Managed Care Contracting Resume

Desired Industry: Healthcare	SpiderID: 4144
Desired Job Location: Columbia, Maryland	Date Posted: 11/11/2005
Type of Position: Full-Time Permanent	Availability Date:
Desired Wage: 75,000
	U.S. Work Authorization: Yes
Job Level: Management (Manager, Director)	Willing to Travel: Yes, More Than 75%
Highest Degree Attained: Bachelors	Willing to Relocate: No

Objective:
I am a detail-oriented, innovative professional with over 11 years experience in the Managed Healthcare field. I possess a thorough knowledge of the laws and regulations affecting Managed Healthcare and have experience in implementing policies and procedures on a Corporate Headquarters level.

Experience:
11/98-Present Director of Managed Care Operations

Lorien Health Systems, Ellicott City, MD

· Analyze operational policies and procedures on an on-going basis to ensure legal compliance
· Write proposals and negotiate contracts with Managed Care Organizations
· Develop and maintain credentialing on insurance contracts
· Serve as a liaison for all aspects of the Managed Care line of business between vendors and customers
· Monitor and review problems with Managed Care companies to make internal policy changes to improve the admissions process and insure successful admissions
· Oversee Managed Care Operations for six nursing facilities within the Columbia, Baltimore, Harford County, Carroll County, and Taneytown areas
· Supervise centralized staff at the corporate office
· Utilize knowledge of Federal and State Laws (i.e. Medicare guidelines, HIPPA) to plan, develop, organize and implement policies and procedures regarding managed care operations
· Develop and maintain key relationships with supervisors in Contracting and Reimbursement Departments in order to reassure correct and timely payments
· Conduct in-services with Managed Care companies to market our organization
· Prepare and submit appeals based on lack of authorizations, denied days and/or clinical issues (85% success rate of overturning denials)
· Communicate and follow up with Case managers on Managed Care patients regarding appropriate level of care for reimbursement
· Direct facilities with Managed Care admissions problems
· Manage billing process by monitoring cash receipts and enforcing strong accounts receivable collections. Maintain A/R collection reimbursements at 90%-95%, obtaining reimbursement in less than 30 days from date of billing
· Approve or deny invoices based on insurance contracts
1/95-11/98 Managed Care Coordinator

Lorien Health Systems, Ellicott City
· Performed billing and collection for Managed care patients for several Sub-Acute nursing homes
· Coordinated and completed month-end close for facilities in a timely manner
· Updated and reconciled monthly census
· Entered and updated Medicare claims electronically
· Communicated with Case Managers on issues regarding Managed Care patients
· Assisted in preparing proposals and negotiating on Managed Care Contracts

11/93-1/95 Accounts Receivable/Collections Coordinator
Mariner Health Care, Baltimore, MD

· Utilized knowledge of Federal and State regulations and the various billing forms to prepare and submit invoices for Sub-Acute nursing and the Rehabilitation Center
· Recorded daily collection of cash receipts and made deposits
· Communicated with patients, family members, and other parties responsible for payment of patient care to provide account status
· Produced timely billing for Managed Care
· Produced UB92 for all Medicare and contract patients as well as for Medicare demand billings
· Completed month-end close in a timely manner
· Reviewed remittance advices for denials and re-billed as required
· Reviewed accounts receivable aging on a timely basis and made collection calls for all payor classes

3/91-11/93 Accounts Receivable Coordinator
Fairfield Medical, Inc., Baltimore, MD
· Performed third party insurance billing for Durable Medical Equipment
· Performed collections on a daily basis by calling customers and insurance companies
· Resolved billing problems
· Extensive knowledge of medical terminology

Education:
College of Notre Dame of Maryland, Baltimore, MD
· Bachelor of Arts in Business Management, with a second emphasis in Human Resources Management

Skills:
· Proficiency using the following software packages:
- Keane Software
- Microsoft Office Suite
- Public Notary for the State of Maryland

Candidate Contact Information:

This candidate has chosen not to make contact information available on this page.
Click "Contact Candidate" to send this candidate a response.