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Click here or scroll down to respond to this candidateCandidate's Name
PHONE NUMBER AVAILABLEEMAIL AVAILABLEProfessional Summary of Qualifications10yrs experience as a Credentialing Specialist for Providers, Facility and Ancillary providers, with Customer Service experience: Managed and maintaining licensure including DEAs, CLIA, and Medical license as well as tracking continuing education for provider and physicians. Data Entry Skills and Very Detailed Oriented Great at Multi-Tasking Coordinate of Credentialing/Contract activities, Knowledge of Medicare & Medicare guidelines Extensive clerical supportProfessional ExperienceAflac/Argus Dental Vision Healthcare 7/2020 PresentCredentialing SpecialistReview credentialing application packet to ensure completeness and accuracy.Secure necessary documentation required to complete provider applications.Performs primary source verification of providers licensing, training, and certifications.Queries the SAM, OIG, NPDB, Medicaid and Medicare database to obtain any sanctions imposed against the provider.Queries the NPDB to obtain any malpratice claims history on file.Verifies clinical/hospital privileges as applicable.Tracks provider appointments and conducts re-credentialing every 3 years.Demonstrates problem solving and decision-making capabilitiesMission Healthcare Communities 1/2020 4/2020Credentialing SpecialistWill review and submit credentialing or recredentialing applications based on the data provided. If data is not complete, the Analyst will make effort to contact the responsible parties and complete the applications within the specified time framesWIPRO 7/2019 1/2020Credentialing SpecialistWill review and submit credentialing or recredentialing applications based on the data provided. If data is not complete, the Analyst will make effort to contact the responsible parties and complete the applications within the specified time frames.Wellcare Health Plans, Inc (Contract) 4/2019 - 6/2019Configuration SpecialistLoads professional contracts into the Diamond System through appropriate research and provider data load activities.Performs accurate and timely provider research, verification and analysis.Resolves provider load issues within established documented processes.Ensures the proper supporting documentation exists and is maintained on file for all load processes.Loads and maintains provider data.Loads new providers as a result of the approved Credentialing Committee Lists.Coordinates with Membership for member move requests.Assists in updating payable procedure codes, price rules and fee schedules.Resolves critical errors forwarded from the claims department.Updates tracking database.Responsible for building and maintaining positive business relationships with business partners.Assists in special projects.Maintains high quality work.Meets productivity expectations.Works Auto Analyzer Reports.Performs other duties as assigned.Argus Dental Vision (Contract) 10/2018 - 4/2019Credentialing SpecialistReview credentialing applicantion packet to ensure completeness and accuracy.Secure necessary documentation required to complete provider applications.Performs primary source verification of providers licensing, training, and certifications.Queries the SAM, OIG, NPDB, Medicaid and Medicare database to obtain any sanctions imposed against the provider.Queries the NPDB to obtain any malpratice claims history on file.Verifies clinical/hospital privileges as applicable.Tracks provider appointments and conducts re-credentialing every 3 years.Demonstrates problem solving and decision-making capabilities.Molina Healthcare 7/2017 10/2018Provider Services Contract, Credentialing SpecialsitPerform 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, URAC, CMS.Performs and documents licensure updates as applicableUpdates provider information and enters malpractice coverage limits into applicable database system (Amisys, Facets, CredTracker, Cactus), as appropriateDocuments provider credentialing verifications in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decisionObtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizationsMaintains current knowledge of the Credentialing Manual and applicable database system (Amisys, Facets, CredTracker, Cactus) changesSolves moderately complex problems on ownCoordinates with Plan staff to obtain missing credentialing information from non-compliant providersUse CAQH to pull up provider applicationsWorks with team to solve complex problemsMaintains log of responses and in appropriate follow-up to obtain verification of informationReview malpractice history, regulatory and disciplinary action report issued by state and federal agencies invoking appropriate processes as defined in policies and procedures.One Call Care Dental & Doctor (Temp Contract) 1/2017 7/2017Credentialing SpecialistPerforms and documents licensure updates as applicableCoordinates with Plan staff to obtain missing credentialing information from non-compliant providersObtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizationsWorks with team to solve complex problemsWellCare (Temp Contract) 9/2016 1/2017Provider Operation CoordinatorSupports the Provider Relations Field Reps to resolve claims and payment issuesRoot cause analysis of operational and health services issuesReview and processes incoming and outgoing paperwork including directory updates, provider credentialing applications, contract maintenance forms and other related formsTracks new contracts through sidewinderAudits configuration loads on new contractsProvides office, project management, provide recruitment and data analysis supportPerforms special projects as assigned or directedAmerigroup 1/2013 8/2016Credentialing SpecialistPerform 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, URACPerforms and documents licensure updates as applicableUpdates provider information and enters malpractice coverage limits into applicable database system (Amisys, Facets, CredTracker, Cactus), as appropriateDocuments provider credentialing verifications in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decisionObtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizationsMaintains current knowledge of the Credentialing Manual and applicable database system (Amisys, Facets, CredTracker, Cactus) changesSolves moderately complex problems on ownCoordinates with Plan staff to obtain missing credentialing information from non-compliant providersUse CAQH to pull up provider applicationsWorks with team to solve complex problemsMaintains 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.Completes rosters changes and provides data entry and data base management updates.Answers and resolve network provider calls and emails inquiriesSkill in managing multiple priorities and deadlines with minimal supervision.Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners and ultimately bill and obtain reimbursement for services renderedSometimes schedule and distribute meeting invitations to Medical Directors and participating external practitionersReview malpractice history, regulatory and disciplinary action report issued by state and federal agencies invoking appropriate processes as defined in policies and proceduresSkillsMicrosoft Words Data Entry Lotus Notes, Excel, Windows 98 Ten Key Cactus System, Health Trio Facet, Amisys, NCQA, URAC, Adobe Acrobat ProX Salesforce, Omniflow, CAQH, QNXT, Sharepoint, Core, Acurity, Aldera, Encompass, Aptrackeer, Andros |
