Summary
Overview
Work History
Education
Skills
Timeline
Generic

Heather Sutherland-Popich

Monongahela,PA

Summary

Dedicated professional with extensive healthcare expertise and sharp analytical skills. Demonstrated success in client advocacy, healthcare investigations, and overseeing cases. Collaborative team player adept at adapting to changing circumstances to reach goals. Proficient in negotiation, communication, and resolving conflicts effectively. Known for reliability and a results-oriented approach focused on providing meaningful solutions.

Overview

13
13
years of professional experience

Work History

Senior Provider Advocate Account Manager

United Health Group
01.2022 - 04.2025
  • Managed multiple large health systems
  • Facets subject matter expert
  • Provide day-to-day management of engagement activities, including project management, reporting, coaching, implementation, problem resolution with defined service partners and other activities to assist in the facilitation of a successful relationship with assigned providers/book of business
  • Identifies solutions to non-standard requests and problems. - Solves moderately complex problems and/or conducts moderately complex analyses.
  • Works with minimal guidance; seeks guidance on only the most complex tasks
  • Provides explanations and information to others on difficult issues.
  • Coaches, provides feedback, and guides others
  • Understand and guide providers to appropriate resources to troubleshoot questions and other business concerns
  • Accountable for the full range of provider relations and service interactions within UHG, contract interpretation and implementation, including working on end-to-end provider claim and call quality, ease of use of physician portal and future service enhancements, and training & development of external provider education programs.
  • Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers
  • Directs and implements strategies relating to the development and management of a provider network. Identifies gaps in network composition and services to assist the network contracting and development staff in prioritizing contracting needs
  • Involved in identifying and remediating operational short-falls and researching and remediating claims
  • Field-based; Frequent on-site visits and meetings with physician groups or hospital systems. Large complexity, high volume, high spend provider groups
  • Current Facets platform and Medicaid subject matter expert
  • Worked effectively with fellow team members to coordinate effective solutions to any question or concern.
  • Delivered friendly service and offered expert support in every interaction.
  • Implemented technology solutions for case management, improving efficiency and data accuracy.
  • Participated in professional development initiatives for consistent improvement and up-to-date knowledge of emerging trends and best practices.

Network Engagement Manager

United Health Group
09.2020 - 01.2022
  • Independently, lead for engagement management initiatives including working with external providers on appropriate use of the network, adoption of point of care enablement technology, self-service adoption, affordability targets and overall education. Work with EPIC, Cerner, EClinical Works, NextGen, Allscripts, and Practice Fusion
  • Provide day-to-day management of engagement activities, including project management, reporting, coaching, implementation, problem resolution with defined service partners and other activities to assist in the facilitation of a successful relationship with assigned providers/book of business
  • In partnership with the UHC Interoperability subject matter expert, operate as the provider adoption leader for all interoperability initiatives (i.e. including UHC Insights, PreCheck MyScript and Point of Care Assist Solutions)
  • Interface with key individuals from provider practices to drive understanding of the provider practice data, act as subject matter expert and support needed practice workflow changes
  • Consistently share practice data so providers understand how they are performing, and can improve their performance to set benchmarks
  • Present practice data and information at external meetings to ensure tools maximize value and collaborative efforts are completed
  • Understand and guide providers to appropriate resources to troubleshoot questions and other business concerns
  • Engage non-HPP provider groups to support performance journey to High Performing Physician (HPP) status
  • Accurately and effectively communicate to status of Point of Care Solutions initiatives to internal UHG business partners
  • Appropriately prioritize and escalate issues to contract leadership in support of ongoing relationship management
  • Meet individual affordability and engagement performance metrics set by National UnitedHealthcare Networks Team
  • Self Service Adoption Efforts: Link, Smart Edits, DPOC & additional technology as they become available
  • New and ongoing Policy Changes (i.e. affordability initiatives)

Senior Network Program Specialist

United Health Group
02.2020 - 09.2020
  • Create, negotiate, and execute Ancillary Single Case Agreements
  • Create, negotiate and implement provider contracts
  • Assesses and interprets customer needs and requirements.
  • Identifies solutions to non-standard requests and problems.
  • Solves moderately complex problems and/or conducts moderately complex analyses.
  • Works with minimal guidance; seeks guidance on only the most complex tasks.
  • Translates concepts into practice.
  • Provides explanations and information to others on difficult issues.
  • Coaches, provides feedback, and guides others.
  • Acts as a resource for others with less experience.
  • Review/Analyze/Validate/Support Network and Provider Performance Data
  • Support/Develop/Drive Effective Network Programs
  • Build/Manage Relationships with Network Program Management Stakeholders
  • Demonstrate Knowledge of Program Management Tools, Regulations, and Systems

Ancillary Provider Relations Advocate

United Health Group
07.2017 - 02.2020
  • Perform deep dive analysis to identify root cause failures and develop remediation action plans for escalated provider issues for Ancillary and HCBS services.
  • Collaborate with business partners to resolve contracting issues impacting providers.
  • Act as the point of contact for escalated provider issues, providing end to end provider service.
  • Contractual interpretation and implementation
  • Report and extract data from internal SharePoint and applications to research potential projects for providers and ensure that all potential claims are audited and adjusted to the provider’s expectation.
  • Track and monitor multiple ongoing provider projects for status and resolution.
  • Triage escalated claims ensuring that the appropriate internal business partners are involved in the investigation of root causes, internal processing failures, and external provider educational opportunities.
  • Investigate and resolve provider claims that have been under Optum review, submit inquiries to Payment Integrity and Recoveries, as well as other internal business partners like Medical Claim Review, Appeals, TRACR, and communicate outcomes to our providers.
  • Conduct meetings with internal and external customers via web ex for various provider relationship management initiatives.
  • Subject Matter Expert in Medicare & Medicaid claims processing, adjustments and escalation procedures.
  • Manage contract, benefit, and administrative exceptions ensuring that claims that fall within the scope of review are included and approved for upper management signatures.
  • Educate providers on contractual adherence and state compliance as it relates to the overall claims process.
  • Perform on-boarding to our customers on the tools and resources available to them via Link, to include enhancement of the ancillary service team model, ancillary service educational decks, and assistance with Link applications as a super user.
  • Link Certified

Business Analyst/Resolution Specialist II-PRISM

United Health Group
09.2015 - 07.2017
  • Perform deep-dive analysis to identify root cause failures and develop remediation action plans for escalated provider issues.
  • Collaborate with business partners to resolve issues impacting providers.
  • Act as the point of contact for escalated provider issues, providing end-to-end provider service, including incident identification and understanding, and following-up with remediating action plans.
  • Collaborate with internal and external business partners to resolve and close out escalated provider issues, communicating the final resolution actions back to the provider.
  • Collaborate with internal and external business partners to identify innovative solutions for resolving escalated provider issues and to decrease the overall number of escalated provider issues in each PRISM market.
  • Track and monitor multiple on-going projects for status and resolution.
  • Identify and resolve global issues that impact multiple providers or lines of business.
  • Participate in standard market issue resolution calls and non-standard war-rooms/urgent issue resolution meetings.
  • Engage in predictive analytics to prevent system and other claim-related issues from impacting providers.
  • Back up SME for the Michigan Health Plan (Assign daily work, run daily huddles, attend bi-monthly health meetings).
  • Extensive experience with CSP Facets.

MSA Facets SME-ROS Team

United Health Group
07.2012 - 09.2015
  • Investigate and resolve provider claim inquiries submitted by provider advocates.
  • Analyzes and identifies trends for provider claims submission.
  • Research and resolve written complex complaints and/or multi-issue provider complaints submitted by provider advocates.
  • Compile information and provide in depth research pertaining to the Central Region (MI, WI, IA, IL, NE, KS, OH, & TX).
  • Responsible for providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of provider claim/system issues.
  • Subject Matter Expert for the Facets claims system and Medicaid products.
  • Communicates with appropriate parties regarding issues, implications and decisions.
  • Complete all tasks in a timely manner within department deadlines.
  • Experience with CSP Facets, UNET, ISET, and NDB.
  • Work hand in hand with other UnitedHealth Group departments to resolve provider issues.
  • Also work and resolve issues for Commercial and Medicare products.

Senior Clinical Appeals Reviewer

United Healthcare/United Healthcare Clinical Services
03.2012 - 07.2012
  • Investigate and resolve appeal inquiries and adhere to policy and procedures related to claims processing, and State/Federal regulatory compliance guidelines.
  • Collect and analyze departmental data and prepare monthly state AdHoc reports.
  • Attend operational staff meetings, present departmental claims data.
  • Research and resolve written complex complaints submitted by providers.
  • Compile information and provide in depth research pertaining to Delaware, South Carolina and Ohio Audits.
  • Responsible for providing expertise and general support in reviewing, researching, investigating and resolving all types of appeals.
  • SME for Delaware, South Carolina and Ohio Community Plans.

Education

Associate of Science - Respiratory Therapy

Western School of Health And Business
Pittsburgh, PA

Skills

  • Proficient in all Microsoft applications
  • WebEx
  • Adobe Acrobat
  • Provider contract systems
  • EPIC and other EHR applications
  • Salesforce
  • Analytical reasoning
  • Healthcare industry
  • Policy interpretation
  • Provider network management
  • Insurance regulations

Timeline

Senior Provider Advocate Account Manager

United Health Group
01.2022 - 04.2025

Network Engagement Manager

United Health Group
09.2020 - 01.2022

Senior Network Program Specialist

United Health Group
02.2020 - 09.2020

Ancillary Provider Relations Advocate

United Health Group
07.2017 - 02.2020

Business Analyst/Resolution Specialist II-PRISM

United Health Group
09.2015 - 07.2017

MSA Facets SME-ROS Team

United Health Group
07.2012 - 09.2015

Senior Clinical Appeals Reviewer

United Healthcare/United Healthcare Clinical Services
03.2012 - 07.2012

Associate of Science - Respiratory Therapy

Western School of Health And Business

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Heather Sutherland-Popich