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Manager Medical

Location:
Miami, Florida, United States
Posted:
February 22, 2019

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Resume:

Precious Bouie – Hughes

ac8ksi@r.postjobfree.com

OBJECTIVE:

Proven – Dependable and Adaptable Quality management & Credentialing Coordinator. Highly detail -oriented . Professional multi skill driven and project focus. Excellent customer services skills with a passion for problem solving and leadership.

PROFESSIONAL QUALIFICATIONS:

• Multitasking abilities

• Able to work well under Time – Sensitive conditions and high pressure environment

• Proficient in Word, Sales Force, MD Staff, (Medicare) GDS Data base software, PECOS website, DEA website Medicaid website, NPPES website, State Medical License website, Multiple States Health Plans enrollment websites for credentialing CVO website based (Parallon credentialing Hospital website). PROFESSIONAL WORK EXPERIENCE

Chen Med- June 2017 – Present

• Credentialing Coordinator / Payer Enrollment Specialist

• Attend weekly meetings and Team project meeting to assure update in reference to spreadsheets, emails, and in person information provider and being distributed.

• Perform timely follow up with recruitment team, candidates throughout the credentialing and enrollment process.

• State Medicare/CMS enrollment ( Initial. Re-assignment) for physicians ability to set the estimate 60 day prior to start date for the physician to coordinate market start requirement . Louisiana PMP Website, Kentucky Kasper Website, Facilities revalidation and approval process for multiple states. Florida/ Kentucky/ Louisiana/ Pennsylvania/Virginia.

• Complete all PSV’s (Primary Source Verifications ) . Background Checks if needed for selective health care providers. Ie (Case Managers ) .

• CAQH- maintain and review for providers, edit/ update and upload according to providers information needs.

• Maintain ongoing relationship with market payors for continual updates and submission of new providers and termination of outgoing physicians. Initiate LOI ( letter of Intent) for any/ all actions that is required.

• Payor Enrollments to submission of new payors via online application to payor, roster or payor required documentation.

• Continuous communication with Senior Management to include reporting departmental update resolving issues on a timely manner and making sure

• Initiating communication to internal Med COE department for physician dispensing to be activated on state dispensing license has been approved.

• Complete and submit Hospital privileges application to CVO for processing . Obtain EMR access for TCC ( Transitional Care Coordinators for monitoring and reviews.

• Request and submit to requestor Malpractice insurance certificates for providers to payors or hospital making sure the coverage amounts and facility are appropriate to requestors needs.

• Work closely with department heads to steam line workflow and follow through on timelines and urgent needs.

• Re-credential process as required every 2 years.

• NPPES – obtain new facility NPI’s and updating physicians information as well as facilities ongoing. HS1/ HN1 Medical Management- Jan 2005 – Dec 2014

Credentialing Coordinator / Quality Management Coordinator

Assisted in updating records based on its application status or credentialing documents.

Responsible for monitoring and verifying expired credentialing documents and doing a follow-up procedure with the network providers.

Made recommendations to the Credentialing Directors on non-compliance concerns.

Performed under minimal supervision with accountability for specific goals/objectives. Works with the credentialing manager to develop performance improvement targets for quality, service, and efficiency.

Responsible for submitting and updating credentialing documents as regulating to regulatory agency requirements.

Data entry on GDS software i.e. credentialing applications, reports, company policy procedures.

Investigated and completed Quality Inquiry Referrals (QIR’s).

Coordinated and prepared files for the credentialing committee, Quality Utilization Committee, and Care Access Health Plan Executive meetings.

Adheres to HIPAA laws and procedures, department policies and client/patient confidentiality.

My notable efforts and dedication resulted in two (2) promotions during my employment.

Developed tracking and trending processes for quality improvement.

Supported on-site audits.

Provider Relations Representative /HN1

• Perform initial contract recruitment for Network for Multiple Companies, Primary Care Physician, Hospital, Diagnostic Center.

• Prepared and presented completed computer generated reports for contracting outcomes on monthly Network gaps/ required specialties.

Meeting with Senior Management/ Executive Representatives for projects goal, task or developments.

• Responsible to visiting all contracted PCP and Specialist site, maintaining good relations and conducting site audits, delivery financial updates and meeting with management to review any delay of services.

• Continual education on regulatory updates as well as internal news or business changes to all primary care physicians and specialty provider and identifying any member provider issues. Problem resolution.

• Retrieving any and all credentialing required documents to ensure provider enrollment into network In timely matter

• Obtaining contractual Approval for Network participation if contract was requiring additional negotiations of additional services or finances .

• Evaluating and resolving any and all critical issues related to assign area of responsibility.

• Effectively and timely response to all emails from management, internal and external Providers.

• Maintain current provider file to reflect every visit and compliance or complaint issues if any.

• Coordinate with all internal departments any grievance / complaints or outstanding credentialing concerns

• Worked closed with Medical Director in regards to contracting or credentialing concerns. Reviewing issues that may or may not have an adverse outcome.

• Internal tracking and monitoring module that housed all incoming and outgoing utilization delays for issuing authorization due to provider network gaps.

• Work with Executive administration with Special Projects and/ or Development of Network out of state to ensure success in business projections

Precious Bouie – Hughes

ac8ksi@r.postjobfree.com

• Full compliment Network that met all required covered areas . To assure the forgoing and implementation of new POS (Points of Service)

• Always available to assist the team and any department to make sure the success of all projects. Miami-Dade State Attorney May 2000 to March 2002

Case Analyst II

Conducted legal research and gathered relevant information for preparation for the paternity case.

Prepared written reports that the attorney used to determine how the case should be handled.

I was responsible for tracking paternity case defendants by investigating their whereabouts through community involvement and confidential personal record database systems and serving them court order documents.

I developed a reputation of consistently collecting large lump-sums of child-support payments. United States Postal Service May 1999 to Feb. 2000 Mail Carrier

Sorted incoming and outgoing mail according to type and destination.

Checked mail to ensure correct postage and that packages and letters are in proper condition for mailing.

I was often asked to assist other mail carriers with their routes once I completed my own. Care Florida / Foundation Health Oct 1994 to Sept. 1998 Credentialing Manager / Quality Assurance Manager

Reported directly to CEO/ Medical Director/ Quality Assurance VP.

Monitored and track responses from primary sources and follow through with plan of action.

Perform and established accounts for NPD/

Interviewed and trained all credentialing staff

Developed data based module to house credentialing, reporting and tracking of provider information.

Prepared reports for providers’ plan participation approval meetings.

Implemented the credentialing department, develop policy and procedure to meet NCQA

Prepared the department for meeting

Developed corrective action plans and work requirements for staff.

Implementing on-going studies to meet healthcare plan’s objective required standards.

Implemented a new credentialing process to include re-credentialing.

Developed all of the company’s re-credentialing programs and implemented a database to hold and track providers’ information.

Managed daily department operations and staff with diligence and efficiency.

Maintained reporting and query accounts.

I created a standard operation procedure for my department that help organized the re-credentialing process.

Foundation Health –

• Quality Assurance Specialist

• Ensured Compliance with the Foundation Health appeals and grievance unity.

• Review all appeals and grievance for timely filing and response . Timelines for follow up and reports and closure

• Meet with Senior Management and maintained data bank for tracking and outcomes, closure.

• Created reports and develop system that reported the out of timelines and compliance regarding the process.

• Work closely with Utilization Director and Medical Director to assure all compliance and regulation standards and

• Bench marks were maintained and completed.

• Review and worked with Customer Service Management team to developed processes to stream line events and reoccurrence’s of complaint to identify errors or potential patterns of causes to high grievances and complaints

Humana Health Care Plans / IMC Jan. 1986 to Oct. 1994 IMC Hollywood Medical Center

Night Shift / Receptionist – Intake apt visits/ set appoints Promotion to :

Referral Coordinator- processing / completing physicians referral for members to see specialist or hospital admissions. Work closely with Medial Director for Stat referrals or direct Hospitals admission request. Promotion to: Corporate Humana

SNF Coordinator: Provided support to plans for placement of members in nursing home facility screened members for eligibility of placement in contracted Tri-county nursing homes. Responsible for obtaining a bed and non contracted facility if one was not available with in our network. Responsible for maintaining a concurrent log show members skilled days available and non skilled days available Responsible to making sure member did not exceed the benefit approval time give for appropriate placement and stay. Credentialing Coordinator

Precious Bouie – Hughes

ac8ksi@r.postjobfree.com

Assist Credentialing Manager with completing and preparing agenda and minutes file for Credentialing Committee Meeting.

Prepared the providers’ files for presentation to the credentialing committee for approval.

Maintained information relating to processing credential requirements in order for providers to keep an active status.

Remained updated on current credentialing standards and guidelines as well as company policy and procedures.

I screened members for eligibility of placement in contracted Tri-county nursing homes.

I developed and maintained well-established relationships with contracted nursing home facilities and network with potential providers.

EDUCATION

Medical Transcribing, Southern Tech Vocational September 1987 Barry University earned 36 credits enrolled in Bachelor’s Program Liberal Studies B.A. Degree, The Gate of Bethel College June 2015

Light University, Certificate of Completion Couples Recovery 2.0 Light University, Certificate of Completions Christian Counseling 2.0 Professional References:

Doris Cuellar – Payor Enrollment/ Credentialing Manager, Chen Med- ac8ksi@r.postjobfree.com 786-***-**** Glady Fernandez – Market President - ac8ksi@r.postjobfree.com 305-***-**** Fredricka Buckles- Ross – Credentialing Specialist –ac8ksi@r.postjobfree.com 786-***-**** Raymond Jimenez - Managing Director Billing & Credentialing - ac8ksi@r.postjobfree.com - 954-***-****



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