Celesia C. Moore has over 15 years of experience in healthcare administration and operations. She has held roles such as Senior Configuration Specialist, Senior Provider Operations Specialist, and Care Coordinator at WellCare Inc. supporting provider networks in Florida, Louisiana, and Texas. Moore is currently seeking a Bachelor's degree in International Business and has experience with systems such as SQL, Microsoft Office, and healthcare IT applications.

1. Celesia C. Moore
8721 Verde Lane Tampa FL 33647 813-377-7088 cell showcase12010@outlook.com
813-979-4516 home
PROFESSIONAL SUMMARY
Senior Support Professional recently worked as a Senior Configuration Specialist to support the Florida,
Louisiana and Texas Market for a healthcare corporation; Assisting Provider Relations and Provider
Operations Coordinators by auditing provider/ancillary contracts,provider directory changes,expediting
Behavior Health & MMA expansions. Work in concert with Professional/Institutional Configuration and
Credentialing Department to ensure compliance is maintained with provider loads. Audit site visits from
the Provider Relations Rep, conduct initial outreach calls to all markets. Past experience with auditing
medical charts to ensure patient charts are properly coded correctly according to CMS state guidelines.
Proven ability to collaborate with internal and external executives, including working with Tampa
Marketing agents. Demonstrating strong research and analytical skills, while displaying excellence in
educating and monitoring the business needs of a corporation. Proficient with SQL, Microsoft Office,
Excel, Emptoris, EMMA, Omni Flow, Xcelys, Cactus and internal IT applications. Successfully
completed all Ethics and Compliance Training along with a background of several completed hours of
Six Sigma Training.
Key Strengths
 Provider Operations
Knowledge/ Contracting
& Financial Controls
 Ethics and Compliance
Training/ Six Sigma
Training in Healthcare
 Team Building &
Leadership/ Quality
Management Strategic
& Long-Range Planning
PROFESSIONAL EXPERIENCE
WellCare Inc. April 2014- June
2015
Senior, Configuration Specialist
 Loads all professional contracts into Xcelys through appropriate research and provider data load
activities
 Performs accurate and timely provider research,verification analysis
 Resolves provider load issues with established documented processes; ensures the proper
supporting documentation exists and is maintained on file for all load processes.
 Creates and updates payable procedure codes,price rules and fee schedules needed for
participating contracts
 Develop and maintain project plans for new business implementation; Researches both State and
Federal mandates and builds State interpretation grids.
 Creates and maintains price rules and fee schedules in coordination within State and Federal
guidelines; Monitors and tests the accuracy of price rules and fee schedules.

2.  Create and maintain SATs as needed; Resolves critical errors forwarded from the claims
department; updates tracking database,builds and maintains positive business relationships with
business partners. Pull queries and utilize SQL to sort and retrieve data.
 Maintain high quality work, productivity of 20-22 loads daily, reviews hospital, SNFs or
ancillary contracts; communicates with provider relations when contracts cannot be
administered properly; Assists in special projects.
WellCare Inc. May 2013- April
2014
Senior, Provider Operations Specialists
 Support Florida, Louisiana and Texas Market expansions such as Behavioral Health & MMA
provider and ancillary contracts to ensure the development of each network. Review
terminations, vendor updates, New Contracts/LOA/LOBs & existing contracts
 Work in concert with Professional/Institutional Configuration and Credentialing Department to
ensure compliance is maintained with provider loads.
 Educate Provider Relations and Provider Operations Coordinators on market calls concerning the
proper documentation needed from the providers
 Educate all markets on properly filling out provider load forms and sub transactions to be used in
Omni Flow by hosting weekly market calls
 Support all markets by distributing reports such as the (319) Report
 Manage & work .PLFexpedite and .OmniAccess by answering emails from all Omni Flow users,
process discards of provider load forms, permanent re-assignments, Add and modifying users to
Omni Flow through process manager for all markets
 Pull reports from Process Manager and provide user access as well
 Troubleshoot system issues in Omni Flow by working with NewGen and IBM
 Assist with UAT testing and new change orders in Omni Flow
 Special Project includes Back file, NPI corrections in Xcelys and clean up QC Mail room queue
in Omni Flow
WellCare Inc. Jan. 2012- May 2013
DSNP, Care Coordinator
 Maintains working knowledge and provides technical assistance on the four tenants of case
management: Assessments, Evaluation, Facilitation and Advocacy.
 Acts as a liaison and member advocate for primary care providers, specialist providers and
members or members' representatives.
 Maintains all documentation associated with the regulatory standards while maintaining an
accurate,complete appeals/grievance record in the electronic database.
 Conducts research,including requesting member records,and organizes documentation.
 Monitors, tracks, and reports on high risk/high volume members as determines by
management.
 Interacts with other departments including (MEU) Member Engagement Unit, Member
Services, Providers Relations and Pharmacy Dept to resolve member and/or provider issues.

3.  Organizes a variety of administrative and clinical tasks and prioritizes in order of importance
and impact on members and providers.
 Develops ideas for performance and process management improvement within the department
 Outreach members that qualify for the meals program.
 Assist the Case Managers by faxing Initial Communication Plan letters over to the member's
primary care physician office.
 Actively assisting senior management by manually running the discharge report daily
for the entire department.
 Assisting senior management by taking on special projects such as: Trizetto; actively
working as a trainer for the entire Health Services Department including implementing
new training job aides and assist the testers with Step Action Plans when needed.
WellCare Inc./ Healthcare Support Staffing Nov. 2011- Jan.
2012
Transitional Care Coordinator
 Demonstrate leadership abilities by assisting managers with coaching new hire coordinators
by explaining how to look up and/or member benefits by following the process of the
scripting; to ensure the quality of the call meets CMS guidelines.
 Conducts outbound calls to members per scripting and service level requirements to help
facilitate administrative discharge needs.
 Collects and verifies information concerning eligibility, provider status, benefit coverage,
coordination of benefits and subrogation.
 Provides customer service functions and coordinates member needs with the appropriate
level of care.
 Meets the call monitoring goals by maintaining 100% call monitoring accuracy
 Applies policies and procedures, regulatory requirements and accreditation standards to all
activities.
 Performs data entry of authorizations and customer contacts in EMMA, Xcelys system and
scheduling callbacks to members using Outlook.
 Maintain professional communication between my immediate manager/supervisor and co-
workers at all times.
WellCare Inc./ Healthcare Support Staffing July 2011- Nov
2011
Member Engagement Rep.,DSNP
 Demonstrate leadership abilities by assisting manager/ supervisor in training new hire
representatives and special project reports, reviews and streamline processes and tracks all
incoming Case/Disease Management referrals; preparing assignments as needed to meet
organizational initiatives and/or objectives.
 Conducts outreach calls to members that may be potential Disease management candidates;
while conducting a low level screening to ensure that the member qualifies for a program.
 Documenting all actions taken regarding referral& contact with the member during the call;
along with assigning the member to a certified nurse for Disease Management.
 Collect and verify information concerning eligibility, provider status, benefit coverage,
coordination of benefits and subrogation.

4.  Implement company policies and procedures, regulatory requirements and accreditation
standards to all activities.
 Performs data entry of authorizations, contacts,in the EMMA system, Xcelys and Paradigm
systems; and schedules nursing assessments in Outlook.
 Receives and sends incoming/outgoing faxes; Receive and distribute incoming/outgoing
mail.
 Collaborate with other team mates to ensure that the expectation of the departmental goals
are being met on a daily bases.
 Maintain professional communication between other departments relating to special project
updates and changes.
Humana Inc. Tampa, FL Sept. 2010- June
2011
In House Medicare Risk Adjustor
 Review each MRA coder's chart review retrieved from each MSO contracted with Humana
Tampa Market
 Gather all supporting documents from patient charts by auditing each finding from each
chart review in order to enter the coder's progress report
 Setup weekly chart reviews with MSO offices for each coder by via email or fax
 Maintain and update Humana's corporate V drive to ensure the quality and the accuracy of
the database in case of a national audit by CMS
 Monitor various reports such as Medicare risk database,Estar and Speed; Each database are
internal applications while entering the information into Microsoft Access as well
 Conduct one-on-ones with coder's to discuss any discrepancies that need to be changed
 Collaborate with each coder in order to track and trend provider offices that have been
considered to be repeat offenders
 Assist Humana's trainers by explaining the MRA process and daily functions also assisting
with clerical duties and conducting Power Point presentations
CarePlus HealthPlan/ Humana Inc. Tampa, FL July 2007- Sept.
2010
Provider Service Executive
 Ensure the quality of new, add to existing and re-contracting contracts for Network
Operations
 Maintain provider records and account executives for the entire Central & South Florida
region
 Monitor weekly field reports for South Florida account executives
 Gather all supporting documents in order to credential new providers for the Network;
includes criminal background checks,review provider licenses, review Tax ID numbers/ NPI
numbers and review CV's submitted by providers and credentialing facilities as well
 Audit new contracts to maintain accuracy in the negotiations concerning reimbursements and
aide the executive by putting together Marketing Materials while working with the Sales
agents to ensure materials are updated accordingly
 Collaborate with department heads by sending monthly memo reports to ensure the quality
of CarePlus Network directory
 Assist Provider Financial Controls Analysis with departmental changes and special projects

5.  Traveled on a monthly bases meeting the VP's and Senior Directors concerning the status of
all entities assigned
Quest Diagnostics Inc. Tampa, FL Aug. 2001- July
2007
Billing Data Acquisition Mix Coordinator
 Managed high dollar revenue accounts to increase revenue by 30% on a monthly basis
 Educate providers by teaching them how to provide supportive diagnosis codes for accurate
billing
 Demonstrated compliance guideline knowledge by completing Six Sigma & Ethics training
 Assist providers by providing them with the correct ICD 9 codes for claim processing
 Analyze numbers by identifying daily inflow by tracking and trending data
 Collaborated with IT to troubleshoot problems with coding and medical billing
o Escalation Support Representative/ Quest Diagnostics Inc.
 Provide exceptional customer service and communicate information
effectively to internal and external customers
 Handle customer concerns and escalated calls by identifying customer needs
which include: proper documentation, ability to help other customer service
reps. with handling difficult calls while modeling the ability to remain
resilient, project patience, empathy and remain professional at all times
o Claims Specialist/ Quest Diagnostics Inc.
 Gather and process information needed to complete medical claims
 Taking inbound/outbound customer service calls to patients and healthcare
providers
 Investigate pending claims resolve discrepancies while working in a call
center environment; data entry, word processing and a knowledge of claims
payment laws as well as medical terminology, familiar with diagnostic
coding procedures,CPT coding and procedures including the process of
paper HCFA 1500/electronic claims work from queues
Chase Manhattan Bank Tampa, FL Jan. 1998- Aug.
2001
Fraud ACD Investigations Specialist
 Monitor various fraud detection queues and reports
 Analyze and review trends while watching customer account activity to detect potential
fraud situations
 Initiate outbound calls to verify potential fraudulent activity to various merchant dealers
 Take inbound calls on fraud issues from both internal and external sources

6.  Investigate suspicious alerts
 Analyze information from closed, open and blocked cards if necessary
 Contact authorities while suspect is on the line to attempt an arrest at the point of sale
 Collaborate with other investigation specialist as needed
 Prepare reports,monitors progress and watch for any developing problems
 Work with cardholders to verify legitimate usage and ensures that losses are minimized
 Perform other duties as assigned and work independently meeting deadlines
EDUCATION AND PROFESSIONAL DEVELOPMENT
Argosy University
HCC Community College Ybor Campus Tampa, FL
Currently seeking a Bachelor’s Degree in International Business at Argosy University as a fulltime
student; with a minor in Healthcare services.
PROFESSIONAL AFFILIATIONS
Available upon request