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Click here or scroll down to respond to this candidateCandidate's Name
Phone: PHONE NUMBER AVAILABLEE: EMAIL AVAILABLESummary and ObjectiveDetail-oriented professional possessing over Fourteen years of experience as Revenue cycle specialist and re-credentialing specialist for Credentialing Verification Organization (CVO), Radiology and Diagnostic Laboratory. I have proven leadership and problem resolution abilities with exceptional communication and organization skills as well the ability to work independently and/or work as a team player.I am seeking an opportunity with responsibility and career development. Also seeking an environment where my experience, professionalism and strong implementation skills can add similar or greater value to an organization.Core QualificationsExtensive experience in managing credentialing, as well as the re-credentialing process and accreditationExtensive experience enrolling, credentialing and Maintaining providers with CAQHOutstanding ability to work well independently or within a teamExperienced in navigating Echo, including updating payor records within this systemKnowledgeable of credentialing guidelines, including NCQA, Joint Commission, URAC guidelines, as well as NPDB (National Practitioner Data Bank), OIG (Office of Inspector General), and SAM (System for Award Management)Familiar with Medicare/Medicaid guidelines, such as:oUpdating provider information using PECO and CAQH (Council for Affordable Quality Health Care)oExperience in working with policies of Commercial, Medicare, Medicaid, Medicare and Medicaid-MCO, HMO, POS, and EPOoKnowledgeable of IMPACT (Initial Interest, Mutual Selection, Pre-Service Training, Assessment, Continuing Development, Teamwork)Superior skills in managing and prioritizing multiple tasks and projects successfullyExtensive experience in managing full revenue cycle medical billing and collectionsERA/EFT and updating information onlineGood written and oral communication skillsExcellent and thorough trainer for new or existing employees with new systems or protocolsWork ExperienceAutism Home Support Services Northbrook, IL 09/16/2019-PresentCredentialing SpecialistCoordinate, monitor, and maintain the credentialing and re-credentialing process for BCBA (Board Certified Behavior Analyst), BCaBA, (Board Certified Assistant Behavior Analyst) and RBT (Registered Behavior Technician) with commercial and government payors for IL, MI, CO, FL, and PA.Enrolling Providers in CAQH databaseMaintain Providers CAQHVerify BCBA, BCaBA and RBT certification through Behavior Analyst Certification Board (BACB)Verify Speech-Language-Hearing certification through American Speech-Langue-Hearing Association (ASHA)Establishes productive relationships with medical providers and office staff to obtain necessary information for credentialing processCollect relevant and critical data from various sources to determine the applicants eligibility to be credentialed.Evaluate and review applications for accuracy and completenessUpdate providers credentialing verified documents in proper electronic folders ; tracking expiration dates to ensure accuracy at time of Credentialing Committee decisionMaintain log of responses and in appropriate follow-up to obtain verification of informationSends second and third notices to those who do not respond to the first one requestResolved practitioner concerns in a timely manner.Reviewed provider files for appropriate documentation required for the credentialing processPerform other tasks, projects, and duties, as assigned.Rush University Medical Center Chicago, IL 01/02/2018 to 09/13/2019Credentialing CoordinatorPerform primary source verifications of licensure, board certification, DEA/CDS Certificates, Education and Training, Medicare/Medicaid Sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB and FSMB queries, NCQA, URACCoordinate, monitor, and maintain the credentialing and re-credentialing process.Facilitating all aspects of appointment and reappointment for managed care, medical staff, and non-physician providers.Establishes productive relationships with medical providers and office staff to obtain necessary information andCollect relevant and critical data from various sources to determine the applicants eligibility to be credentialed.Evaluate and review applications for accuracy and completenessPerform primary source verifications of licensure, board certification, DEA/CDS Certificates, Education and Training, Medicare/Medicaid Sanctions (OIG and SAM), hospital privileges, malpractice history, insurance coverage, and NPDB queries.Update providers credentialing verified documents in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decisionMaintain log of responses and in appropriate follow-up to obtain verification of informationSends second and third notices to those who do not respond to the first one.Contact and follow up with contracted managed care payers, Departments, and contracted MSO facilities to obtain documentation relevant to the credentialing process and data entry ofResolved practitioner concerns in a timely manner.Reviewed provider files for appropriate documentation required for the credentialing process while assuring NCQA complianceIdentifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.Update Medicare and Medicaid status and payer record status in EchoPerform other tasks, projects, and duties, as assigned.Swedish Covenant Medical Group Chicago, IL 08/04/2017 to 12/21/2017Supervised Cardiology Revenue CycleKforce Staffing and Solutions: Swedish Covenant Medical Group 12/05/2016 to 08/03/2017Supervised Cardiology Revenue CycleServe on project teams to improve revenue cycle results and support other organizational priorities. Assume lead role in identifying, recommending, drafting, and implementing of standard policies, procedures, and workflows, as applicable and with appropriate management authorization and approvalSupervise a team of revenue cycle professionals, including billing, follow-up, and claim status checking staff, as appropriate. For supervised staff, oversee work assignments and performance management. Additionally, assist in hiring, training, mentoring, and coaching of team members. Contribution to the creation of a strong team environment.Demonstrate strong understanding of federal, state, and payor-specific laws, regulations, and contract provisions relating to billing, coding, and follow-up.Oversee the accounts receivable portfolio for an assigned single or group of practices and payors. For the assigned portfolio, assume responsibility for functions including as listed below:oPerform formal and informal quality reviews to ensure that billing and follow-up team members are adhering to established policies, procedures, and standards.oMonitor work-queues relating to outstanding claims, claims rejections, and claim denials and ensure that underlying issues are identified and addressed in accordance with established quality expectations and turn-around timesoOversee claim status checking and (or) collaborate with claim status team to monitor aging and follow-up on claims requiring clearinghouse or payor action or response.oCollaborate with the payment posting and reconciliation team to understand payment, adjustment, and denial trends and to address and resolve issues and questions as these ariseoPrepare and provide regular and ad-hoc reporting on trends, issues, and aging.Develop expertise with practice-specific and payor-specific billing, coding, claim submission, and follow-up matters applicable to assigned areas of responsibility.Gain facility and expertise with ECW practice management system design as it relates to all aspects of revenue cycle operations and revenue realization; including: demographics; insurance; referral, authorization, precertification; coding and charge capture; locking of notes; creation of claims; claims submission and follow-up; and, reporting and analysis.Develop strong working relationships and actively collaborate with other internal and external teams involved in revenue cycle and revenue realization, including: call center; front office; providers and clinical staff; practice management; credentialing and enrollment; charge entry and coding; coding compliance and education; informatics; billing and follow-up; patient financial services; managed care.Provide regular communication of trends in claim rejections and denials to the practice management, coding, credentialing, informatics teams, and other parties to aid in resolving underlying revenue cycle issues at their source.Exercise consistently sound professional judgment, demonstrating a clear understanding of the circumstances when it is appropriate to make decisions and act individually and when it is necessary to make decisions and act only after consultation with management or other appropriate parties.Perform other tasks, projects, and duties, as assigned.USA Vein Clinics: Northbrook, IL 04/2016 to 08/2016Credentialing and Revenue Cycle Specialist Oversaw 6 clinics for revenue cycle and coordinate credentialingManaged accounts receivable, follow up the aging report, appeal claims, and posting (Insurance and patients)Trained and supervised new employees on full revenue cycle responsibilities, processes & computer systemsEnsured that all new employees training was on-target and that their work was accurateApplied troubleshooting strategies to bring revenue cycle to the most current dateThoroughly researched newly identified diagnoses and/or medical procedures to expand skills and knowledge.Diligently filed and followed up on third party claims.Performed qualitative analysis of records to ensure accuracy, internal consistency/correlation of recorded data.Managed claim denials and/or appeals; posted and adjusted payments from insurance companies.Evaluated patients financial status and established payment plans on self-pay balances.Printed and reviewed monthly patient aging report and solicited/collected on overdue paymentsExamined patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicableMolecular Imaging Chicago: Chicago, IL 11/2015 to 04/2016Medical Credentialing ManagerManaged 10 Radiology clinics credentialing, re-credentialing.Updated PECOS and Impact info: Medicare: loaded and unloadedUpdate Banking information online.Updated Impact info: Medicaid: loaded and unloadedProvided regular reports on Credentialing status to CEO and CFOManaged revenue cycle for Account receivable, follow up the aging report, appeal claims, and posting (Insurance and patients)Thoroughly researched newly identified diagnoses and/or medical procedures to expand skills and knowledge.Diligently filed and followed up on third party claimsPerformed qualitative analysis of records to ensure accuracy, internal consistency/correlation of recorded data.Actively maintained a current working knowledge of CPT and ICD-9 and ICD-10 coding principles, government regulation, protocols and third-party requirements regarding billing.Precisely evaluated and verified benefits and eligibilityPosted and adjusted payments from insurance companiesResponded to correspondence from insurance companiesIdentified and resolved patient billing and payment issuesConfidently and adeptly handled claim denials and/or appealsEvaluated patients financial status and established appropriate payment plansPrinted and reviewed the monthly patient aging report and solicited overdue paymentsExamined patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicableSimple Laboratories: Chicago, IL 01/2015 to 11/2015Medical Claims/Credentialing SpecialistManaged credentialing, re-credentialing, and revenue cycle for diagnostic laboratoriesProvided regular reports on Credentialing status to CEO and CFOUpdated Impact info: Medicaid: loaded and unloadedObtained online access for ERA/EFT for major insurances (BCBS, Availity, Aetna, Humana, UHC)Diligently filed and followed up on third-party claims, managed claim denials and/or appealsReviewed, analyzed, and managed to the code of diagnostic and treatment procedures contained in outpatient medical recordsResearched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracyActively maintained a current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third-party requirements regarding billingManaged collections claim for unpaid bills against the estates of debtorsResponded to correspondence from insurance companies, posted adjusted payments from themEvaluated patients' financial status and established appropriate payment plans for self-pay balancesMRI Lincoln Imaging Center: Chicago, IL 02/2002 to 01/2015Credentialing Specialist/ Medical CollectorManaged diagnostic credentialing for 6 clinics (12 radiologists: Neurologist, Chiropractors, and podiatrists)Managed revenue cycle for 6 clinics (Account receivable, follow up the aging report, appeal claims, and postingTrained and supervised new employees on full revenue cycle responsibilities, processes & computer systemsEnsured that all new employees training was on-target and that their work was accurateCompleted appropriate claims paperwork, documentation, and system entryAn expert in billing and collection procedures, as well as insurance referralsVerified patients' eligibility and claims statuses with insurance agenciesDiligently filed and followed up on third-party claims, managed claim denials and/or appealsDetermined prior authorizations for medication and outpatient proceduresReviewed, analyzed, and managed to the code of diagnostic and treatment procedures contained in outpatient medical recordsResearched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracyMaintained strict patient and physician confidentialityActively maintained a current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third-party requirements regarding billingManaged collections claim for unpaid bills against the estates of debtorsInteracted with providers and other medical professionals regarding billing and documentation policies, procedures, and regulationsAccurately posted and sent out all medical claimsResponded to correspondence from insurance companies, posted adjusted payments from themIdentified and resolved patient billing and payment issuesEvaluated patients' financial status and established appropriate payment plans for self-pay balancesExamined patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicableComputer SystemsOffice: Microsoft and ExcelMedical: Echo, eClinicalWorks, Medisoft, Medical Manager, Intergy, Athena, Rislinq, and TelcoreEducationNortheastern Illinois University, Chicago, ILBachelors Degree in Biology - May 2013Harry Truman College, Chicago, ILAssociate in Biotechnology - September 2000AMS Medical BillingCertification - February 2000 |
