STANLEY'S RESUME-10.25.16
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S. Stanley Smith, BS 1116 Bramlett Forest Road, Lawrenceville, GA 30045 (678) 226-7924 – [email protected] Achievement-oriented provider service professional with diversified experience in provider relations and network business support, claims and contracting - Effective communicator and problem solver with strong written, oral and interpersonal communication skills and excellent computer skills in MS Office, Word, Excel and Access Professional Experience: Blue Cross and Blue Shield of GA (an Anthem Plan), Inc. (January 1999 – October 2015) Network Management Representative II – Georgia Networks - Atlanta, GA (March 2007 – October 2015) Prepared new and/or modified existing provider contracts and conducted provider training Developed and maintained positive relationships with the provider community by periodic on-site visits, communicating administrative or programmatic changes and facilitating the resolution of provider issues Conducted negotiations and lead contracting efforts with providers to build and maintain a cost effective, accessible provider network Researched, analyzed and recommended resolution for contract dispute, non-routine claim issues, billing questions and other practices Coordinated communication process on such issues as administrative and medical policy, reimbursement and provider utilization patterns Network Management Representative I – Georgia Networks - Atlanta, GA (May 2006 – March 2007) Conducted formal review of Contracts and Credentialing documents Coordinated approval and issuance of all provider contracts to appropriate parties such as credentialing, reimbursement, and provider database Created boilerplate provider contracts and selects and inserts optional paragraphs/riders as directed Maintained automated status logs and prepares monthly and periodic reports Coordinated with provider database to ensure that provider reimbursements are loaded in accordance with contractual agreements and that provider data is current Responded to providers regarding status of documents and other contracting related issues Created and maintained provider files and related documentation and process provider data changes and provider terminations Medical Review Representative – State Health Benefit Plan – Atlanta GA (January 1999 – May 2006) Managed incoming calls or incoming post service claims Determined contract and benefit eligibility, provided authorizations for admissions, outpatient precertification, post service requests and emergency room visits Ensured claim payment accuracy by verifying various aspects of the claim including
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Transcript of STANLEY'S RESUME-10.25.16
S. Stanley Smith, BS1116 Bramlett Forest Road, Lawrenceville, GA 30045
(678) 226-7924 – [email protected]
Achievement-oriented provider service professional with diversified experience in provider relations and network business support, claims and contracting - Effective communicator and problem solver with strong written, oral and interpersonal communication skills and excellent computer skills in MS Office, Word, Excel and Access
Professional Experience:Blue Cross and Blue Shield of GA (an Anthem Plan), Inc. (January 1999 – October 2015) Network Management Representative II – Georgia Networks - Atlanta, GA (March 2007 – October 2015) Prepared new and/or modified existing provider contracts and conducted provider training Developed and maintained positive relationships with the provider community by periodic on-site visits, communicating
administrative or programmatic changes and facilitating the resolution of provider issues Conducted negotiations and lead contracting efforts with providers to build and maintain a cost effective, accessible
provider network Researched, analyzed and recommended resolution for contract dispute, non-routine claim issues, billing questions and other
practices Coordinated communication process on such issues as administrative and medical policy, reimbursement and provider
utilization patterns
Network Management Representative I – Georgia Networks - Atlanta, GA (May 2006 – March 2007) Conducted formal review of Contracts and Credentialing documents Coordinated approval and issuance of all provider contracts to appropriate parties such as credentialing, reimbursement, and
provider database Created boilerplate provider contracts and selects and inserts optional paragraphs/riders as directed Maintained automated status logs and prepares monthly and periodic reports Coordinated with provider database to ensure that provider reimbursements are loaded in accordance with contractual
agreements and that provider data is current Responded to providers regarding status of documents and other contracting related issues Created and maintained provider files and related documentation and process provider data changes and provider
terminations
Medical Review Representative – State Health Benefit Plan – Atlanta GA (January 1999 – May 2006) Managed incoming calls or incoming post service claims Determined contract and benefit eligibility, provided authorizations for admissions, outpatient precertification, post service
requests and emergency room visits Ensured claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing,
pre-authorization and medical necessity Performed medical chart reviews
United Healthcare – Atlanta GA (January 1998 - March 2003)Customer Service Representative Interpreted and explained plan benefit design, resolved claim, benefit and enrollment issues Acted as trusted advisor and educator on health care related inquiries
WellPoint Pharmacy Management – Calabasas, CA (January 1996 – January 1998)Provider Service Representative Responded to inquiries from physicians, sales team, and members related to formulary and prescription benefits Processed prior authorization requests from physicians’ offices
Education: B. S. Political Science (minor Psychology), Tuskegee University - 1976
