Network Contractor II at Blue Cross Blue Shield of Florida

Sarasota, Florida, United States

Blue Cross Blue Shield of Florida

Network Contractor II

WellCare

Senior Network Development Specialist

Network Development Specialist

Utilize previously established relationships with providers in Sarasota and Manatee counties to build rapport between Universal Health Care and the provider community.  Analyze network toidentify gaps in the Medicare Advantage (both risk and non risk contracts) and Medicaid networks.  Negotiate with physicians and ancillary providers needed to have a complete network. Educate, train and service all providers including hospitals in interaction with Universal Health Care and (when needed) facilitate resolution of claims issues.Developed contract and successfully negotiated contract for first Birthing Center for Medicaid in Sarasota CountyEffectively facilitated resolution of ongoing contract, load and claims issues for multiple providers

UNIVERSAL HEALTH CARE

Provider Operations Representative

- Supervised staff of between 6 and 17 exempt Provider Relations Specialists in multiple gepgraphic locations- Coached staff to meet or exceed set goals- Developed relationships with key providers as well as County Medical Societies- Cultivate relationships with internal partners at all levels of the organization

BCBSF

Manager

- Negotiated, educated and assisted with issue resolution for all contracted providers (physician, multi-specialty groups, hospital based physicians and ancillary) for specified territory- Established strong relationships with provider community and internal partners- Supervised and trained Network Contract Analysts- Created, reviewed and analyzed various reports including rate simulations, cost saving initiatives and claims analysis

Network Manager

Negotiated, educated and assisted with issue resolution for all contracted providers (physician, multi-specialty groups, HBP, and ancillary) in Sarasota and Desoto counties.  Established strong relationships with the provider community as well as internal contacts.  Supervised and provided training for Network Contract Analysts.  Created, reviewed and analyzed various reports including rate simulations, cost saving initiatives and claims analysis.  Expanded responsibilities included coordination among three geographic offices, oversight of Claims Liaison and accountability for 3 additional counties.  Guided Claims Liaison in issue resolution and worked on resolution for more difficult issues.  Successfully shifted from geographic focus to specialty specific focus with greater geographic accountability.Negotiated contract with first dermatologist in Manatee to accept BCBSF insurance.Within time frames, built approximately 80% of the new Network Blue Network for Sarasota and Manatee counties.Identified over utilization issues, assisted in developing corrective action plan and implemented plan and monitoring.  Successfully reduced over utilization of radiology in Manatee County

BLUE CROSS BLUE SHIELD OF FLORIDA

Provider Contracting Representative

- Interviewed, hired and trained staff for new department focusing on BCBSF Medicare Risk product-Co-designed accelerated training program-Collaberated with many functional areas including Network Contracting and Finance.-Supervised both exempt and non-exempt employees

Sr Contract Analyst

Supervised staff of between 6 and 17 Provider Relations Specialists (PRS) in multiple geographic locations throughout Florida.  Coached staff to meet or exceed both team and individual goals. Troubleshot hot provider issues to obtain resolution and improve provider satisfaction.  Developed relationships with key providers as well as County Medical Societies.  Cultivated relationships with internal partners at all levels of the organization. Initial focus on ancillary and hospital based providers (HBP). Expanded span of provider types to include physicians and hospitals however remained the ancillary subject matter expert for the statewide department.  Participated on various workgroups including Black Belt Projects and implementation of new initiatives.Consistently achieved "Highly Successful" for electronic claims submission and claims inquiry goals with increases between 4% and 25%. Manager, Physician and Provider Relations Department continued. Averted multiple potential legal actions, Department of Insurance complaints, and provider terminations through communication, negotiation and issue resolution. Mentored, coached and trained initial team of 17 inexperienced new staff in provider servicing and ancillary/HBP area achieving 95% provider satisfaction in the first year.Achieved improvements in Ancillary electronic claims submission statewide from 0% for provider types to approximately 84% as key member of Six Sigma project.

Elizabeth Grantham

Elizabeth Grantham