Paulina Jaymes
Newport News
Summary
Dedicated Provider Contracting Specialist with expertise in contract negotiation and credentialing. Proven track record of optimizing processes and negotiating favorable terms with providers. Skilled in auditing procedures and maintaining high levels of customer service. Strong interpersonal communication and teamwork abilities to drive successful outcomes.
Overview
13
13
years of professional experience
Work History
PROVIDER CONTRACTING SPECIALIST 2
Humana
03.2021 - 02.2025
- Implementation of policies to maximize efficiency of contract and credentialing processes
- Reviewed and revised sustainability proposals or policies
- Investigated markets to determine areas for opportunity
- Negotiated favorable terms with providers while maintaining a high level of customer service
- Processed incoming requests from Providers to become In Network with TRICARE
- Performed audits on contracts and credentialing
- Received and processed documents for credentialing
- Oversaw contracts for over 7 different departments using both manual and automated strategies
NETWORK CONTRACTING SPECIALIST
Logistics Health INC
04.2019 - 03.2021
- In my role as a Network Contracting Specialist with LHI, I recruited and contracted specialty practices to provide consults for military applicants in the MEPCOM II program
- Performed fee negotiations with existing providers as well as expanding current contracted providers to additional contracts and processed documentation for credentialing practitioners
- Made recommendations for best-fit contractual guidelines, developed and executed sound contract administration negotiation of contract modifications, Support activities for finalizing a contract and credentialing, manage workloads utilizing a variety of acquisition management information systems
PROVIDER RELATIONS SPECIALIST
Logistics Health INC
01.2019 - 04.2019
- Served as a Provider Relations Specialist maintaining a successful working relationship between LHI and network providers through a full range of provider relations and service interactions to ensure provider retention
- Identify and remediate operational short-falls, respond to customer complaints, customer satisfaction surveys and provider questions, and research and resolve accounts payable issues
- Routinely negotiate cost effective fees for single services, confirm service capability and educate providers on contract expectations, processes and paperwork
- Comprehend detailed knowledge of customer requirements in order to translate subcontractor agreements, contractual requirements and fee agreements to the providers
Provider Network Specialist
Health Net Federal Services
01.2012 - 01.2019
- I've performed in several positions such as a Supervisor to more than 10 customer service agents supporting United Military West, a lead supporting more than 20 PC3 (Patient Centered Community Care) agents scheduling veterans for VA appointed healthcare, a Provider Network Coordinator where I provided contracts to providers requesting to join the Tricare and PC3 network, a PROS (Provider Relations Outreach Specialist) verifying all information for contracted network providers, I credentialed practitioners and conducted webinars for providers on various Tricare/PC3 topics, and assisted with recruiting providers for the new VA Choice program, and as a Provider Network Management Specialist handling multiple providers in a span of five states resolving contract, credentialing and claims related issues with the Department of Veteran Affairs programs
Skills
- Auditing procedures
- Contract Administration
- Workflow Management
- Interpersonal and written communication
- Contract Negotiation
- Teamwork and Collaboration
- Attention to Detail
- Time Management
- Problem-solving abilities
- Organizational Skills
- Credentialing
Timeline
PROVIDER CONTRACTING SPECIALIST 2
Humana
03.2021 - 02.2025
NETWORK CONTRACTING SPECIALIST
Logistics Health INC
04.2019 - 03.2021
PROVIDER RELATIONS SPECIALIST
Logistics Health INC
01.2019 - 04.2019
Provider Network Specialist
Health Net Federal Services
01.2012 - 01.2019
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