Jesus Ortiz

Experience

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  Cinema Video

  Apr 1998 - Sept 2001

  Manager

  * Improve the operational systems, processes and policies in support of organizations mission -- specifically, support better management reporting, information flow and management, business process and organizational planning.* Manage and increase the effectiveness and efficiency of Support Services (HR, IT and Finance), through improvements to each function as well as coordination and communication between support and business functions.* Supervise employees and prepare payroll.* Computer system and building maintenance.* Inventory control, data entry and purchaser.* Managed cash register and money deposit. Show less

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  Bellester Hermanos Warehouse

  Oct 2001 - Jul 2003

  Accounting Clerk

  * Prepare invoices for customers and providers, data entry, reconciled invoices.* Assist clients with telephone inquiries, and credit issues.* Managed new merchandise and entered it to the system.

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  La Cruz Azul de PR

  Jul 2003 - Oct 2007

  Fraud and Abuse Auditor

  * Data base analyst using Mainframe Programs (Access, MHS, Star Sentinel, Inmediata)* Identify potential fraud abuse; recover overpayments for unnecessary billed services.* Regulatory compliance, credentialing and audits of validation documents.* Customer and Provider services, handling appeals.* Visit Providers and Hospitals to get evidence for medical audits and service.* Review and analyze utilization of medical services and pharmacy, identify over utilization. * Prepare statistics reports for medical management staff meetings. * Audit Payments, Its claims, regular claims and Medicare claims with Access program.* Knowledge of medical terminology (Medicare, CPT-4, ICD-9, Revenue Codes, HCPCS).* Manage change of information, Provide technical assistance.* Handle provider’s requests and complaints, follow up for resolution.* Manage the flow of information to and from sites.* Audit Payments, Its claims, regular claims and Medicare claims with Access program. Show less

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  Medical Card System

  Jul 2003 - Oct 2007

  Grievance and Appeal Specialist

  * Identify and investigated complaints and appeals with different time frames.* Refer all investigation to appropriate department and take the finally determination.* Provide information and support to customers/providers over the telephone.* Document every case using Mainframe Programs (CMS, HPMS, Infrocrosing)* Call backs to resolve situations for subscribers (Pre-authorizations of services, case maintenance, etc.)* Send customer and providers resolutions of complaints and appeals.* Vast knowledge of coverage and benefits of Medicare Advantage Program, Commercial and Medicaid.* Coordinate preauthorization of services and benefits. Show less

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  Medical Card System

  Mar 2010 - Dec 2017

  * I offer the service contracted facilities in order to develop and maintain a healthy business .* Help facilities to obtain services, audit invoices, guide in everything related to the company, codes of procedures, medical policy among others.* Ongoing field service visits to assign providers and facilities, establishing and maintaining effective relationships.* Monitoring and review specific reports each facility such as financial reports, medical utilization and quality to identify trends in order to implement corrective action plan according to the need of the facility. Show less * Ongoing field service visits to assign providers, establishing and maintaining relationships.* Conducting initial provider orientations. * and auditing providers’ credentials. * Data analyst for the Comercial, Medicaid and Medicare Advantage business lines.* Supporting other department strategies, Develop provider growth plan. * Conducting on-going meetings with the PNA Provider Network Administration participate in provider events (seminar, conferences, etc.)* Prepare and maintain PNA reports as needed.* Coordinating PNA office committee meetings quarterly.* Routine visits to all primary care providers with no members monthly and visits to primarycare providers with members weekly * Identifying Medical Associations Meetings in the Alianza for networking opportunities.* Coordinate and conduct training and educational programs on site. * Help grow their membership with MCS, Identify leads for sales opportunities.* Respond to inquiries related to policies, procedures and operational issues.* Manage change of information, Provide technical assistance.* Handle providers requests and complaints, follow up for resolution.* Manage the flow of information to and from sites.* Help provider with the process contracting and ensure contract compliance, Comprehensive Health Risk Assessment (CHRA), Capitations, and other incentive. Show less

  • Ficilities Provider Relations Specialist

    Jun 2014 - Dec 2017

  • Provider Service & Marketing Specialist

    Mar 2010 - Jun 2014
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  Constellation Health

  Jun 2018 - Apr 2019

  Provider Network Relations Representative

  • Schedule and conduct regular provider visits to educate providers and office staff on topics including, introductory meetings about our services, health plan operations policies and procedures, preventative and quality outcome metrics & risk adjustment.• Managing and negotiated aspects of the health plan physicians, physicians’ group, sometimes hospitals of contracting process including credentialing documentations and site visits. • Coordinate meetings for Provider Relations Department, including tracking provider visits and identifying trends in the market.• Identify and analyze problems, plans tasks and formulate solutions.• Participate in strategy initiatives of new markets.• Claims and data analyst for the Medicare Advantage.• Assisted in credentialing and re-credentialing process to ensure provider's, groups, facilities applications are correct and expedited.• Recruited physicians, groups, facilities in accordance to network requirement goals.• Investigate and resolve member complaints regarding providers to ensure satisfaction at both levels. Show less

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  Diamond Resorts™ Resort Operations

  Aug 2019 - Nov 2019

  Contracts Specialist

  • Review and data entry of purchase proposals for accuracy and legibility.• Retrieve, contract, credit, loan, documentation and account history of prospective clients.• Prepare contracts and making copies and creating packs for distribution.• Track, monitor and transmit money from sales, cash outs, etc. Includes deposit transmittal.• Reconcile daily batch transactions.• Prepare opening and closing reports and distribute to the appropriate personnel.• Maintain databases of marketing personnel and various sales and/or marketing logs.• Support the sales sites as necessary to complete paperwork for contracts generated.• Assist Sales and Verification departments regarding owner-related issues at point of sale or after. Show less

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  Healthfirst

  Sept 2019 - Aug 2021

  The Senior Provider Operations Representative is responsible for performing all duties of a Provider Operations Representative, as well as serving as resource for the Provider Operations Representative including training, coaching, and guiding performance of Provider Operations Representative. This role will support the Supervisor and Manager as a resource department representative for cross-functional projects and meetings.• Setting up new or existing providers and benefits then validating the configuration.• Analyst Provider profile data into MHS database as requested. • Analyst and identify inconsistencies and conflicts between Provider, Benefits and Facility records. • Validating Providers profile data for compliance with Provider set up guidelines as required to execute and file Providers application. • Analyzing Provider records and reports within MHS system and compare the data against the initial set up instructions provided. • Communicating discrepancies to both internal and external customers as appropriate to clarify and resolve any inconsistencies to ensure database accuracy. • Analyst and maintain a daily production sheet including all work completed for the workday. • Managing work assigned through prioritization to meet expected completion deadlines foreach request received. • Communicating with department leadership to ensure that assigned workload can be completed as assigned. • Conducting comprehensive and thorough review of requests for Provider profile set-up and updates initiated by other departments and received via Macess, fax, or e-mail for accuracy and completeness. Show less • Conducting comprehensive and thorough review of requests for Provider profile set-up and updates initiated by other departments and received via Macess, fax, or e-mail for accuracy and completeness. • Collaborating with internal and external customers to obtain any missing information required to complete requested set up and update.• Entering Provider profile data into MHS database as requested. • Identify inconsistencies and conflicts between Provider and Facility records. • Validating Providers profile data for compliance with Provider set up guidelines as required to execute and file Providers application. • Analyzing Provider records within MHS and compare the data against the initial set up instructions provided. • Communicating discrepancies to both internal and external customers as appropriate to clarify and resolve any inconsistencies in order to ensure database accuracy. • Maintaining a daily production sheet daily to include all work completed for the workday.• Providing daily updates to Senior Representatives on the status of all active projects until completed.• Managing work assigned through prioritization in order to meet expected completion deadlines for each request received.• Communicating with department leadership to ensure that assigned workload can be completed as assigned.• Participating in special projects. Show less

  • Sr. Provider Operations Specialist

    May 2021 - Aug 2021

  • Provider Operations Representative

    Sept 2019 - Aug 2021
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  UnitedHealth Group

  Aug 2021 - now

  Senior Network Program Specialist

  The Sr. Network Program Specialist is responsible for analyzing networks and reports with different systems and data, ensuring the network composition includes an appropriate distribution of provider specialties. Responsibilities also include establishing and maintaining strong business relationships with providers in the Long-Term Care and Comprehensive health plan (Medicaid dual MMA and LTC). This role will involve oversight of LTC Provider Credentialing and Re-Credentialing and will present provider packets and files to the Health Plan Credentialing Committee.• Work with existing database (Pivot Tables, VLOOKUP’s, etc.) to extract reports, analyst data to producerequired results with reports and presentations.• Create and Analyst reports using different programs (Share Point, Excel Access, Microsoft Forms)• Serve as team lead for Network Contract Associates, network operations.• Use Microsoft Excel, Power BI, Amaardi, Orbit, Quest Analytics, Network 360, Micro Strategy, Citrix, CSP for data tracking, trending, analyst and reporting for network adequacy, reports, or presentations.• Responding to provider network inquiries.• Use existing procedures and facts to solve routine problems or conduct routine analysis.• Works closely with Provider Advocate team, supporting network needs.• Communicates with providers via phone/email/letters.• Produce PowerPoint presentations to include graphs and charts. Show less