VERNESSA SMITH
St Louis,MO
Summary
I have been in the Health plan industry for 20 plus years and confident that I can be an asset to your company. My resume reflects that I have been a consistent front-line representative for my employer, servicing providers, members and decision makers of various social service organizations. I have demonstrated myself as a leader and am committed to new challenges that will allow me to aggressively add my attributes to a team of winners. I am a results-driven prospective employee aiming to secure a position with opportunity to apply my experience and ambition, I welcome the opportunity to work in-front and behind the scenes by addressing the needs and concerns of the department with diligence and professionalism. I am resourceful Coordinator possessing outstanding prioritization, multitasking and planning abilities to juggle responsibilities and exceptionally qualified to fulfill the needs of this position and honoring the business initiatives of the department.
Overview
27
27
years of professional experience
Work History
Lead Member Risk Adjustment Coordinator I
Centene Corporation/Homestate Health
11.2023 - Current
- Onboarding contracted employees, training on all systems utilized by department.
- Improved team productivity with regular communication and progress updates, fostering a collaborative work environment.
- Requests medical records by making outbound phone calls, emails and fax request to provider groups. Direct medical record requests to the responsible party, perform audits on team daily production
- Manage projects for Medicare, RADV, and Marketplace to meet project timelines.
- Create and Maintain accurate records of departmental activities of products, reporting to Corporate counterparts.
- Assist with ad hoc requests
- Remote position-Team Lead
Member Risk Adjustment Coordinator I
Mindlance/ Home State Health
10.2021 - 11.2023
- Training contracted employees on all systems and portals use.
- Make outgoing calls, email or fax request to facilities and provider's office to request medical.
- Maintained an accurate log of daily work production for audits.
- Multitask between projects during season of overlapping CMS audits.
- Abstract medical records from portals to be uploaded for coding.
- Volunteer to assist other team members in the absence of Supervisor.
HEDIS Coordinator
Healthcare Support/Centene Corp.
02.2020 - 05.2020
- Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities
- Assist with quality improvement initiatives in the service and clinical areas
- Coordinate, complete, and update management on clinical quality metrics and HEDIS processes and results
- Establish and maintain an action plan to improve HEDIS scores
- Implement process to request and evaluate member compliance reports for each HEDIS measure, including evaluating improvement opportunities
- Collaborate with providers and internal departments on rate investigation and validation activities, including maintaining all evidences, documentations, and changes
- Manage the HEDIS project to include assignment of nurses, adherence to plan timeline, and vendor oversight for timeliness and quality
- Conduct quality audit and maintain all data and process controls to ensure compliance
Clinical Administrative Coord
UNITED HEALTH GROUP/Optum
07.2019 - 01.2020
- Scheduled appointments in accordance with facility calendar and provider availability
- Kept permanent records current to support auditing processes and meet requirements
- Acted as patient advocate and implemented total patient care as part of nursing team covering approx
- 140 client calls per shift
- Coordinated Quality Improvement Activities (QIA's) to identify performance areas for improvement
- Set and managed patient appointment schedules
- Served as liaison between management, clinical staff and the community
- Maintained HIPAA compliance across all patient data-handling, systems and training
- Automated office operations, managing client correspondence, record tracking and data communications in database and case management software.
Data Management Spc II
Magellan Health
07.2018 - 12.2018
- Responsible for timely, accurate provider rates maintenance in multiple databases to support claims payment
- Researches and resolves provider claims issues and ensures systems are updated, timely, appropriately and accurately to support accurate claims payment
- Manages special projects within the unit, including prioritizing, distributing work, keeping records and keeping management informed of progress as well as outcome
- Researches information regarding complex inquires, develops solutions and communicates outcomes by email
- Performs peer audits within the unit, load provider/facilities and groups to data base
- Records daily activities using electronic and manual systems as directed
- All duties assigned.
PROVIDER RELATIONS REP
Well Care Health Plans, Inc.
01.2018 - 07.2018
- Liaison between Health Plan and Providers in the Southern Illinois Medicaid market
- Facilitate monthly meetings to address credentialing, claims, contract interpretation, quality measures and incentives offered by health plan
- Educate providers/facilities on policy, procedure, web portal, coordinate with all departments to share benefits that are offered
- Exercise research skills to obtain resolution to prevent provider abrasion
- Conduct in-services and site visits, primary purpose is to maintain business relationship and market company as a leader in the Market.
PROVIDER NETWORK SPC II
Healthcare Support/Home State Health Plan
08.2016 - 11.2017
- Internal/External Representative
- Liaison between Health Plan and provider
- Provider orientation when provider becomes par
- Hedis assignments
- Collect missing documents for credentialing via email, phone or in person
- Verify credentials, collect documents review dates, specialty, tax id numbers along with billing location and office location for loading purpose
- Follow up on appointment access surveys for monthly reporting for compliance
- Auto assign members to new providers upon provider termination
- Run claim reporting
- Review contracts for provider interpretation in regard to claim resolution
- Retrieve/request medical record request for audits and claim disputes
- Assist external reps on participation on effective dates and renewal.
PROVIDER NETWORK SPC II
Coventry/Aetna HealthCare
08.2012 - 04.2016
- Liaison for Provider and Health Plan
- Once provider has been established, maintenance of business relationship, through education and in-services on company benefits, policies and other incentives offered
- Coordinate with credentialing to update provider data, reimbursement rates/contract agreement/updates/termination
- Site visits
- Review monthly capitation payments
- Strong decision making/problem solving, claim researching on reimbursement resolutions.
PROVIDER RELATIONS REP
Molina Healthcare of Missouri
03.1997 - 07.2012
- Liaison for Provider and Health Plan
- Recruitment and education of new providers, provider agreements from application through implementation
- Contracting, cold calling, build and market health plan network in new territory
- Monthly reporting to discuss and identify gaps, to meet State requirements
- Coordinate with credentialing to update provider data, reimbursement rates/contract agreement/updates/termination
- Maintenance of business relationship, through education, in-services on company benefits, policies and other incentives offered
- Site visits
- Review monthly capitation payments, strong decision making/problem solving
- Claim researching, reimbursement resolutions.
Education
N/A DEGREE - COMPUTER SCIENCE
WILBERFORCE UNIVERSITY
WILBERFORCE, OHION/A DEGREE - COMPUTER SCIENCE/NURSING
FOREST PARK COMMUNITY COLLEGE
St Louis, MON/A DEGREE - NURSING
SIU CARBONDALE
ST LOUIS, MOHigh School Diploma - HIGH SCHOOL BASICS
OFALLON TECHNICAL HIGH SCHOOL
ST LOUIS, MO01.1985
Skills
- MICROSOFT WORD
- OUTLOOK
- EXCEL
- POWERPOINT
- KNOWLEDGE OF CPT/ICD-10 CODES
- COMMERCIAL, MEDICARE AND MANAGECARE INSURANCE BACKGROUND
- 15 PLUS YEARS IN HEALTHCARE INDUSTRY, MARKETING HEALTH PLANS BENEFITS AND SERVICES
- SHAREPOINT
- CHANGEHEALTHCARE
- INTERPRETER (PROGRAM SYSTEM)
- RECRUITING
- CREDENTIALING
- CONTRACTING
- MAINTAINING BUSINESS RELATIONSHIPS
- CLAIM RESOLUTION
- PROJECT AND PROVIDER MANAGEMENT
Timeline
Lead Member Risk Adjustment Coordinator I
Centene Corporation/Homestate Health
11.2023 - Current
Member Risk Adjustment Coordinator I
Mindlance/ Home State Health
10.2021 - 11.2023
HEDIS Coordinator
Healthcare Support/Centene Corp.
02.2020 - 05.2020
Clinical Administrative Coord
UNITED HEALTH GROUP/Optum
07.2019 - 01.2020
Data Management Spc II
Magellan Health
07.2018 - 12.2018
PROVIDER RELATIONS REP
Well Care Health Plans, Inc.
01.2018 - 07.2018
PROVIDER NETWORK SPC II
Healthcare Support/Home State Health Plan
08.2016 - 11.2017
PROVIDER NETWORK SPC II
Coventry/Aetna HealthCare
08.2012 - 04.2016
PROVIDER RELATIONS REP
Molina Healthcare of Missouri
03.1997 - 07.2012
N/A DEGREE - COMPUTER SCIENCE
WILBERFORCE UNIVERSITY
N/A DEGREE - COMPUTER SCIENCE/NURSING
FOREST PARK COMMUNITY COLLEGE
N/A DEGREE - NURSING
SIU CARBONDALE
High School Diploma - HIGH SCHOOL BASICS
OFALLON TECHNICAL HIGH SCHOOL
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