Summary
Overview
Work History
Education
Skills
Timeline
Generic
TONYA TOWNSEND

TONYA TOWNSEND

Greensboro,NC

Summary

MANAGED HEALTHCARE PROFESSIONAL Qualified healthcare industry subject matter expert with end-to-end knowledge of provider network development, provider retention, and satisfaction. Extensive background in managed care service coordination for state-funded, Medicaid, Medicare, and commercial insurance providers. Skilled in physician, ancillary, hospital contracting, and regulatory compliance. With additional experience in: ◼ Provider Recruitment ◼ Rapid and Adaptive ◼ Project Management ◼ Provider Orientations ◼ Skilled Collaborator ◼ Network Development ◼ Provider Relations ◼ Committed High Achiever ◼ Training/Development ◼ Contract Negotiations ◼ Solutions Oriented ◼ Presentation Skills Strong leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency. Uses independent decision-making skills and sound judgment to positively impact company success. Collaborative leader with dedication to partnering with coworkers to promote engaged, empowering work culture. Documented strengths in building and maintaining relationships with diverse range of stakeholders in dynamic, fast-paced settings. Resourceful Manager offering history of success coordinating and monitoring operations across various departments. Effective leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency. Highly committed with hardworking mentality to maintain quality of services and products.

Overview

16
16
years of professional experience

Work History

Provider Relations Manager

Modivcare
01.2023 - Current
  • Drive ongoing network development and ensure available contract rate capacity through a commitment to their assigned territory's overall network health
  • Manage provider network relationships through contract negotiations and network development to prevent network deficiencies, provide oversight of transportation provider onboarding, and ensure credentialing requirements are met
  • Educate transportation providers on meeting performance metrics in Tableau and implement plans to grow ongoing network development while minimizing network deficiencies
  • Implement corrective action plans for transportation providers based on performance reviews and contract deficiencies
  • Oversee digital platform use and function as the first contact for transportation providers to guide resolutions on digital platform projects
  • Developed presentations and new workflows to streamline processes companywide in collaboration with other southeast markets.

Account Executive I

AmeriHealth Caritas
09.2021 - 01.2023
  • Analyze Medicaid network gaps to identify, recruit and contract ancillary facilities, hospitals, and physician groups to meet state Medicaid adequacy guidelines in the assigned North Carolina region
  • Conduct provider orientations and weekly billing hours virtual meetings to respond to questions and resolve escalated issues involving claim payments, provider data management, and contractual language
  • Assisted in verifying provider information to ensure provider data and par status is up to date in Facets system
  • Conduct provider orientations regarding the provider portal, website access, contacts for authorizations, electronic claims, and provider appeals
  • Created an Excel spreadsheet system to record, manage and troubleshoot provider and health systems related issues such as claims, billing, and prior authorizations
  • Created best practices, email correspondence, and contract templates to collect all providers’ required information promptly and efficiently.

Contract Negotiator

Centene/WellCare Inc
09.2019 - 09.2021
  • Developed Medicaid and Medicare networks for a 14-county region in North Carolina in advance of the go-live date
  • Recruited ancillary facilities, hospitals, and physicians to meet state adequacy
  • TONYA TOWNSEND PAGE 2 guidelines
  • Contracted and negotiated with primary care, specialty physicians, ancillary providers, and vendor contractors for Medicaid product lines in assigned markets with a 98% accuracy rate
  • Facilitated credentialing configuration to ensure accurate claims adjudication
  • Partnered with provider relations representatives to provide guidance regarding onboarding new providers until contract implementation
  • Resolved escalated issues involving claim payments, provider data management and contractual language
  • Amended provider contracts when retirements, sales of practices or provider group mergers occurred
  • Developed relationships with non-contracted providers through phone calls, emails, and virtual meetings
  • Utilized value-based programs to recruit specialty providers such as transportation vendors including air and land ambulances, fire departments, and health departments to ensure total network coverage
  • Advised providers of government programs to supplement members cost of care at regular billing rates.

Network Relations Consultant

Anthem
03.2017 - 05.2019
  • Identified and recruited physicians and specialty service providers within a designated territory to close network gaps
  • Visited provider sites to conduct orientations and workshops on new protocols, policies, and procedures
  • Resolved escalated issues from provider relations representatives involving claim payments, provider data management, and contractual language
  • Negotiated rates for new physicians and renegotiated rates for existing providers seeking higher rates due to expanded services
  • Selected by manager to train new employees on systems, processes, conflict resolutions, commercial benefits, contract negotiations and contract guarantees.

Provider Relations Representative

05.2016 - 03.2017
  • Assisted with physician recruitment
  • Identified specific providers within a designated territory, facilitated provider agreement distributions, negotiated rates for new physicians, and renegotiated contracts for existing physicians
  • Visited provider locations to ensure adherence to contract guidelines, resolved issues, and maintained provider database
  • Communicated with providers seeking contracts with Aetna, answered questions, and returned documents for contracting and implementation
  • Developed training for providers on protocols, policies, and procedures
  • Coached new and existing employees on workflows and applications systems
  • Created a communication plan for the Contract Management Department
  • Detailed meeting minutes about new business and updated processes to navigate software systems
  • Filtered frequently asked questions into job aids and created a quick reference guide/ training checklist to improve performance
  • Initiated the implementation of SharePoint site to store department training documents.

Aetna
08.2007 - 03.2017

Senior Complaint and Appeals Analyst

10.2010 - 05.2016
  • Served as a Subject Matter Expert (SME) for unit workflows, fiduciary responsibility, and appeals processes and procedures
  • Coordinated interdepartmental efforts to successfully resolve claims, research SPD/COC interpretation, letter content, and state and federal regulatory language
  • Assembled all data used in medical appeal denial determinations
  • Researched claim processing logic and used various systems to verify claim payments, member eligibility data, billing, and payment status and summarized findings before initiation of the appeal process
  • Responded to Executive complaints and appeals, Department of Insurance, Department of
  • Health, and Attorney General complaints or appeals on behalf of members or providers.

Education

Bachelors - business administration

North Carolina Central University
Durham, NC

Masters in business administration - undefined

University of Phoenix
Alpharetta, GA

Masters - project management

University of Phoenix
Atlanta, GA

Skills

  • Market Positioning
  • Administrative Support
  • Negotiation and Conflict Resolution
  • Growth Planning
  • On-Site Visits
  • Strategic Business Relationships
  • Provider Orientations
  • Plan Projects
  • Collaborate Cross-Functionally
  • Administration and Reporting
  • Managing Operations and Efficiency
  • Provider Enrollment

Timeline

Provider Relations Manager

Modivcare
01.2023 - Current

Account Executive I

AmeriHealth Caritas
09.2021 - 01.2023

Contract Negotiator

Centene/WellCare Inc
09.2019 - 09.2021

Network Relations Consultant

Anthem
03.2017 - 05.2019

Provider Relations Representative

05.2016 - 03.2017

Senior Complaint and Appeals Analyst

10.2010 - 05.2016

Aetna
08.2007 - 03.2017

Bachelors - business administration

North Carolina Central University

Masters in business administration - undefined

University of Phoenix

Masters - project management

University of Phoenix
TONYA TOWNSEND