consisting of Provider Inquiry, EDI Technical Support, Client Relations, and Field Representatives.
- Provided guidance to team on development, performance, and productivity issues.
- Represents the team, presenting team suggestions and recommendations to senior management on processes and procedures in accordance with organization cost, quality, and productivity goals.
- Kept apprised of developments in the field of expertise to ensure accuracy.
- Recommended and implemented changes to improve efficiency and effectiveness.
- Monitors, tracks, and reports to account and/or corporate management on team accomplishments, achievements, and productivity.
- Developed and maintained reports for presentation of department performance.
- Articulated and communicated to the team the assignment, project, problem to be solved, actionable events, milestones, and/or program issues under review, and deadlines and time frames for completion.
- Maintained an effective work relationship with the Department of Behavioral Health and Department of Disabilities Services to stay abreast of new directions and developments, understand policy changes and issues, and assist with provider education and claims inquiries.
- Ensured that the organization's strategic plan, mission, vision, and values are communicated to the team and integrated into the team's strategies, goals, objectives, work plans and work products and services.
- Assigned training duties and responsibilities to training staff.
- Provided users and staff with consultative support and education.
- Evaluated current and emerging instructional technologies for the applicability to the current training activities.
- Worked with multiple departments to make sure provider’s needs are met for more complex issues; this includes claim processing, customer service, and account management.
- Input and retrieve data, prepare analyses and present recommendations to staff, supervisors, or others as appropriate.
- Lead efforts in the use of information to improve quality, safety, effectiveness, and efficiency.
- Analyzed, validated, and documented business, organizational and/or operational requirements to support business needs.
- Conducted minimally complex case research and resolution of projects involving overpayments.
- Responsible for developing and executing the training plans for contracted providers, internal and client (DHCF) staff.
- Lead the team in identifying, distributing, and balancing workload and tasks among employees in accordance with established workflow, skill level and/or occupational specialization.
- Ensured operations staff is implementing policies for Medicaid and CHIP.
- Ensured coordination and consistency among health care and reimbursement policies developed by various Administrations within DHCF.
- Conducted quality reviews of financial transactions, and high dollar claim payments to ensure proper claim adjudication per policy.
- Worked with internal operations and client operations to develop and implement review/audit/recovery protocols and internal review guidelines.
- Developed, implemented, and managed an audit follow-up function to assure appropriate corrective action has been taken on recommendations resulting from reviews.
- Worked cohesively with the audit team and the client.
- Assisted in reviews of state complaints related to overpayments or negative balances.
- Performed long-range planning and development of annual provider trainings.
- Posted and managed documents on the DC Medicaid website.
- Designed methods for integrating function and process.
- Participated in assessing data to identify, quantify and resolve organizational problems.
- Workforce management experience including forecasting, scheduling, and real-time operations.
- Analyzed Call Center quality data to establish trends and best practices.
- Coordinated reporting related to workforce management.
- Maintained and analyzed workforce performance, leads analysis and staffing change data for continuous quality.
- Provided guidance on improvement of workflow to ensure actions are handled for priority activities.
- Worked in conjunction with the Education Department to develop and present training programs and resource materials for staff development, provider education, and client (DHCF) awareness.
- Routine interaction (verbal & written) with client (DHCF) staff, District agencies and the provider community.
- Analyzed the efficiency and effectiveness of management practices within the organization to make recommendations for operational improvements.
- Formulated procedures to existing guidance to improve the effectiveness of managerial operations.
- Developed solutions to drive continuous improvement of the organization's efficiency and effectiveness.
- Addressed issues regarding internal/external problems ranging from call escalation to customer service.
- Reviewed and evaluated proposed changes in operating procedures to improve efficiency in the organization.
- Attended meetings to inform management of developments and results.
- Evaluated managerial policies to determine gaps where additional guidance is needed.
- Designed and developed training, quality, and content oversight standards for call center operations.
- Performed quality reviews of the call center and field services staff.
- Participated in annual healthcare audits, SOC1 and SCEPTR.
- Provided technical directions to my subordinates, providers, and client staff.
- Assisted the Provider Enrollment department with the provider enrollment process and credentialing consisting of assisting providers with completing applications both written and electronic version and outreaching to the providers for an updated business/professional license to enter in the MMIS.
- Human Resource activities include but not limited to hiring, monitoring & management of employee timecard records, mentoring, expense reporting, coaching, resolve grievances/complaints, and disciplinary actions.
- Assisted in other duties as assigned.
Payment Methodology Consultant
Conduent
Washington
07.2013 - 03.2016
- Coordinated major hospital payment reform effort, implementing new payment methods across services.
- Consulted with Department of Healthcare Finance for annual maintenance of APR-DRGs and EAPGs.
- Designed and delivered training on EAPG and APR-DRG to client, hospitals, and fiscal intermediary staff.
- Conducted claim research and analysis for DC and Alaska Medicaid agencies utilizing Excel VLOOKUP.
- Assisted in certifying Medicaid Management Information System for New Hampshire Medicaid with IV&V.
- Supported D.C. Medicaid in maintaining professional services fee schedule for CPT/HCPCS codes.
Education
Master’s in science - Healthcare Informatics Administration
University of Maryland Global Campus
College Park05.2021
Bachelor of Arts - English
New Jersey City University
Jersey City, NJ05.1999
Skills
- Account management and client success
- Contract negotiation
- Data analysis and fraud detection
- Claims adjudication and billing
- Salesforce and ServiceNow proficiency
- Medical auditing and compliance
- Provider relations and recruiting
- Healthcare coding expertise (ICD-10, CPT, HCPCS)
- Government program administration (Medicare/Medicaid/CHIP)
- Quality control and KPI tracking
- OKR implementation
- Training facilitation and presentation skills
- Vendor relations management
- CPC certification and CRC certified coder
- Provider network management
- Compliance monitoring
- Healthcare policy development
- Client relationship management
- Performance tracking and improvement
- Change management strategies
- Regulatory compliance oversight
- Policy implementation and documentation
- Revenue management strategies
- Workforce management
Certification
- MLC Certified Medicaid Professional, 11/01/16
- CPC (ICD-10, CPT 4 & HCPCS), 12/01/17
- Certified Risk Coder (CRC), 09/01/25
Timeline
Manager, Provider Network Management
AmeriHealth Caritas
01.2024 - Current
Manager, Client Success
HealthEdge/Burgess Group
04.2021 - 12.2023
Senior Client Success Manager
HealthEdge/Burgess Group
03.2019 - 04.2021
Provider Relations Manager
Conduent
03.2016 - 03.2019
Payment Methodology Consultant
Conduent
07.2013 - 03.2016
Master’s in science - Healthcare Informatics Administration
University of Maryland Global Campus
Bachelor of Arts - English
New Jersey City University