CONSULTANT

Sotero Z. Marinas, MBA

**** **** ** *******, ********** 94531; 58 Country Village Rd Jersey City, NJ 925-***-**** ad8u4b@r.postjobfree.com

PROVIDER NETWORK MANAGEMENT

Provider Relations Healthcare Billing & Fees Analysis & Reporting Collaborative Team Leadership Dedicated, innovative provider network and operations leader with extensive experience in fast-paced health insurance environments. Analytical professional skilled in successfully navigating a large provider network through periods of accelerated growth. Collaborative communicator continually focused on building relationships within an organization and the provider base to drive new sources of stable revenue and transparency in healthcare services.

Analytic Problem Solving

Project Management

Task Priority & Focus

Team-Oriented Leader

Solutions Driven Thinker

Transparent Communication

Rate Request Changes

Fee Schedules

Billing Coding

Regulatory Requirements

Provider Networks

Policies & Procedures

Market Analysis

Contract Review

Vendor Services

Risk Assessment

Quality Assurance

Data Warehousing/Mining

PROFESSIONAL EXPERIENCE

BZ Commerce, Antioch, CA January 2015 to Present

Self Employed Merchant

KEY ACCOMPLISHMENTS:

Provide Home Improvement Services

Buy and sell building materials

Specialized and promote artificial turf landscaping

Engaged in international trades or import\export Anthem Blue Cross, Walnut Creek, CA July 2014 – December 2015 Provider Network Manager II

Effectively managed the entire provider network from management duties to administrative aspects. Regularly reviewed provider rate requests, reviewed contracts and analyzed the provider’s market analysis and overall fee schedule. Terminated and on-boarded providers based on their contractual obligations, fee schedules and rate increases. KEY ACCOMPLISHMENTS:

Supported and translated Anthem’s business objectives in to contract terms and conditions with providers. Met and exceeded goals and objectives through the active management of the provider network.

Participated in special projects like QHIP, ACO, Value Based for Performance and PC2 that covered various cost-of- care, payment innovations and improved health outcomes. Slashed costs thru contracting standard fee schedule. Lead resolution to innovative payment incentives and ACO contract by identifying contract issue and making amendments, contract and pricing configuration claims reprocessing.

Engaged a cross-functional team in a special project that aimed to correct the ACO implementation due to the limitations of the system. Ensured the program complied with all SOX auditing requirements.

Forged strong relationships with new and existing providers. Expanded the depth of relationships through regular, transparent communication and data sharing.

Empire BlueCross BlueShield, New York, NY November 2007 – July 2014 Network Management Consultant (EDI)

Represented the organization in sourcing and maintaining relationships within the vendor/provider community. Negotiated supplier contracts, ensuring favorable terms were met for all parties involved. Expanded the depth of relationships through proactive communication and data sharing based on the contract and HIPAA regulations. KEY ACCOMPLISHMENTS:

Assertively negotiated health provider terms, conditions and contractual obligations. Encompassed 95% of health providers under the same contract and evaluated each case for special circumstances.

Prepared statistical and demographic reports for senior management’s analysis during decision-making meetings. Guided the overall development of strategy for the network. Sotero Z. Marinas

Acted quickly to resolve provider data errors and integrity issues. Deployed advanced problem solving techniques and virtually eliminated repeat incidents of the same root cause.

Effectively executed cost-of-care initiatives. Continually searched for areas of improvement through customer and end- user feedback.

Resolved all provider inquiries in a timely manner. Escalated concerns to the appropriate resource when necessary. St. Vincent Corporation June 2006 – January 2010

Board member and Facilities Manager

Operated as the principal stakeholder and project manager for the facility’s major renovation and construction project. Oversaw all contractor management activities. Ensured the readiness of the site for city, county and state required inspections. KEY ACCOMPLISHMENTS:

Obtained the Certified California Adult Residential Facility (ARF) Administrator designation. Upgraded policies, procedures and standard operations that were deficient or did not meet ARF requirements.

Completely remodeled and oversaw all construction projects to ensure that they complied with ARF requirements as well as all local city and fire regulations. Finished the project on-time and within budget.

Formed a corporation and acquired the appropriate state licenses to effectively and legally operate the ARF. Pacific Dental Benefits Inc., Concord, CA November 2002 – July 2003 Programmer / Analyst

Enforced and evaluated HIPAA X12N transactions set compliance. Mapped out the link to various databases and application servers. Received EDI transaction sets based on the regulatory requirements outlined by the X12 standard in the healthcare system. KEY ACCOMPLISHMENTS:

Designed, tested and signed off on the entire architecture/setup of the system. Strictly enforced quality control and testing standards within the application.

Crafted the database to easily link to frontend services for user-friendly interfaces. Enhanced the accessibility of data throughout the system by compiling it in one common location.

Applied testing controls and procedures during the validation of newly developed software packages. Increased first time validation test acceptance by approximately 95%. Peregrine Systems (Harbinger Corporation), Concord, CA April 1998 – April 2001 Senior Technical Consultant

Served as Senior Technical Consultant for the Professional Services and Outsourcing Practice division. Controlled the timely delivery of packaged and non-packaged services. Launched products at the client’s site and followed through with aftercare and support. KEY ACCOMPLISHMENTS:

Strategically utilized staff and other resources to complete professional services contracts and deliverables. . Arranged resources in the most efficient way and realized increase in productivity.

Integrated various ERP systems into newly installed applications and updates. Streamlined ERP operations and directly increased productivity within the system.

Collaborated with the customer’s management team and various vendors in the quest to successfully integrate EDI systems into sales order, invoicing, shipping and other required business transactions. Foundation Health System, San Rafael, CA November 1996 – July 1997 AS/400 Security Officer

Accurately performed user administration within AS/400 and RS6000 systems. Installed and frequently updated/maintained business-critical applications. Directly supported end-users with a variety of support and troubleshooting tasks. KEY ACCOMPLISHMENTS:

Evaluated software vendors and their application offerings. Assertively negotiated pricing for products while simultaneously leveraging volume purchases for discounted pricing.

Championed the administration and maintenance of the change management system throughout the organization. Upheld and enforced system changes and the security/confidentiality of documents. EDUCATION & CREDENTIALS

MASTER OF BUSINESS ADMINISTRATION IN HEALTHCARE ADMINISTRATION SAINT PETERS UNIVERSITY, Jersey City, New Jersey

BACHELOR OF SCIENCE IN COMMERCE

SAN SEBASTIAN COLLEGE, Manila, Philippines

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