Quality Assurance Medical Billing

REGINA A. GERTHERS

*** **. **** ******, *** *B

BRONX, NY 10454

CELL: 347-***-**** EMAIL: *********@*****.***

SKILLS

. Ability to communicate effectively with customers, management, staff

and able to assess organizational needs to implement administrative

procedures.

. Proficient in Microsoft Office Suite (Word, Excel, Access, PowerPoint

and Outlook) and types 50-55 wpm.

. Skilled in CPF database, Medical Manager, E Clinical Works, Facets and

Cactus.

PROFESSIONAL EXPERIENCE

Affinity Health Plan, Bronx, NY Jan 2012 - Present

Credentialing Specialist (Temp)

. Maintains current knowledge of state guidelines and regulatory

requirements, and all business rules pertaining to assigned Health

Plan. Maintains current knowledge of the credentialing process and

applicable database system ( Facets, and CACTUS) changes

. Tracks progress of working files to ensure submission to Credentialing

Committee in a timely manner, to meet department Service Level

Agreements. Coordinates the transfer of files ready for Committee

review to the Health Plan on a weekly basis.

Public Health Solutions, NY, NY Oct. 2008 - July

2011

Credentialing Coordinator/Patients Account Associate

. Conduct activities related to initial credentialing, re-credentialing

and ongoing file maintenance. Conduct all process to remain compliant

with all applicable regulatory/accreditation agencies (NCQA, NYS, CMS

etc)

. Review applications for completeness and thereafter initiates

confidential information collection, verification and documentation in

accordance with established policies and procedures for continuous

credentialing and re-credentialing.

. Ensures the credentialing and re-credentialing of providers is

coordinated in an accurate and up to date manner and that this

information is disseminated internally and externally and in a timely

manner.

. Monitors system for reporting information and quality improvement

staff to ensure that a linkage of provider information is maintained

in all databases (credentialing and quality assurance).

. Prepares and submit clean claims to various insurance companies,

electronically and by paper.

. Process payments from insurance companies and provide provider support

for (6) centers.

Health Insurance of New York, NY, NY Dec. 2004 -

Sept. 2008

Credentialing Specialist

. Coordinate the credentialing, re-credentialing and audit process.

. Maintain the confidentiality, integrity and security for all

providers' documentation.

. Ensure credentialing files are compliant with NCQA standards.

. Follows up with prospective providers regarding applications status

and contact providers to secure missing documentation as applicable.

. Participate in special projects; assist in the recommendation of

innovative workflow strategies to maximize efficiency and

effectiveness.

. Worked in a timely and efficient manner with strict attention and

performed various related duties as assigned.

. Interface with provider relations representatives regarding provider

credentialing and re-credentialing status.

EDUCATION

Hostos Community College, Bronx, NY Nov. 2000 -

June 2001

. Certification Program in Medical Billing and Office Management

Touro College, New York, NY Sept. 1998 - June

2000

. Computer Science

REFERENCES UPON REQUEST

Contact this candidate