Credentialing Specialist resume examples

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

• 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.

• 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.

• Provided customer service for an average of 80 + calls per day, answering customer inquiries, solving problems, and providing account information.

• Guaranteed positive customer experiences and resolved all customer complaints.
• Directed calls to appropriate individuals and departments.
• Tracking and shipping UPS packages.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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

• 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.

• 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.

• 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.

• 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.

• 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.