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Credentialing Specialist

Location:
Long Beach, CA
Salary:
$20-25
Posted:
December 30, 2018

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Resume:

DEMETRIA JACKSON

*** ******** ***, #**

LONG BEACH, CALIFORNIA, 90802, UNITED STATES

562-***-****

ac720e@r.postjobfree.com

PROFESSIONAL EXPERIENCE

OPTUM/HEALTHCARE SUPPORT IRVINE, CA

RxCCR Quality Analyst-Contractor August 2018 – Present

Responsible for the auditing/ review of prescription benefits housed in several databases against a SOT.

Responsible for keeping track of all failed cases and making sure that they are corrected in a timely manner.

The following systems/programs are used during the review are Sales Force, Service Now, AS400 and other additional databases.

HEALTHSMART MSO, INC CYPRESS, CA

Administration/Credentialing Supervisor June 2001 – December 2017

Responsible for the credentialing and recredentialing of IPA providers ( doctors, allied health physicians and HDOs)

Responsible for accurately data entering initial credentialing and recredentialing applications in the Credentialing Data Management system in a timely manner

Prepared credentialing/ recredentialing files with the primary source verifications obtained via fax, mail, internet or email (all information obtained in-house, not outsourced)

Updated (any new demographics) and distributed all of the IPA provider rosters via the intranet

Monthly/Quarterly monitoring of providers on each medical licensing board, sanctions list and quarterly member grievances and performance evaluations.

Kept track monthly of all the expired licenses, DEA's and insurance of all providers

Prepared Credentialing meeting agendas and minutes for 8 medical groups (15 at one point in time)

Back-up for Healthplan reporting

Supervised & audited the work of the Credentialing staff to ensure adherence to quality standards, deadlines, and proper procedures, correcting errors or problems

Provided employees with guidance in handling difficult or complex problems or in resolving escalated calls

Participated in the yearly audits done by all contracted healthplans (95-98%, the score was 100%)

Operated office equipment such as fax machines, copiers, and phone systems, and use of computers for spreadsheets, word, database management

Computer Programs-Word, Excel, Outlook, Micro-Med and E-Healthcare (familiar with Powerpoint)

Had all newly Credentialied providers contracts signed by the Medical Director of each group

Back-up reception coverage - Answered phone calls, directed calls to appropriate parties or took messages

Oversaw the maintenance and repair of all the office equipment for 13 years (fax machines, printers & copiers)

Coordinated the repair of other office issues-plumber, handyman and elevator repairman

Purchased and monitored inventory of office supplies for the whole company and submitted invoices to Finance for payment

Documented all incoming checks in a excel spreadsheet and made daily deposits via courier for 4 years

BRIGHT MEDICAL ASSOCIATES WHITTIER, CA

Administrative Assistant December 2000 - June 2001

Operated office equipment such as fax machines, copiers, and phone systems, and use computers for spreadsheets, word, database management

Back-up reception coverage - Answered phone calls, directed calls to appropriate parties or took messages

Located and attached appropriate files to incoming correspondence requiring replies

Open, read, and distributed incoming mail or other materials and answer routine letters

Set up and maintained paper and electronic filing systems for records, correspondence, and other material

Maintained scheduling and event calendars

Coordinated and set up meetings (invitations, food and IT request for special equipment)

KPC MEDICAL GROUP, FORMER NAMED MEDPARTNERS MEDICAL GROUP CERRITOS, CA

Administrative Assistant September 1997 - November 2000

Operated office equipment such as fax machines, copiers, and phone systems, and use computers for spreadsheets, word and database management

Maintained scheduling and event calendars

Oversaw the maintenance and repair of equipment (fax, printer & copier)

Ordered and dispensed supplies for my floor

Coordinated and set up meetings

Took escalated calls (for the manager) in a call center of 100 representatives, if unavailable

Back-up reception coverage - Answered phone calls, directed calls to appropriate parties or took messages

The 1st year I gathered patient complaints, compliments and concerns from the Patient Advocates located at the clinics.

Prepared monthly reports of the patient trends by region.

EDUCATION

JORDAN HIGH SCHOOL September 1987 - June 1990 LONG BEACH, CA

3.1 GPA, Member of the Honor Society, Member of the Upward Bound Program

SAN DIEGO STATE UNIVERSITY August 1990 - May 1991 SAN DIEGO, CA

Completed 1 year in the study of Social Work

REFERENCES

Sandee Muro ac720e@r.postjobfree.com 714-***-****

Current Position - Credentialing Manager - Applecare Medical Group

Former Position - My Credentialing Supervisor - HealthSmart MSO, Inc

Carrie Greek ac720e@r.postjobfree.com 657-***-****

Current Position - Senior Credentialing Auditor - CalOptima

Former Position - My Credentialing Manager - HealthSmart MSO, Inc

Cindy Chaleekul-Sanabria ac720e@r.postjobfree.com 626-***-****

Current Position - Credentialing Manager - Inland Empire Health Plan

Former Position - My Credentialing Co-Worker - HealthSmart MSO, Inc

Shelby Gresham ac720e@r.postjobfree.com 310-***-****

Current Position - AVP of Member Services & Capitation - HealthSmart MSO, Inc

Audrey Denton ac720e@r.postjobfree.com 562-***-****

Current Position - Claims Manager - HealthSmart MSO, Inc



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