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Click here or scroll down to respond to this candidateCandidate's Name
Street Address
PHONE NUMBER AVAILABLEEmail: EMAIL AVAILABLESUMMARYDedicated Credentialing Professional with extensive experience in managing provider enrollment and credentialing processes. Proven track record of ensuring compliance with regulatory requirements and maintaining accurate credentialing records. Strong attention to detail, analytical skills and to effectively communicate with external stakeholders. Seeking to utilize my experience in a dynamic healthcare organization to support the credentialing process and contribute to the overall success of the organization. EMPLOYMENTPROVIDER ENROLLMENT SPECIALIST 2023- 2024Amerihealth Caritas / NTT Data Services Raleigh, North Carolina Communicates notification of changes to appropriate providers, members and other departments within the contracted time frame. Coordinates the provider mailing for all claims in the invalid provider queue that could not be processed due to missing or invalid information. Researches and resolves returned checks and provider mail. Assists provider and internal customer by responding to and resolving all request and inquiries related to the Panel Transfers, Panel Releases, & Special Needs PCP assignments process. Coordinates the provider mailing for all claims in the invalid provider queue that could not be processed due to missing or invalid information. Process notification of changes for providers and facilities within the contracted time frame.CONCURRENT REVIEW & CARE COORDINATOR 2022-2023San Francisco Health Plan / NTT Data Services Raleigh, North Carolina Work with a multi-disciplinary team, serving primary in an administrative support capacity. Research utilization management requests using a variety of resources including the companys evidence of coverage, policies and procedures, and electronic resources. Compiles data for utilization management review and submits the data to the Concurrent Review & Care Transition Nurse Team for clinical decision making. Maintains ongoing tracking and appropriate documentation to facilitate the determination process within the regulatory timeframes and standard and urgent authorization request. Assist in discharge planning efforts for members requiring post discharge follow up care through telephonic coordination with primary care providers. Maintain an accurate census of the companys members. Provide administrative and clerical support for utilization management activities. Ensure correspondence distribution compliance by working closely with the designated clinicians to generate Notice of Actions Letters for the requesting providers and members. CREDENTIALING SPECIALIST I 2017 - 2022Alliance Health Morrisville, North Carolina Process Initial Credentialing, Re-Credentialing Applications and provider change request Screen practitioners applications and supporting documentation to ascertain their eligibility Collect information From National Practitioner Database (NPDB), applicant and their malpractice insurers, verify license and Education, perform Intellicorp Backgrounds Checks and other relevant sources Analyze documentation from an array of primary source websites i.e. SAM, OIG, PPT, State Exclusion Report and SOS. Ensure compliance with applicable laws, regulations, procedures and policies Collaborate with the contracts department by processing service and site location removals, additions and general changes. Communicate directly with providers regarding credentialing results (i.e. approvals, denials, pending) of network status Maintain and insure that all provider data files are in compliance with EQRO, NCQA and URAC Guidelines Manage reports to insure Credentialing and Re-Credentials applications are processed in a time and accurate manner.CREDENTIALING SPECIALIST II 2012 - 2017Magellan Health Services Columbia, Maryland Responsibilities included receiving and data entering initial credentialing source documents from provider/group. Insuring that all initial documents have been received within guidelines. Verify license type, validation and if license has sanctions listed. Obtain certificate verification for provider who hold specialty license. Check systems/websites for state sanctions and or exclusions. Check state med opt out listing Forward completed application and supporting documents to Regional Committee for final approval. Assist with primary source verifications and quality audit corrections Manage reports to insure Credentialing and Re-Credentials applications are processed in a time and accurate manner.EDUCATIONDiploma - East Orange High School, East Orange, New Jersey 1982 - 1986 CRIMINAL JUSTICE MAJOR - Essex County College, Newark, New Jersey 1991 - 1992 |
