Profile:

Over ** years of privileging/credentialing and managed care experience for various states (specialty: ANES, EM, Hospitalist – Internal Medicine and Family Medicine).

* ***** ** ********* **ficial with Medicare WPS Part B in Illinois on behalf Northshore University HealthSystem.

Solid knowledge of Joint Commission and NCQA credentialing standards.

Member of Georgia Association Medical Staff Services (GAMSS) from 2009-2010.

Member of National Association Medical Staff Services (NAMSS) from 2015.

Successful ability to work as a team player and independently.

Dedicated to maintaining confidentiality on a daily basis.

Highlights and Accomplishments:

Leadership and Development:

Human Resources responsibilities included facilitating in hiring and orientation of new employees.

Overseen the daily functions of the Credentialing Department.

Implemented and facilitated the use of the online credentialing application through the provider portal. Created provider portal manual.

Created, implemented and overseen the Credentialing Internship program.

Delegated special projects and other tasks as needed.

Held weekly/bi-weekly meetings

Privileging/Credentialing:

Facilitate the procurement of provider documents required to associate him/her with a client hospital, including the hospital medical staff application, abbreviated provider enrollment packet, provider agreement and any other collaborative or supervisory paperwork that might be required if the provider is a midlevel (States: AZ, FL, GA, IL, NC, MA, NM, OH, SC, WV).

Perform background check (Insight-FirstPoint, Vericon), verification on AMA/AOA, CertiFACTS, DEA, ECFMG, EPLS, FSMB, NPDB, NPI, OFA, and OIG.

Assist physicians with obtaining medical license(s), state control substance license(s), and Federal DE.

Maintain current documents on all physicians and midlevels by sending out monthly expiration notices and updates database with updated information.

Facilitate timely reappointments.

Create letters and spreadsheets. Contacted health plans requesting participation status, contracts and current fee schedule.

Processed applications for physician(s) regarding health plan participation and new physician joining practice.

Update applicant’s information on Council for Affordable Quality Healthcare’s national online database.

Established Individual NPI for physicians and midlevels (State: IL).

Managed Care:

Assist with internal audits.

Obtained all required prescription(s), medical records, letters of medical necessity and any other additional documentation for patients requesting Durable Medical Supplies within state and federal regulations (i.e. Medicaid, Blue Cross Blue Shield, Cigna, Superior Health, Medicare, and other carriers) obtained all required documentation for patients requesting Durable Medical Supplies within state and federal regulations using CPT ICD-9 and HCPCS codes.

Processed Medicare, Blue Cross Blue Shield, and Medicaid individual applications for physicians and midlevels (States: AL, FL, CO, GA, IL, TN, TX, VA).

Processed DMEPOS Surety Bond Application for Florida Medicaid Group participation (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies).

Established group NPI/Medicare/Medicaid/BCBS/ W-9 for various states.

Entered contractual information into credentialing database (length of contract, amount, and stipends).

Processed DMEPOS application for Illinois Medicaid Individual participation.

Professional Experience:

Privileging and Credentialing Coordinator – IN Compass Health, Alpharetta, GA July 2012 – Present

Medical Staff Liaison - Schumacher Group, Atlanta, GA July 2011 – July 2012

Documentation Specialist - UroMed, Suwanee, GA March 2011 – July 2011

Director of Credentialing – Anesthesia Healthcare Partners, Duluth, GA October 2009 - July 2010

Contract Credentials Specialist - Mount Vernon Internal Medicine, Atlanta, GA April 2009 - June 2009

Credentials Specialist - Northshore University HealthSystem, Evanston, IL February 2003 - August 2008

Education:

Diploma in Medical Insurance Billing & Coding - Everest Institute, Norcross, GA 2011

Associates in Liberal Arts - Lincoln College, Lincoln, IL 1991

Software:

Microsoft Office, IntelliCred, AppCentral (Cactus), Echo, SalesForce, MSO for Windows (Morrisey), MDSTAFF, Sage SalesLogix, Fastrack, MedFORCE, Inscrybe, Medkinetics, SharePoint, ClaimGear 8.2.7, Medisoft 16 SP1, Outlook

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