Credentialing Specialist resume examples

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Skillful Credentialing Specialist resume

Maria Jackson
Professional Summary
Dedicated customer service representative with motivation to maintain customer satisfaction and contribute to company success. Qualified with 6+ years in fast-paced customer service and call center environments. Personable and professional under pressure.
Skills
  • Creative problem solver
  • Exceptional communication skills
  • MS Windows proficient
  • Quick learner
  • Medical terminology knowledge
  • Local/state health laws knowledge
  • Multi-line phone talent
Work History
Utilization Management Rep., 04/2018 to Current
Aerotek/Simply Healthcare Plans Inc. Tampa, FL

Manages incoming calls or incoming claims work.

Determines contract & benefit eligibilit; Provides authorization, post service request.

Refers cases requiring clinical Review to a nurse reviewer.

Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.

Responds to telephone and written inquiries from clients, provides and in-house departments.

Conducts clinical screening proces.

Authorizes initial set of sessions to providers.

Checks benefits for facility based treatment.

Developes and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

Intake Coordinator; Staffing Rep; Lead, 02/2013 to 03/2018
CareCentrix Inc. Tampa, FL

Answered an average of [50+] calls per day by addressing customer inquiries, solving problems and providing new product information.
Assist valued patient's with home health and durable medical equipment.
Provide authorization status to provider's assisting Blue Cross Blue Sheild patients.
Provide excellent customer service using "Ulysses" call stradegy

Customer Service, 09/2012 to 02/2013
Aerotek/ Streetlinks Lender Solutions Tampa, FL
  • Provided accurate and appropriate information in response to customer inquiries. Addressed customer service inquiries in a timely and accurate fashion.Properly directed inbound calls in phone queues to improve call flow.
  • Inbound/outbound calling to appraiser's to obtain update on the status of the appraisal report.
Credentialing Specialist, 06/2012 to 08/2012
WellCare INC Tampa, FL
  • Researched providers background, education and work experience history to ensure they meet the expectations of the company to provide services to valued members of the health care plan Customer Service.
Customer Service Representative, 12/2009 to 08/2011
Freedom Health Insurance Tampa, FL
  • Provided customer service for an average of 80 + calls per day, answering customer inquiries, solving problems, and providing account information.
Customer Service Representative III, 02/2006 to 12/2009
Tele-Tech Customer Service Tampa, FL
  • Guaranteed positive customer experiences and resolved all customer complaints.
  • Directed calls to appropriate individuals and departments.
  • Tracking and shipping UPS packages.
Education
High School Diploma: 2004
Wharton High School - Tampa, FL
High School Diploma
D.W Waters Career Center - Tampa, FL
  • Completed Advanced Customer Service training
Certifications
Ulysses Learning
Successful completion of "Service Mentor"

Service Mentor helps your employees be able to take control of the call, instill confidence in the caller, defuse highly emotional situations and leave the customers feeling good about your organization.
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Job-winning Credentialing Specialist resume

Cossetty P. Denbow
Professional Summary
Results oriented individual with diversified experience in the managed care field, financial field and retail field. Strengths include knowledge of delegation audits related to a major insurance carrier, requirements for the Agency for Health Care Administration and the National Commission for Quality Assurance, claims processing, data entry, credentialing, and auditing.
Skills
PC knowledge, Mac knowledge, QuickBooks Pro, QuickBooks POS, Microsoft RMS, Microsoft Office, Microsoft Access, Microsoft Publisher, SweetQ, AMISYS, Bloomberg and Quotron
References
References Will be furnished upon request
Work History
Credentialing Specialist II, 02/2015 to Current
Parallon Workforce Solutions Sunrise, FL
  • Responsible for supporting the development and implementation of the Credentialing Processing Center policies and procedures.
  • Responsible for credentialing new and established health care providers.
  • Responsible for the maintenance of information to include primary source verification, follow up, data collection, data entry, and document review.
Manager of Credentialing, 10/2014 to 12/2015
Eden Health Plans Inc Doral, FL
  • Responsible for performing the credentialing and re-credentialing functions in accordance with the Plan's policies and procedures to ensure compliance with all regulatory agencies requirements.
  • Interfacing with physicians and office staff and other interdepartmental staff to effectuate completion of files.
  • Responsible for credentialing all providers in network.
  • Responsible for the administration of The Data Bank, AMA, AOIA, CAQH, and all other websites required for primary source verification.
  • Responsible for coordinating Delegation audits with the Chief Compliance Officer.
  • Responsible for the maintenance and accuracy of the Network database.
  • Responsible for the coordination and preparation of the Credentialing Committee Meetings.
  • Worked closely with the CEO, CCO, and VP of Network Management to ensure compliance with the Agency for Healthcare Administration, Office of Insurance Regulators, and the Centers for Medicare and Medicaid Services.
Credentialing Coordinator, Team Lead, 01/2014 to 10/2014
MCNA Dental Plans Fort Lauderdale, FL
  • Responsible for performing the credentialing and re-credentialing functions in accordance with the Plan's policies and procedures to ensure compliance with all regulatory agencies requirements.
  • Interfacing with physicians and office staff and other interdepartmental staff to effectuate completion of files.
  • Responsible for credentialing all providers in network.
Insurance Agent, 07/2013 to 12/2013
Sentinel Casualty Insurance Pembroke Pines, FL
  • Develop and implement sales plan and manage all phases of the sales cycle- from prospecting to close and follow-up support.
  • Represent a full line of insurance and financial products, serving as a trusted advisor to businesses and individuals.
Comptroller, 01/2009 to 05/2013
National Armory LLC Pompano Beach, FL
  • Responsible for overseeing the day-to-day operations of the business; responsibilities include but are not limited to human resource issues, accounting, scheduling, compensation and benefits.
  • Handled human resource issues including maintaining human resource files, maintaining employee complaints and reviews, maintaining proper payroll records.
  • Responsible for daily cash flow operations, recording of daily deposits, tracking credits and debits in QuickBooks Accounting Software, reconciling daily, monthly, quarterly, and annual accounting reports.
General Manager, 01/2002 to 01/2009
National Law Enforcement Distributors, Inc Davie, FL
  • Responsible for overseeing the day-to-day operations of the retail business; ensuring that the sales floor staff is scheduled for proper coverage; tracking the daily sales and entering the credits and debits into the accounting ledger; negotiating the pricing for new products; overseeing the implementation of a computerized point of sale; maintaining relationships with vendors and law enforcement agencies.
Managed Care Lead Analyst, 01/2001 to 01/2002
PhyAmerica Physician Services, Inc Ft. Lauderdale, FL
  • Responsible for overseeing analysis, preparation and reporting on medical service contracts and utilization data; preparing and explaining managed care comparison reports; creation and maintenance of managed care database; importing and exporting of data into and out of Microsoft Access databases.
Credentialing Supervisor, 01/1999 to 01/2001
Coordinated Care Solutions, Inc Coral Springs, FL
  • Responsible for ensuring the accuracy and completeness of facility, ancillary, and physician files abiding by NCQA guidelines, allowing payers to delegate CCS for credentialing.
  • Prepares and submits to management monthly reports of credentialing activities.
  • Creates and updates company's Policies and Procedures in accordance with NCQA, JCAHO, and URAC guidelines.
  • Supervises the Credentialing Coordinators, Clerks, and Temporary Staff.
  • Major duties include but are not limited to: tracking receipt of credentialing and/or recredentialing applications through recording of requests made and receipt of applications.
  • Identifying and requesting needed information and clarification for the credentialing and/or recredentialing process verbally and in writing.
  • Identification and tracking of files for providers failing to comply with the credentialing and/or recredentialing process.
  • Ensure that the records in the SweetQ database are accurate and complete.
  • Organize and present credentialing/recredentialing files for review at Credentialing Committee meetings.
  • Ensures files are processed in accordance with regulatory requirements (e.g.
  • NCQA, JCAHO, URAC).
  • Monitor and follow-up as required ensuring timely processing.
  • Prepare reports for management summarizing credentialing activities.
Credentialing Coordinator,
  • Ensures accuracy and completeness of facility, ancillary, and physician files in accordance with NCQA, JCAHO & URAC accreditation, individual state standards, company policies and procedures and other outside auditors.
  • Major duties and responsibilities include but are not limited to: initiating the credentialing process through data entry in the SweetQ database; requesting primary source verification from appropriate sources.
  • Accomplishments.
  • Upgraded SweetQ database to current edition.
  • Acquired proper verification tools to ensure compliance with regulatory agency standards.
  • Revised and created proper policies and procedures to ensure compliance with regulatory agencies and contracted insurance companies.
  • Computerized form completion for credentialing meetings via downloads into Microsoft Access.
  • Implementation of new internal credentialing forms and credentialing applications for facilities, ancillary providers, allied health providers, and physicians.
Credentialing Specialist, 01/1997 to 01/1999
Foundation Health Sunrise, FL
  • Responsible for performing the credentialing and recredentialing functions in accordance with the Plan's policies and procedures to ensure compliance with all regulatory agencies requirements.
  • Interfacing with physicians and office staff and other interdepartmental staff to effectuate completion of files.
  • Responsible for credentialing all providers in network.
Secretary I,
  • Shared secretary between two departments responsible for the maintenance of the departmental logs, maintaining of agendas, preparing purchase orders, generating and circulating interdepartmental correspondence, receiving and directing incoming calls, assisting in the coordination of the workflow between departments.
  • Accomplishments.
  • Instrumental in creating duo-departmental log for documenting workflow.
  • Key team member for updating policies and procedures and attachments for roadmaps during the AHCA and NCQA Accreditation audits.
  • Critical in assisting with the creation of the Delegation Agreement.
  • Instrumental in generating reports utilizing SweetQ data.
  • Expanded the use of technology in daily credentialing functions.
  • Moonlighted in the claims department to assist in processing claims.
  • Moonlighted in Data Management department to correct and enter data in the AMISYS database.
New Accounts Clerk, 01/1993 to 01/1996
Investacorp, Inc Miami Lakes, FL
  • Responsible for the posting of various trading documents into the clearing firm's data files as well as the firm's in house database; provide strong support for approximately 400 stockbrokers.
  • Service included but was not limited to the following: establishment and maintenance of new accounts (i.e.
  • trading accounts, retirement accounts and specialty accounts), liaison between clearing firms and brokers.
Stock Broker Assistant,
  • Responsible for maintaining client files, typing and mailing correspondence, answering client phone calls, opening client accounts, dictation, back-up to the trade desk, assisting accounting department with verification of daily trade blotters, shipping and insuring of securities received.
Insurance Licensing Coordinator,
  • Responsible for updating registered representative's insurance files, appointing the various representatives with different insurance companies, distributing commissions, liaison between insurance representatives and the insurance companies and verifying the licensure status with the respective states.
  • Responsible for maintaining continuing education files for president of company and in house insurance representatives.
  • Accomplishments.
  • Instrumental in creating commission pay out spreadsheet for insurance commissions.
  • Instrumental in maintaining records detailing requirements for insurance licensure in each state.
Education
High School Diploma: 1992
American Senior High School -
Human Resources, Current
Broward College -
Pre-Law, 1993
Syracuse University -
Affiliations
Former Member, Legal Assisting Society of Broward Community College
Languages
English: excellent communication skills - written and verbal Spanish & French: fair understanding and communication skills
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Experienced Credentialing Specialist resume

Tina M. McGill
Professional Summary
To work in a position that enhances not only the business, but also my own personal daily and long-term goals.

Positive credientialing specialist with demonstrated capabilities in provider credentialing. Committed to excellent work, learning and collaboration.

Skills
  • Exceptional customer service skills combined with patient care knowledge
  • Compassion and desire to help people
  • Knowledge of Microsoft Word, Excel and multiple software platforms
  • Ability to prioritize, multi-task and complete work accurately in a timely
  • manner
  • Exceptional customer service skills combined with patient care knowledge
  • Proficient in CAQH, PECOS and
    NPPES
  • Compassion and desire to help people
  • Knowledge of Microsoft Word, Excel and multiple software platforms
  • Excellent organizational skills for prioritizing tasks to meet set deadlines
  • Outstanding social skills
  • Excellent cognitive and judgment skills
  • Manage the completion and submission of provider enrollment applications
  • Maintain documentation and reporting regarding provider enrollments in process
  • Send out provider applications, forms and other provider correspondence as requested
  • Problem solving skills for the identification of issues and the ability to develop appropriate courses of action
  • Maintain strict confidentiality of information as dictated by current HIPAA requirements
Work History
Senior Patient Coordinator 03/2009 to 10/2016
James L. Boerner
  • Experience in both hospital and clinical offices Strong organizational skills with attention to detail BLS Heart saver certified and HIPPA compliant Performs all duties at the front desk such as: greeting patients, making appointments, answering multiple phone lines, making reminder calls, checking patients out, taking co-pays and verifying insurance Handles all referrals to Tennessee Maternal Fetal Group and any other specialist that may be required Schedules all surgical procedures and obtains prior authorizations 2 Prepares financial plans for the patients according to commercial insurance deductibles and consults patients about financial obligations Prepares and mails all billing statements for the practice every 4 weeks Works clinically when necessary to facilitate the flow of patients.
Credentialing Specialist 11/2016 to Current
Medical Practice Solutions Murfreesboro, TN
  • Proficient in DEA licensure and renewal
  • Handles crendentialing for multiple healthcare practices keeping all providers current and up to date in CAQH, malpractice insurance, payors and facilities
  • Understand the credentialing process for many networks such as BCBS, Cigna, Aetna, Medicare, Medicaid, TNCare, United Healthcare,  and many others
  • Can complete applications and requirements for each provider quickly and will followup on missing items
  • Outstanding communication skills that allow a good relationship between payors, practice and providers.  
  • Billing and claims experience for pediatric dental claims
Senior Patient Coordinator 03/2009 to 10/2016
James L. Boerner. M.D. Murfreesboro, TN
  • Experience in both hospital and clinical offices
  •  Strong organizational skills with attention to detail 
  • BLS Heart saver certified and HIPPA compliant 
  • Performs all duties at the front desk such as: greeting patients, making appointments, answering multiple phone lines, making reminder calls, checking patients out, taking co-pays and verifying insurance 
  • Handles all referrals to Tennessee Maternal Fetal Group and any other specialist that may be required Schedules all surgical procedures and obtains prior authorizations 
  • Prepares financial plans for the patients according to commercial insurance deductibles and consults patients about financial obligations 
  • Prepares and mails all billing statements for the practice every 4 weeks 
  • Works clinically when necessary to facilitate the flow of patients.
Patient Service Representative/Patient Care Technician 07/2006 to 03/2009
Vanderbilt University Medical Center Nashville, Tennessee
  • Provides exceptional customer service, including telephone etiquette, processes insurance updates and conducts patient check in/out Proficient in Vanderbilt's Epic, Star Panel, Trace Master, as well as ImageCast software and VPIMS Directs patients in filing out appropriate paperwork, kiosk check-in, future appointments and pager system Cancels and schedules appointments for One Hundred Oaks location, as well as the overflow of the main campus VPEC appointments.
  • Communicates wait times or delays to patients at the time of check-in Communicates with physicians, nurse practitioners about patient status.
Certified Surgical Technologist 01/1994 to 01/2003
Middle Tennessee Medical Center Murfreesboro, Tennessee
  • Full-time and PRN positions in Operating Room, Labor & Delivery, PACU and Newborn Nursery.
  • Preparing the surgical table with sterile technique, assisting with patient care in PACU such as vital signs, foley care and EKG.
  • Pulling case supplies and suture according to physicians preference cards.
  • First assisting when necessary with the ability to suture skin and dress incisions appropriately.
Patient Service Representative/Patient Care Technician 07/2006 to 03/2009
Vanderbilt University Medical Center Nashville, Tennessee
  • Provides exceptional customer service, including telephone etiquette, processes insurance updates and conducts patient check in/out 
  • Proficient in Vanderbilt's Epic, Star Panel, Trace Master, as well as ImageCast software and VPIMS
  • Directs patients in filing out appropriate paperwork, kiosk check-in, future appointments and pager system 
  • Cancels and schedules appointments for One Hundred Oaks location, as well as the overflow of the main campus VPEC appointments.
  • Communicates wait times or delays to patients at the time of check-in 
  • Communicates with physicians, nurse practitioners about patient status.
Certified Surgical Technologist 01/1994 to 01/2003
Middle Tennessee Medical Center Murfreesboro, Tennessee
  • Full-time and PRN positions in Operating Room, Labor & Delivery, PACU and Newborn Nursery.
  • Preparing the surgical table with sterile technique, assisting with patient care in PACU such as vital signs, foley care and EKG.
  • Pulling case supplies and suture according to physicians preference cards.
  • First assisting when necessary with the ability to suture skin and dress incisions appropriately.
Credentialing Specialist 11/2016 to Current
Medical Practice Solutions Murfreesboro, TN
Education
Diploma:
High-school diploma: Academic 1988 Riverdale High School -
Certification: 1995 -
Tennessee Technology Center Surgical Tech program Shelbyville, TN 37086: 1994 Middle Tennessee State University - Murfreesboro, TN Nursing Curriculum
3 years of college: Nursing Middle Tennessee State University -
References
REFERENCES Available upon request
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