Yanet Guada

Sr Manager, Provider Relations & Claims Resolution Operations @Aetna, A Cvs Health Company

Provides direction to operations regarding policy and procedures related to claims/providers.• Manages a team of Provider Relations Representatives who ensure the provider data entered into the provider database is accurate and the provider documentation is complete and accurate• Facilitates Provider Advisory Group meetings and works with management to implement suggested changes.• Works with Quality Management to develop appropriate provider measures and implement those measures in the provider community.• Develops provider communications including provider newsletters.• Develops and implements provider satisfaction surveys and uses results to manage relationships and educate staff.• Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures• Negotiates, reviews, and prepares draft agreements with alternative delivery system facilities, laboratories, and group practices• Manages the development and monitoring of provider contracts• Resolves administrative problems affecting network providers, patients, and Plans within contracted guidelines• Researches and coordinates the resolution of provider’s claims and capitation issues.• Coordinates provider status information with member services and other internal departments.• Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions.• Developed QuickBase Database for tracking and trending of team assignments as well as provider procedures• Handled Credentialing for Non Delegated and Delegated Groups• Handle all Provider Disputes, State Complaints, Reconsiderations, etc.