Toya Martin
Nashville,TN
Summary
Experienced Contract Analyst with a proven track record at HCA Healthcare, specializing in contract analysis and quality improvement. Successfully utilized Microsoft Office skills to enhance managed care contract modeling, resulting in a 75% reduction in provider inquiries. Committed to streamlining processes and promoting educational development within the organization.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Contract Analyst
HCA Healthcare
Nashville, TN
01.2022 - Current
- Conducted What-if modeling for managed care contracts.
- Managed and structured contracts using advanced modeling tools.
- Managed upkeep of service definitions.
- Streamlined results organization to enhance analytical efficiency.
- Assist with designing, developing, and implementing ad hoc reports.
- Assist in identifying and documenting reporting requirements
- Extracted and manipulated data from databases based on identified sources.
- Conducted QA evaluations aligned with established standards.
- Utilized data mining tools to efficiently fulfill customer data requests.
- Compiled contract hand-off packets for Shared Services Center.
- Audit monthly data loads of the End of Month data within the Enterprise Data Warehouse (EDW) and the Managed Care/DSS Business Objects Universe
- Produce training and education for outside users in addition to maintaining the education documentation
- Collaborated with senior department members to foster responsive customer relationships.
Quality Incentive Consultant
BLUECROSS/ BLUESHIELD OF TENNESSEE
Nashville, TN
01.2017 - 01.2022
- Proactively served and educated contracted physicians and health care practitioners on preferred Stars reporting, gaps in care documentation and BCBST Quality programs policies, procedures, technologies through site visits and workshops
- Collaborate with internal departments, including but not limited to: Healthcare Services, Product Strategy and Customer Service, to understand and participate (where appropriate) in addressing all issues related to providers and healthcare community within assigned territory
- Possess a deep understanding of the Medicare STARS program and become subject matter expert and conduct training assist with implementation and execution of strategy related to the quality incentive program
- Provide onsite education to change provider behaviors so that they are utilizing self-service tools
- Aid in reduction of phone calls from providers to BCBST regarding quality incentive programs and Pay for performance
- Contribute to the development and management of provider and office staff training programs for capture of STARS and Pay-for-performance codes
- Proactively facilitate interaction between providers and appropriate BCBST departmental staff for clarification or correction of quality incentive program provider concerns and/or issues; follow issue through to resolution with subject matter experts and close issues/inquiries out with the provider
- Contribute to the development and execution of multiple provider campaigns focused on improving clinically oriented HEDIS and HOS scores as well as customer satisfaction oriented CAHPS survey results
- Addressed all issues related to providers and healthcare community within the Middle and West Tennessee regions
- Assist with the execution of provider pay for performance programs aimed at aligning goals to achieve high quality care
- Provide onsite education to 130 providers quarterly helping them improve their overall STARS rating
- Aid in reduction of phone calls by 75% from providers to BCBST regarding the quality incentive program
- Educate providers on changes in HEDIS and Stars measures and their respective reporting requirements, internal initiatives designed to improve the collection and reporting of HEDIS supplemental data and on best practices in delivering high quality care
Provider Inquiry Specialist
BLUECROSS/ BLUESHIELD OF TENNESSEE
Nashville, TN
01.2015 - 01.2017
- Provided technical expertise through reporting, data research, and analysis for the effective resolution of complex provider inquiries received in their appropriate lines of business while also maintaining a comprehensive knowledge of BCBST/ BlueCare processes that impact the provider community
- Receives 150+ inquiries directly from providers via telephone, email, or provider visits and works to find root cause and resolution
- Work within FACETS and other software products to review necessary claims configuration and adjudication
- Served as subject matter expert on the authorization process and answered provider inquiries regarding the process
- Worked with providers to resolve authorization issues, Maintain in-depth knowledge of provider contracts, billing guidelines, ad reimbursement methodologies
- Provides technical expertise through reporting, data research, and analysis for the effective resolution of complex provider inquiries received in their appropriate line(s) of business
- Responsible for maintaining a comprehensive knowledge of BCBST/BlueCare processes that impact the provider community
- Receives inquiries directly from providers via telephone, email, or provider visits and works to find root cause and resolution
Team Lead
BLUECROSS/ BLUESHIELD OF TENNESSEE
Nashville, TN
01.2013 - 01.2015
- Supported care coordination through oversight of scheduling, records maintenance, coordination with providers as well as members of the coordination team
- Provided leadership for all care coordination teams in supporting members and their families
- Validated plans of care and resolved discrepancies with the care coordinator when necessary
- Lead a team of 35 Care Coordinator Assistants proactively monitored Healthcare plans administration on the marketplace to ensure governmental compliance to avoid adverse fines, fees, and penalties
- Trained 15 new hires for the ECF and Choices 6–8-week programs with a completion of 10 training cycles
- Responsible for quality and performance metrics and completion of intricate tracking logs and reports Coordinated the implementation of ECF Choices program
- Maintained positive relationships with providers and referral sources
- Ensured accurate validation of plan of cares and initiated services for members
- Provided guidance when needed to everyone on the care coordination team
- Received incoming calls from members and providers and assisted with any issues or concerns
- Worked closely with the support center supervisor to identify issues and propose solutions
Care Coordinator Assistant
BLUECROSS/ BLUESHIELD OF TENNESSEE
Nashville, TN
01.2010 - 01.2012
- Delivered proactive support to the Care Coordinator throughout daily operations ensuring sound decisions, developed and maintained relationships, researched and resolved inquiries through research to ensure completeness and accuracy
- Analyzed member care plans and synthesized information to educate callers on Long-Term Services and Supports
- Maintained records and created departmental reports
- Conducted administrative tasks and managed multi-line phone systems to respond to clients or route calls to necessary parties
- Produce and interpret reports for missing authorizations, expiring authorizations, non-members with authorization and multiple authorizations
- Field calls and emails from Care Coordinators, members and customer service representative and investigate and resolve any issues in a timely and efficient manner
- Send delay correspondence
- Improve HEDIS compliance percentages for Diabetic CHOICES members by at least 10% or one higher percentile for 3 of the 4 following Diabetic Care Screening measures: HbA1C testing, Nephrology screening, LDL screening or Eye Exam
- Specialized in project management to resolve provider payment issues
- Maintained up-to-date knowledge about care options and referrals for various health needs
- Utilized active listening and provided strong customer service to all clients
Business Office Manager and Customer Service Representative
CORNELIA HOUSE/TENNESSEE CARRIERS
Nashville, TN
01.2005 - 01.2010
- Provided top quality Customer Service through clear, effective communication on standard operating procedures and trusted processes providing customers and the general public top quality customer service by expeditiously answering questions regarding client appointments, scheduled appointments, handled difficult calls, performed training, general administration and clerical support
- Assisted with new hire training, general administrative duties and clerical duties including preparation of letters, documents, and mail
- Performed background checks on potential employees and administered drug screens
- Prepared the manifest using excel, typed documents, ordered supplies, inspected vans, transported clients to and from doctor’s appointments, verified insurance, faxed, e-mailed, and filed
- Handled patient billing, petty cash, patient funds, cash receipts, and census reports
- Performed audits on patient trust accounts-maintained records for Medicaid, private pay, and Medicare residents
- Resolved customer complaints by investigation of the issue and clear and consistent communication
- Order supplies, issued gas cards made bank deposits, updated insurance information and claims
Education
Bachelor’s Degree - Business Administration
Argosy University
Medical Assistant Diploma -
Nashville College of Medical Careers
Skills
- Quality Improvement
- Analyzing clinical data
- Billing and collections procedures
- Private and commercial insurance carriers
- Contract reviews and edits
- Professional relationship building
- Document review
- Contract analysis
- Insurance and collections procedures
- Insurance eligibility
- Process implementation
- HIPAA
- Writing educational material
- Database management
- Microsoft Office
- Project Management
- Inventory Management
- Budgeting
- Continuous Process improvement
- Research & Analysis
- Training/Program Development
- Medicaid/Medicare
- CMS
- CPT
Certification
Six Sigma Yellow Belt
Timeline
Contract Analyst
HCA Healthcare
01.2022 - Current
Quality Incentive Consultant
BLUECROSS/ BLUESHIELD OF TENNESSEE
01.2017 - 01.2022
Provider Inquiry Specialist
BLUECROSS/ BLUESHIELD OF TENNESSEE
01.2015 - 01.2017
Team Lead
BLUECROSS/ BLUESHIELD OF TENNESSEE
01.2013 - 01.2015
Care Coordinator Assistant
BLUECROSS/ BLUESHIELD OF TENNESSEE
01.2010 - 01.2012
Business Office Manager and Customer Service Representative
CORNELIA HOUSE/TENNESSEE CARRIERS
01.2005 - 01.2010
Bachelor’s Degree - Business Administration
Argosy University
Medical Assistant Diploma -
Nashville College of Medical Careers
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