Managed Care Resume Sample
Ansley Cruickshank
7508 Moises Courts,
Los Angeles,
CA
+1 (555) 672 7768
Work Experience
VP, Managed Care Contracting
03/2018
-
PRESENT
San Francisco, CA
- Finance & Medical Economics
- Quality Performance Management (STARs)
- Business Operations Support
- Overnight travel as required by car and airplane
- Minimal travel less than 10%, 1 to 2 times per year
- Assist agency’s with any issues such as contract cancelation and denials/appeals
- Process referrals and pre-certifications as required by patient’s insurance carrier in a timely manner
- Effectively communicates with co-workers regarding the status of patient insurance and runs a daily clinic schedule for the PSS check in staff with any patient’s insurance changes
- Performs routine and regular analysis of the contracts' performance in comparison to the modeled results; details and communicates the key drivers of any variance detected
Managed Care Analyst
09/2015
-
10/2017
New York, NY
- Accountable for the growth and profitability of a portfolio of business relationships with managed care companies and provider-sponsored organizations (e.g. delegated “risk bearing” entities, Accountable Care Organizations, etc.) spanning various insurance segments (e.g. Commercial, Medicare Advantage, Managed Medicaid, Dual Eligibles, Workers Comp)
- Develops and maintains effective working relationships across all levels (both executive and mid-management) of payer organizations (e.g. Contracting/Network Management, Provider Relations, Medical Management, etc.)
- Responsible for developing, coaching, leading a staff of contracting and payer relations professionals responsible for a wide ranging portfolio of agreements with third party payers in multiple markets throughout the eastern United States, in order to achieve net revenue and earnings growth objectives
- Collaborates with corporate and market-based executives, physician leaders, sales and marketing, other support services and staff to design and execute on business development and growth activities in order to achieve the company’s business objectives
- Lead multi-disciplinary work groups, including peer groups outside of chain of command, as necessary to effectively address managed care related issues and opportunities
- Participate in Kindred operational reviews, strategic planning and budgeting processes
- Serve as one of the company’s managed care experts and provide content, insight, counsel and recommendations on industry/market dynamics, both internally and externally
- Strategic, action oriented leader with good communication skills
Managed Care Coordinator Assistant
11/2012
-
05/2015
Dallas, TX
- Assists team members in codifying the final contract terms into the contract management system
- Assist in the development and implementation of Carolinas HealthCare System�s strategies and objectives related to managed care contracting for assigned Managed Care Organizations
- Performs routine and regular analysis of the contracts' performance in comparison to the modelled results; details and communicates the key drivers of any variance detected
- Assists team members in codifying the final contract terms into the contract management system.Search Jobs US
- Generate invoices and electronic bill files for assigned contracts and review billing edits for accuracy
- Handle inquiries from internal and external areas pertaining to the collection of assigned accounts
- Review EOP for denied or partially paid invoices. Identify the reason for denials and resubmit invoices accordingly
- Use computerized systems and possess excellent written and verbal communication skills
- Responsible for developing and executing Kindred’s managed care strategy and related activities on behalf of the Company’s affiliated entities in assigned markets throughout the United States (e.g. Florida, Texas, Ohio, Kentucky, New Jersey, Pennsylvania, etc.)
Education
University of Phoenix - Colorado Campus
2007 - 2012
Bachelor's Degree in Business
Professional Skills
- Strong presentation skills and excellent negotiation, sales, analytical, communication and PC skills
- Analytical & interpretive skills; excellent judgment, troubleshooting, problem solving skills
- Proven strong organizational skills and attention to detail. These are absolutely necessary
- Strong negotiating skills, inclusive of interacting with organizations’ senior leadership
- Exhibit strong time management, oganizational and research skills
- Strong organizational and project management skills to ensure projects are completed timely and accurately
- Possess a strategic and problem solving orientation and superior planning and organizational skills
How to write Managed Care Resume
Managed Care role is responsible for interpersonal, organizational, analytical, excel, research, analysis, advanced, microsoft, organization, reporting.
To write great resume for managed care job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Managed Care Resume
The section contact information is important in your managed care resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Managed Care Resume
The section work experience is an essential part of your managed care resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous managed care responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular managed care position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Managed Care resume experience can include:
- Solid interpersonal skills, ability to work in a team environment with all levels
- Proficient with Microsoft Office including: Word, PowerPoint, Access, and has advanced Excel skills including use of Pivot Tables
- Experience working with SQL querying or equivalent experience
- Proficient in the Microsoft Office Suite, including MS Access, Advanced Excel Skills required
- Experience in analytics or medical economics department or combination of related consulting experience
- Ongoing evaluation of the department structure, activities, programs, functions, practices, resources, and employee effectiveness to maximize productivity
Education on a Managed Care Resume
Make sure to make education a priority on your managed care resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your managed care experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Managed Care Resume
When listing skills on your managed care resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical managed care skills:
- Excellent skills in searching web browsers
- Excellent communication skills, oral, written and by use of telephone
- Excellent interpersonal skills and the ability to interact well with all customers and employees
- Excellent interpersonal skills with the ability to professionally communicate clearly both written and verbally
- Prior experience with sophisticated modeling and financial reporting tools
- Learn and grasp computer skills quickly for data warehouse analysis and reporting
List of Typical Experience For a Managed Care Resume
1
Experience For Managed Care Analyst Resume
- Work effectively with individuals across multiple departments throughout the organization
- Establishes and demonstrates thorough understanding of contracting and negotiating fundamentals
- Extensive experiences in handling complex managed care finance issues, including profitability analyses of both capitation and fee-for-service contracts
- Experience in building sustainable partnerships between payers and providers
- Develops a strong command of available resources and tools; fully leverage those resources to support selling strategies and maximize impact
2
Experience For VP, Managed Care Contracting Resume
- Experience managing from remote locations/home office
- Two or more years’ experience providing administrative support in a professional environment
- Business to business, distributor experience managing high level/key accounts
- Identify and deploy standard account management tools for effective problems resolution
- Review performance of prior executed contracts and identify opportunities for improvement
3
Experience For Managed Care / EDI Systems Analyst Resume
- Understanding of health care delivery setting
- Working knowledge of computers, including MS Word and Excel and proficiency in Outlook and PowerPoint
- Understanding of health management policies, ethical standards, and regulatory requirements and insistence on such compliance by others
- Knowledge of principles of Managed Care, including plan types (HMOs, PPOs, etc.) and understanding of progressive health care dynamics, including Risk-Sharing
- Collaborates with Credentialing staff to facilitate the credentialing/provider application and re-credentialing processes
- Provide education and training to sales and managed care staff regarding all aspects of managed care
- Reconciles attributed patients and providers. Using standardized reporting formats, updates leadership on variations
4
Experience For Manager, Managed Care Analytics Resume
- Participate in financial statement audit by providing requested reports and answering inquiries
- Creates tools or systems, including databases and spreadsheets, to improve financial data analysis and reporting
- Supports the Manager to design and automate data tools to inform all managed care decision making including but not limited to
- Develops and tests pricing models with contracted payors that maximize net operating margins and ensure market competitiveness
- Provides resolution to managed care contractual issues pertaining to contract interpretation and coding with payers
- Prepare regular internal Management Reports as requested, including the Contract Dashboard, Contract Summary Grid and the A/R Tracking Grid
- Develop territory specific business plans for payer contracting, retention and growth
- Ensures that systems and practices are in place that allow for timely collection of AR to maximize cash flow and borrowing ability for pharmacy and Optical
5
Experience For Regional Manager, Managed Care Resume
- Develops annual business plan and operating budget
- Analyze workers’ compensation costs for reducing medical exposure
- Analyze medical provider outcomes and billing practices
- Attend bi-weekly operating meetings and present results
- As requested, prepare quarterly claim detail downloads for outsourced Vendor to analyze for IME and Home Health recoupment and process invoicing from Vendor
- Knowledge of Hospital Third Party Billing and Managed Care Contractual Rates and reimbursement methodologies highly desirable
- Articulate LabCorp's value proposition and communicates LabCorp's test offerings to health plan contracting and medical teams
6
Experience For Medical Collections Team Lead-managed Care Resume
- Assists National Payor Database (NPD) Coordinator in maintaining accurate databases of contracts and fee schedules
- Communicates with VP of Sales & Marketing to provide routine demographic changes and updates to payor networks
- Complete and distribute monthly reporting packages for JOUMs
- Responsible for encounter processing
- Ad hoc reporting and analysis, as needed
- Manages access controls to T360 and Legal Analytics platforms, ensuring appropriate security protocols are in place and enforced
- Assists in implementation activities of new clients, including client disenrollment activities
- Serves as network contact for managed care contracting functions
- Assesses managed care contracting requirements and standards as they relate to industry/regulatory issues and market implications
7
Experience For VP, Managed Care Resume
- Recommends and implements necessary improvements and revisions to contracting requirements and standards
- Perform contract analytics and risk analysis to support leadership decisions about managed care contracting
- Create and communicate contract finance and risk terms with internal and external leadership including high-level hospital administrators and physician leaders
- Five to Seven years working in a managed care environment in a similar capacity
- Work in a fast paced, evolving organization
8
Experience For VP Managed Care Resume
- Be detail-oriented and fully grasp the concept of multi-tasking with a sense of urgency
- Translate corporate and division level strategies into clear market level action plans with defined goals and objectives
- Reviews and evaluates contract performance models for renewal/ renegotiation. Maintains responsibility for contract implementation, internal and external in-servicing of contract terms
- Supports executive management in revenue recovery activity with payers. Coordinates and facilitates Joint Operations Meetings with payers and affiliated partners. Provides oversight of employees within the work group using advanced technical skills
- Conducts performance reviews and provides input on direct reports for human resource decisions such as hiring, promotions and disciplinary actions. Participates in the development of employees
- Strong knowledge of reading and interpreting EOB’s
- Understanding payer website and retrieval of information and EOB’s
- Maintains responsibility for adherence to budget for specific projects. Participates in the preparation of the department budget
9
Experience For Associate Managed Care Director Resume
- Place alerts in patient’s accounts with detailed reason for patient balance
- Maintain a working knowledge of each payer account in your territory. Within each account, understand the managed care clinical decision-maker’s product thought processes, formulary review and approval process, and various clinical/pharmacy touch points within the account
- Drive the overall strategy of the company with health plans and payers to achieve short-term and long-term goals. This includes customer targeting, understanding key customer needs and aligning the company value proposition appropriately
- Collaborate with Sales management and staff to ensure alignment on priority service issues effecting the region(s)
- Negotiate contracts and prices, driving profitable revenue growth
- Manage contracting and contract renewals in collaboration with managed care operations
10
Experience For Senior Financial Analyst Managed Care Resume
- Develop and manage relationships with health plans and medical directors to drive in-network coverage decisions and reimbursement
- Involved with the development of strategies for efficient day to day account management for client and/or segment nationally and/or across multiple regions
- Develop key organizational links to people and functions and removes barriers to problem resolution
- Identify and develop strategic initiatives/opportunities to support sales to meet volume, and revenue goals by customer, segment and client
- Work with the MCED and Sales leadership to develop territory goals and objectives for the assigned territory
- Responsible for the successful negotiation and management of financially beneficial managed care relationships
List of Typical Skills For a Managed Care Resume
1
Skills For Managed Care Analyst Resume
- Strong financial analytical skills and demonstrated problem solving and negotiation skills
- Proven leadership skills, with ability to communicate effectively with internal and external stakeholders
- Proven track record of implementing market accessplans for new technologies, experience with oncology market is strongly desired
- Creative problem identification, conceptualization, and contingency thinking skills are required
- Extremely organized with strong sense of priority, urgency and commitment to deadlines
- Experience: Three to five years of professional business or health care management experience
2
Skills For VP, Managed Care Contracting Resume
- Advanced Skills in Microsoft Office as well as Crystal Report Writer is required
- Proficient in the Microsoft Office Suite with advanced Excel skills
- Possess professional, articulate, and financially astute negotiation skills
- Experience with health insurance, patient accounting and/or managed care including payor or provider contracting background
- A proven track record for consistently meeting or exceeding qualitative and quantitative goals at both an individual and team level
- Experience managing contracting and/or payor relations
- Experience building dashboards, preferably using Tableau
- Solid understanding of Managed Care or Medicare
3
Skills For Managed Care / EDI Systems Analyst Resume
- Experience with the Cleaning and Care Industry within the Fire Service Market
- Three to five years experience in managed care ambulatory health care setting
- Self-motivated individual able to handle fluctuating volumes of work, able to prioritize to meet deadlines
- Experience using Cerner Contract Management Software
- Health care experience with contracting knowledge, preferably in managed care or revenue cycle
- Strong understanding of Managed Care Organizations and related internal structure
- Consultative sales experience calling on all levels within a managed care organization
- Experience in a healthcare financial setting (provider or health plan-based) with progressive responsibility
4
Skills For Manager, Managed Care Analytics Resume
- Proven track record of implementing market access plans for new technologies
- Demonstrated ability to analyze problems and issues from a variety of perspectives and to understand legal, risk, and operational impact of decisions
- A consultant with 3 years of Healthcare Financial Analysis experience
- Experience working in a professional healthcare environment
- Demonstrates a high-level of integrity and a proactive approach to customer service
- M.D., Ph.D or Pharm D, with clinical expertise and experience
5
Skills For Regional Manager, Managed Care Resume
- Experience in contract and financial negotiation
- Strong written and verbal communciation
- Build strong and positive business relationships
- Experience
- Experience with leadership of health care systems
- Experience as Managed Care Director in a hospital or health system or in a Managed Care organization is desirable
6
Skills For Medical Collections Team Lead-managed Care Resume
- Managed care experience is prefered
- Program leadership experience is prefered
- Experience in data management/data operations/data analysis in a SAS and SQL based environment
- Understanding of capitated and fee-for service reimbursement arrangements and knowledge of CPT and ICD-10 coding
- Monitoring payer contract terms and deliverables ensuring that all parties are compliant with all terms and conditions
- Willing to relocate for the program
- Contracting knowledge, preferably in Managed Care and Revenue Cycle
7
Skills For VP, Managed Care Resume
- Training in Excel required
- Proficient in MS Office - Excel (creating spreadsheets) and PowerPoint (creating sales presentations)
- Knowledge of regulatory compliance, including information privacy laws, access, release of information, and release control technologies
- Work collaboratively in a team setting or independently as needed
- Private and public payer coding, reimbursement policies and procedural expertise within the health care industry
- Passionate about making a difference one individual at a time
- Proficient with all Microsoft Office products, including Outlook and Word
- Motivate in a team setting
- Diagnosis and procedural coding knowledge
8
Skills For VP Managed Care Resume
- Maintains a collaborative relationship with peers and Revenue Cycle teams to share information regarding payor financial arrangements and contract models
- Retain and grow new and existing regional managed care clients
- Serve as internal SME for managed care team for genetic, pathology, and esoteric testing
- Serve as internal SME for managed care specialty testing team
- Report metric data
- Knowledge of hospital and clinics protocols and procedures
9
Skills For Associate Managed Care Director Resume
- Knowledgeable of ACO and MSSP requirements and structures
- A consultant with the ability to look at large amounts of data and figure out the "how" and "why"
- A consultant that is highly proficient with Microsoft Access, Excel, and SQL
- A consultant with the ability to look at large amounts of data and figure out the how and why
- A personal presence which is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values
- Work collaboratively in a team environment or independently, as applicable
10
Skills For Senior Financial Analyst Managed Care Resume
- Communicates professionally and effectively in written and verbal manner with payers, third-party administrators, health plan networks, negotiating agencies, department manager and director, as well as other departments within the organization
- Abides by policies and procedures that ensure consistency with the organization’s mission and directives
- Takes initiative to identify barriers and opportunities and provides solutions through process and operational improvements
- Anticipate obstacles to a goal and initiates appropriate resolution. Takes initiative to identify barriers and opportunities and provides solutions through process and operational improvements
- Knowledge of Microsoft Office, particularly Word and Outlook
- Knowledge of multiple on-line registration applications and use
- Electronic Medical Records and Electronic Practice Management knowledge
- Expert level in use of Microsoft Excel spreadsheets for analysis purposes
- Participate in monthly meetings or conference calls with Service Area executives, Hospital Presidents, physician organization leaders, CFO’s, and Strategy leaders and ensure adequate staff support to these conference calls. Make or oversee key presentations and recommendations to participants
List of Typical Responsibilities For a Managed Care Resume
1
Responsibilities For Managed Care Analyst Resume
- Previous experience leading larger-scale departmental planning processes, to include development & implementation of such plans, goals and metrics
- Experience working in a managed care setting with commercial and senior HMO members
- Experience performing onsite concurrent review or case management functions
- Computer proficiency in all Microsoft Office products with a strong emphasis on Excel is required
- Validates and processes user requests to access necessary systems
- Leverage HCA Clinical Quality outcomes within payer negotiations ensuring full understanding of HCA’s results to ensure contract optimization
2
Responsibilities For VP, Managed Care Contracting Resume
- Delivers nursing assessment, evaluation, screening, and develops action plans to ACO attributed patients that are consistent with stated medical plan of care
- Independently and accurately, analyze third party payment variances and determine root causes for discrepancies, utilizing database tools in a timely manner
- Keep informed of developments and trends relating to all areas of the company and IPAs/managed care plans
- Responsible for business development of company’s specialty testing group’s managed care initiatives
- Productivity in the timely and efficient generation of reports and analyses within a demanding workload
- Able to work independently as a team member on a variety of assignments with minimal direction, fluctuating workload, and under deadline pressures
- Monitor competitive activity and strategic trends both within the managed care industry and within the laboratory industry
- Continually analyze competitive landscape and environment within assigned accounts to determine trends and provide customer feedback to leadership
- Embrace, embody and represent the BioReference Laboratories company culture at all times to external and internal constituents
3
Responsibilities For Managed Care / EDI Systems Analyst Resume
- Coordinates with hospital care management team to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs
- Uncovers and closes new business leads/opportunities, qualifies new sales opportunities, fosters and improves relations with customers (new and current), and develops strategies to penetrate accounts to maintain and gain market share within the Infusion market segment
- Medical, Dental, Vision, Health Care Flexible Spending Accounts
- Develops, recommends, and implements short and long range objectives
- Employee's Savings Plan (401k)
4
Responsibilities For Manager, Managed Care Analytics Resume
- Provide leadership to the integration of new joint ventures, affiliations and partnership arrangements
- AR management for Retail Health (Pharmacy and Optical) in excess of $800 million
- Analyzes daily/weekly management reports to ensure maximum profits and proactively make GM improvement recommendations
- Develops and communicates dashboard report for Key Performance Metrics for Managed Care AR
- Works with IT, Finance and Pharmacy/Optical Retail Health teams
- Builds constructive and effective relationships and can identify others’ needs for information and communication. Can adapt communication style to meet needs of others
5
Responsibilities For Regional Manager, Managed Care Resume
- Professional, articulate and financially astute salesperson
- The primary responsibility of the AVP is to oversee SP&A’s optimization of the fee-for-service price/volume equation of a net revenue portfolio greater than $1.0B but no more than $1.5B
- Practice and adhere to HCA’s mission and values statement and code of conduct, and attend all required ethics and compliance training and retraining
- Assist with the development of HCA’s risk tactics and APM’s methodologies: i.e.; disease management, population management
- Serves as the “point person” to the IASIS hospitals’ business offices with regard to tracking and reducing managed care denials and underpayments, including restitution or other prompt pay penalties
- Develop and manage cost driver action plans
- Assist in the expansion of managed care services nationally
6
Responsibilities For Medical Collections Team Lead-managed Care Resume
- Review complex medical bills
- Provide technical expertise for complex cases
- Conduct routine review of all managed care products currently utilized by Everest
- Benchmark individual program results
- Ability and willingness to present to senior management and other group settings
- Develop and enhance relationships with internal and external contacts. Proactively plan, prioritize, collaborate and communicate regarding projects, issues, and negotiations to ensure relationships are maintained
7
Responsibilities For VP, Managed Care Resume
- Negotiate managed care contracts with new and existing payers (health plans and physician organizations) based on: strategic and financial goals, prior contract performance, projected contract performance, and thresholds approved by the ACN CEO and Board of Managers
- Lead and coordinate the activities of personnel in the analysis, negotiation and implementation of existing contracts with payers, including the development and production of a variety of financial projections in support of contract negotiations and projects
- Collaborate with other ACN leaders to plan and implement strategies to grow accretive market share and to increase the value of ACN’s services by developing innovative approaches to deliver quality care and to enhance the value proposition of ACN with all payer segment patients
- Direct the establishment and maintenance of internal communication and education processes that assure operations are conducted in compliance with contractual terms, and the establishment and maintenance of ongoing tracking and reporting systems and methodologies, in order to measure and document departmental and contract performance
- Represent Arizona Care Network (ACN) in meetings with other organizations, associations, providers and payers regarding all aspects of ACO arrangements and managed care requirements
- Organize and plan monthly conference calls with Hospital Presidents, physician organization leaders, CFO’s, Managed Care leaders and Strategy leaders and ensure adequate staff support to these conference calls. Make or oversee key presentations and recommendations to participants
8
Responsibilities For VP Managed Care Resume
- Provide consultative support to ACN leadership and management with respect to managed care and related issues, including employee medical benefit plans and service line issues and new innovative strategies in which Dignity and Abrazo collaborates with health plans and/or medical groups to increase the value of services we provide
- Effectively handle challenging situations and balance multiple priorities
- Managed Care experience
- Demonstrates attention to detail and monitors own work for accuracy and efficiencies
- Consolidate and manage physician contract rates across company to ascertain appropriate rate targets
- Disseminate contracts to the field based on the effective date of the contract
- Responsible for collaborating with internal and external partners to plan and implement communications regarding ACN managed care activities
- Performs analytical procedures on operating results and statistics, as well as analyzes financial performance against business metrics
9
Responsibilities For Associate Managed Care Director Resume
- Produce ad-hoc and routine reports based on information that is requested from end-user
- Exceptional interpersonal skills, including the ability to establish and maintain effective relationships with payers, physicians, management, staff and other customers
- Analyze and compile large data for decision making purposes
- Gather physician based incentive contracts and organize into a manageable database of recommended terms, conditions, and budgets
- Maintain contact with field representatives in charge of facility managed care contracts
- Maintain knowledge of healthcare and managed care regulatory/legislative and industry matters
- Perform estimate of financial impact for newly proposed contract terms
- Assist in preparation and maintenance of managed care reports
10
Responsibilities For Senior Financial Analyst Managed Care Resume
- Develop and maintain adjustable Volume & Rate Sensitivity Analyses
- Identifies compliance issues related to each contract; prepares reports to be presented to the payer with the total amount due. Calculates interest payments due
- Analyzes claims and payment data to identify trends in denied or underpaid claims. Works with appropriate staff and payers to resolve issues and facilitate payment
- Reviews language of managed care contracts. Participates in negotiations as assigned. Coordinates contract processing through legal review and execution
- Analyzes financial results and related information. Compares to projections. Provides reports to appropriate parties
- Prepares complete and accurate financial and statistical reports for distribution on a routine or ad-hoc basis as designated
- Assists in the development or revision of strategic models, plans and/or forecasts
- Maintains and enhances payment compliance Access databases
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