Valerie Gibbs
Henderson,NV
Summary
Seeking to use my extensive knowledge with HEDIS developed while working in the health insurance industry to contribute to the efficient management and future growth of Center Well medical offices.
Overview
26
26
years of professional experience
Work History
Provider Quality Liaison
Centene
Las Vegas, NV
05.2021 - Current
- Coordinated quality improvement initiatives by collaborating with healthcare providers to enhance care standards.
- Led cross-functional teams in evaluating member care quality, identifying areas for improved patient outcomes.
- Implemented effective communication strategies between stakeholders to resolve claims issues and enhance provider satisfaction.
- Managed comprehensive reviews of HEDIS measures to drive performance improvement across the provider network.
- Established strong relationships with key stakeholders, fostering open lines of communication to discuss and resolve quality issues promptly.
- Championed cross-functional collaboration in the pursuit of shared objectives, fostering a cohesive work environment where team members felt empowered to contribute meaningfully towards organizational goals.
Network Relations Consultant
Anthem Inc.
Las Vegas, NV
12.2012 - 05.2015
- Establish and maintain strong business relationships with Southern Nevada physicians, educating providers and identifying issues
- Successfully train providers on computer interfaces for accurate billing and authorization policies
- Ensure quality of member care and quality standards of provider network
- Interpret and explain various types of services provided in Nevada and other states with providers and members
- Contracts and payment schedules (e.g., fee for service, capitation, single case agreement)
- Reimbursement methodologies
- HEDIS measurement reports
- Claims investigation and research on an array of diverse provider inquiries and issues
- Efficient use of Salesforce software to implement tracking of underpayment or denial of claims
- Act as liaison between providers and claims adjustors
- Coordinate and supervise Joint Operations Committees with local hospitals and large provider groups
Network Relations Consultant
Amerigroup Community Care
Las Vegas, NV
01.2009 - 12.2012
- Establish and maintain strong business relationships with Southern Nevada physicians, educating providers and identifying issues
- Successfully train providers on computer interfaces for accurate billing and authorization policies
- Ensure quality of member care and quality standards of provider network
- Claims investigation and research on an array of diverse provider inquiries and issues
- Efficient use of Salesforce software to implement tracking of underpayment or denial of claims
- Acclaimed multiple instances as nominee for quarterly employee of the month
- (Amerigroup acquired by Anthem December 24, 2012)
Senior Network Education Representative
Anthem Blue Cross Blue Shield Partnership Plan
Las Vegas, NV
12.2006 - 12.2009
- Develop and maintain relationships with medical providers in Southern Nevada through in-office and telephonic appointments
- Computer interface training
- Provide research and resolution of claims inquiries
- Collaborate with national representatives for health issue promotions including diabetes management
- Member outreach at local health fairs; community resource center housed at main business office
- Awarded recognition for exceptional engagement with provider community
Lead Utilization Management Intake Specialist
Blue Cross of California
Camarillo, CA
10.2005 - 12.2006
- Assist with inbound calls from hospitals and physician offices to provide quick and accurate call resolution
- Implement prior authorization guidelines to approve cases; provided successful training to new staff
- (Wellpoint)
Customer Care Associate III
Blue Cross of California
Camarillo, CA
11.2001 - 10.2005
- Provide quick, reliable and accurate resolution of calls for several insurance products at high-volume call center
- Awarded and honored for exceptional and dedicated service
- (Wellpoint)
Individual & Small Group Claims Examiner
Unicare
Newbury Park, CA
09.2000 - 11.2001
- Professional Claims Processor
- Specialized Assignment: Contributed to resolution of Texas Clean Claim Act
- (Wellpoint)
Education
Teaching Credential - Multiple Subject
California State University Northridge
Northridge, CA06-1997
Bachelor of Arts - Liberal Studies
California State University Northridge
Northridge, CA06-1997
Skills
- HEDIS Measure Training for physician offices varying in size from 1:1 to small groups
- Interface between health plan system & provider network offices
- CAHPS Survey Results and Discussions with physician and office staff
- In office chart retrievals for HEDIS season using multiple EMR systems
- Collaborated with Risk Adjustment Representatives on presenting and training the correlation between the Continuity of Care (COC) incentive program and the HEDIS Pay Four Quality Medicare incentive
Timeline
Provider Quality Liaison
Centene
05.2021 - Current
Network Relations Consultant
Anthem Inc.
12.2012 - 05.2015
Network Relations Consultant
Amerigroup Community Care
01.2009 - 12.2012
Senior Network Education Representative
Anthem Blue Cross Blue Shield Partnership Plan
12.2006 - 12.2009
Lead Utilization Management Intake Specialist
Blue Cross of California
10.2005 - 12.2006
Customer Care Associate III
Blue Cross of California
11.2001 - 10.2005
Individual & Small Group Claims Examiner
Unicare
09.2000 - 11.2001
Teaching Credential - Multiple Subject
California State University Northridge
Bachelor of Arts - Liberal Studies
California State University Northridge