Rhonda C. Rader
Roanoke
Summary
Dependable and devoted healthcare professional with a proven track record of cultivating strong relationships, showcasing an exceptional work ethic, and exhibiting top-notch communication skills. Adaptable to change, whether working independently or collaborating seamlessly within a team. Proficient in crafting impactful presentations, generating comprehensive reports, and identifying opportunities that drive organizational success. Committed to furthering the goals of the organization through strategic development initiatives.
Overview
24
24
years of professional experience
Work History
Sr. Network Relations Consultant
Aetna Better Health of Virginia
09.2017 - 02.2024
- Act as the primary resource for assigned, high profile providers or groups (i.e., local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs
- Working with Appeals and Grievances to research issues and provide follow up and having claim’s adjusted if necessary
- Pulling in Medical Management or Medical Director for resolution when necessary
- Provide credentialing updates to providers as well as reaching out when additional information is needed or CAQH needed to be updated
- Working in Quickbase and CRM systems to resolve inquiries from providers and keep track of outreach
- Design, develop, contact, maintain and enhance relationships with facilities, physicians and ancillary provider which serve as contractual networks of care for members; foster growth of managed care products; and enhance profitability of Aetna
- Attending and presenting at provider and DMAS events to distribute Aetna Better Health of VA information
- Assisting HEDIS with record retrieval from providers
Benefit Administrator
Benefit Plan Administrator’s
01.2017 - 07.2017
- Responsible for creating efficiency and streamlining processes
- Keeping current with trends and regulatory issues
- Work directly with members, carriers, providers, and brokers to monitor systems and provide the highest level of customer service to plan participants
- Experienced administering benefits to small groups as well as larger groups with up to 500 lives
- Excellent Communication Skills
- High Attention to Detail
- Creative Problem Solver
- Demonstrated customer service focus
- Exceptional time management skills enabling ability to effectively multi-task on numerous projects & tasks
- A solid understanding of healthcare laws and regulations
Membership Representative – Anthem Health Care
Kelly Temporary Services
10.2016 - 11.2016
- Responsible for enrollment, billing activities and/or maintaining assigned accounts
- Responds to incoming calls and may initiate outgoing calls, providing customer service to plan members, providers, and employer groups by answering benefit questions, resolving issues and educating callers
- Verifies enrollment status, make changes to records, research, and resolves enrollment system rejections; addresses a variety of enrollment questions and/or concerns received by phone or mail
- Maintains enrollment database
Data Analyst - Anthem Health Care
Jacobson Group Temporary Service
04.2016 - 10.2016
- Updating spreadsheet and maintaining formulas for correct 2017 benefits and rates for competitors
- Gather date by extracting information on products from other carrier plan filings
- Provider enrollment and data updates
Quality Assurance Analyst – Anthem Health Care
Kelly Temporary Services
10.2015 - 01.2016
- Auditing recorded telephone calls for the individual sales department to score incoming and outgoing telephone calls
- Monitor and ensure staff adheres to established standards for excellent customer service, including protecting enrollee confidentiality
Provider Relations Consultant
Humana Health Plan
03.2011 - 04.2015
- Liaison with all providers (doctors, hospitals, ancillary providers) in a designated geographic area
- Educate and support providers regarding Humana’s Medicare Advantage Plan and CCC operations and issues through telephonic contact, individual meetings, and group seminars
- Maintain a broad knowledge of Medicare Advantage plan designs, claims processing, customer service, enrollment, electronic claims transfer, networks, and system capabilities
- Assisting HEDIS with record retrieval from providers
External Provider Relations Representative
Arcadian Health
11.2009 - 03.2011
- Develop provider network for SW Virginia to assure a marketable product
- Evaluate and complete provider contracting
- Work directly with providers and provider groups to resolve issues relating to claims payment, eligibility, reporting and other issues as they arise and any assigned by the Executive Director
- Effectively communicate responses to providers and provider groups using both verbal and written communication
- Create outreach meetings for Sales and non-Sales events to communicate and educate on the Medicare Advantage Plans
Plan Advisor I - Marketing
Virginia Premier Health Plan
01.2008 - 11.2009
- Conduct informational sales and non-sales events at community events in the service area with marketing materials for Virginia Premier Gold Medicare Advantage Plan
- Perform duties that will result in enrolling beneficiaries into a Special Needs Plan (SNP)
- Maintain current knowledge of federal Medicare regulations; assess impact of regulation changes and assure compliance with all Centers for Medicare and Medicaid Services regulations and guidelines
- Responsible for application completion and submission within 24hours of receipt
- Answer phone lines to create referral and authorization based on information provided
Quality Assurance Specialist
United Health Group/Ovations
10.2005 - 01.2008
- Auditing customer service calls follow up work and correspondence
- Monitor and ensure staff adheres to established standards for excellent customer service, including protecting enrollee confidentiality
- Providing feedback to Supervisors and agents regarding quality scores and provide input by make suggestion for improvement
- Assisted with the development, implementation, and maintenance of tracking procedures for the Record-on-Demand, QFiniti
- Project leader for HIPPA verification Team
Credentialing Coordinator
CIGNA Healthcare Inc.
06.2004 - 07.2005
- Project lead for all functions of physician and ancillary credentialing within VA, Maryland, and DC
- Use of CAQH system to obtain physician information, when necessary
- Build and maintain relationships with key providers and facilities
- Act as a resource to other staff members, as well as providers, regarding status of application and credentialing process
- Processing provider applications and reapplications
- Created and maintained the provider profiling system as well as updating databases for continuity
- Complete and maintain weekly report for management
Provider Data Management
CIGNA Healthcare Inc.
12.2001 - 06.2004
- Manage accurate, timely loading and maintenance of provider demographic and contract/financial data within 3 systems
- Research and work inquiries to ensure provider fee schedules and fees are loaded correctly
- Submit template and fee schedules to ensure accurate claims processing
- Create and maintain weekly reports for inventory management
Associate Provider Relations Representative
CIGNA Healthcare Inc.
03.2000 - 12.2001
- Performed “key” provider service visits to promote provider satisfaction
- Resolved and responded to telephone and written inquiries from providers and facilities regarding complex claim issues, eligibility, benefits & issues involving contract or fee schedule disputes
- Performed detail query of systems to investigate complex claim or provider services issues
Education
High School Diploma -
Patrick Henry High School
Roanoke, VASkills
- Excellent Communication Skills
- High Attention to Detail
- Creative Problem Solver
- Demonstrated customer service focus
Timeline
Sr. Network Relations Consultant
Aetna Better Health of Virginia
09.2017 - 02.2024
Benefit Administrator
Benefit Plan Administrator’s
01.2017 - 07.2017
Membership Representative – Anthem Health Care
Kelly Temporary Services
10.2016 - 11.2016
Data Analyst - Anthem Health Care
Jacobson Group Temporary Service
04.2016 - 10.2016
Quality Assurance Analyst – Anthem Health Care
Kelly Temporary Services
10.2015 - 01.2016
Provider Relations Consultant
Humana Health Plan
03.2011 - 04.2015
External Provider Relations Representative
Arcadian Health
11.2009 - 03.2011
Plan Advisor I - Marketing
Virginia Premier Health Plan
01.2008 - 11.2009
Quality Assurance Specialist
United Health Group/Ovations
10.2005 - 01.2008
Credentialing Coordinator
CIGNA Healthcare Inc.
06.2004 - 07.2005
Provider Data Management
CIGNA Healthcare Inc.
12.2001 - 06.2004
Associate Provider Relations Representative
CIGNA Healthcare Inc.
03.2000 - 12.2001
High School Diploma -
Patrick Henry High School
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