Danielle Nesbit
Bluffton
Summary
Accomplished professional specializing in provider network management and healthcare operations. Demonstrated success in resolving intricate claim issues and optimizing processes to improve efficiency. Strong analytical skills and experience in managed care operations contribute to organizational success.
Overview
11
11
years of professional experience
Work History
Provider Network Management Specialist Lead
Zing Health
10.2021 - Current
- Maintained provider demographic information through roster management.
- Researched claims processing guidelines, provider contracts, fee schedules and system configurations to ensure proper claim reimbursement.
- Created detailed reports outlining progress on various claims projects as well as identifying potential issues.
- Cultivated relationships with healthcare systems, vendors, and stakeholders through effective communication and problem solving skills.
- Provided leadership by motivating employees towards common goals while managing their workloads effectively.
- Facilitated training sessions for new hires in team building, customer service, and conflict resolution.
- Analyzed data to identify trends and develop action plans for improvement.
Provider Relations Specialist
MDwise, Inc
01.2021 - 10.2021
- Organized and coordinated provider orientations/monthly meetings with provider groups by documenting discussions, issues, attendees, and action items and researched claim issues on site fostering effective communication and issue resolution strategies.
- Investigated, resolved, and communicated provider claim issues and changes.
- Educated providers on policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and other related topics.
- Managed day-to-day operations related to provider relations including responding promptly to inquiries from providers or other stakeholders.
Provider Network Specialist
Centene Corp.
10.2019 - 12.2020
- Served as the primary contact for providers and act as a liaison between the providers and the health plan.
- Organized and coordinated provider orientations/monthly meetings with provider groups by documenting discussions, issues, attendees, and action items and researched claim issues on site fostering effective communication and issue resolution strategies.
- Investigated, resolved, and communicated provider claim issues and changes.
- Educated providers on policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and other related topics.
Provider Inquiry Research and Resolution Specialist
Molina Healthcare
05.2018 - 10.2019
- Researched claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
- Provided assistance to providers and support staff regarding claims issues, eligibility and benefits.
- Analyzed incoming claims ensuring proper ICD -10 CM codes, pay rates, claim forms are used and timely filing deadlines are maintained.
- Educated providers on important changes to State regulations, policies, and procedures.
- Trained other new Associates on proper procedures for Provider Services.
- Made use of multiple licensing internet sites to obtain required verification on new Provider enrollments and reenrollments.
- Utilized problem solving skills to effectively resolve customer concerns and disputes.
- Managed multiple projects simultaneously while meeting tight deadlines without sacrificing quality or accuracy of work product.
- Assisted other teams members with escalated cases when required.
Long Term Disability Claim Support Specialist
Metlife
10.2017 - 05.2018
- Responsible for assessing, analyzing and rendering appropriate claim decisions pursuant to certificates.
- Communicating with a variety of constituents to gather information relevant to claim based upon provisions of the policy.
- Clarify functional capacity through independent problem-solving measures and discretion.
- Utilize tools independently and accurately to identify work to be completed across the entire claim block, prioritize work, determine if/when to involve specialty resources.
- Adhere to federal and state law to maintain appropriate and timely claim outcomes.
Provider Inquiry Research and Resolution Specialist
Molina Healthcare
11.2014 - 10.2017
- Researched claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
- Provided assistance to providers and support staff regarding claims issues, eligibility and benefits.
- Analyzed incoming claims ensuring proper ICD -10 CM codes, pay rates, claim forms are used and timely filing deadlines are maintained.
- Educated providers on important changes to State regulations, policies, and procedures.
- Trained other new Associates on proper procedures for Provider Services.
- Made use of multiple licensing internet sites to obtain required verification on new Provider enrollments and reenrollments.
- Successfully managed customer complaints and inquiries, providing timely resolutions to ensure customer satisfaction.
- Utilized problem solving skills to effectively resolve customer concerns and disputes.
- Managed multiple projects simultaneously while meeting tight deadlines without sacrificing quality or accuracy of work product.
Education
Medical Coding and Billing - undefined
Ultimate Medical Academy
Associate - Healthcare Administration
University of Phoenix
Skills
- Claim research and analysis
- Experience with managed care organizations
- Customer relationship development
- Provider contract management
- Operations oversight
- Analytical data skills
Timeline
Provider Network Management Specialist Lead
Zing Health
10.2021 - Current
Provider Relations Specialist
MDwise, Inc
01.2021 - 10.2021
Provider Network Specialist
Centene Corp.
10.2019 - 12.2020
Provider Inquiry Research and Resolution Specialist
Molina Healthcare
05.2018 - 10.2019
Long Term Disability Claim Support Specialist
Metlife
10.2017 - 05.2018
Provider Inquiry Research and Resolution Specialist
Molina Healthcare
11.2014 - 10.2017
Medical Coding and Billing - undefined
Ultimate Medical Academy
Associate - Healthcare Administration
University of Phoenix
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