Customer Service Medical

Stacey Milton

*** ******** **., ******, ** *****

857-***-**** ****************@*****.***

WORK EXPERIENCE

ValueOptions (contract) Boston, Ma

Credentialing Specialist July 2015 to November 2015

Performs provider credentialing and re-credentialing for behavioral health.

Ensure that all credentialed files are current and complete pursuant to expiration date of medical licenses, board certification, professional-liability insurance coverage, DEA and other pertinent information per policy and procedures.

Maintain high quality, timely and accurate credentialing processes per department standards. Organize and maintain credentialing files.

Monitor collection of all information received. Follow up on missing items and incomplete forms. Submit follow up requests for verifications as needed.

Work with Network Operations and other Beacon staff to ensure follow up with providers when applications are incomplete.

Perform Primary Source Verification for individual credentialing & confirmation of facility accreditation and licensure.

Track all credentialed providers for the purpose of re-credentialing. Accurately enter information into Beacon’s system of record.

Knowledge of NCQA credentialing and re-credentialing standards.

Prepares files for monthly Credentialing Committee. Support special projects as needed. Other duties as assigned.

Maximus, Inc (contract) Boston, MA

Provider Enrollment & Credentialing Specialist August 2014 to March 2015

Researched, verified, and documented provider credentialing information through various government agencies and license boards as part of provider enrollment regulations.

Contacted providers either by phone or email to clarify or obtain missing documents from the provider application submission.

Communicated with providers or office staff and walked them through the application and update process and requirements.

Documented communication notes and resolution outcomes.

Reviewed the application and update submission in its entirety and confirmed that all data is accurate and all revalidation documents were completed and uploaded, and also check that all verification documents are complete and uploaded.

Respond to inquiries on the status of application and update submissions for various providers and support the department's administrative requirements including preparing educational documents and supporting other reporting needs.

Plexus Management Group Boston, MA

Credentialing Specialist May 2012 to April 2014

Completes payer credentialing and re-credentialing, which includes completion of provider applications and renewals, collecting required backup documents with adherence to NCQA, state and federal regulations

Maintains and updates credentialing information utilizing credentialing software

Prepares and mails notice letters to providers that require updated information

Reports recurring delinquent staff to management

Maintain provider files and assists with filing

Provides general administrative assistance such as maintaining files pertinent to clinical information

Troubles shoot any problems with insurance applications

Pursues resolution to insure timely and current licensure, and follow up

Handles W9 and 1099 form information such as keeping organized and sending them to insurance carriers when requested and verifies tax ID and NPI numbers when received

Handles various provider related issues and contract/payment issues

Resolves unpaid claims issues with third party payers and pursues resumption of reimbursement if non-payment is due to credentialing/contracting issues

Keeps follow-up queues worked daily and claims resubmitted as necessary

Boston Medical Center (contract) Boston, MA

Credentialing Coordinator January 2009 to December 2010

Received and performed intake process on new contracts including checking information for accuracy and completeness, record set-up in the system, data entry etc. and putting contracts and credentialing documentation in process

Researched claims submitted by unknown providers

Received and processed provider information updates and follow up with departments for more information if needed

Determined status of patient accounts in order to optimize reimbursement by reconciling billing activities; and comparing authorizations to claims through the use of medical records and billing software

Processed executed contracts, mail out contracts and provider letters file and scans executed contracts, update contract grids and initiate fee schedule loading

Adjudication, reconciliation and/or appealing claims denials

Children’s Hospital Boston Boston, MA

Administrative Associate II November 2005 to December 2008

Provided administrative support to the Department of Endocrinology in the areas of payroll and personnel administration

Assisted the Chief of Endocrinology with the scheduling of his calendar, travel arrangements, and organization of the winter holiday party and annual summer party

Assisted in grant submission and preparedness

Coordinated and oversaw weekly/monthly payroll process with review of time card information and submission into payroll systems

Processed physicians credentialing and re-credentialing with 3rd party payers and licensing boards

Processed faculty appointments and credentialing forms

New England Medical Center (contract) Boston, MA

Patient Services Coordinator III February 2004 to October 2005

Overall supervision of front desk operations, including the training of staff on encountering and exiting patients using online scheduling database

Coordinated information and care requirement with other care providers

Interacted with involved departments to negotiate and expedite scheduling and completion of tests, procedures and consults

Provided educational information in conjunction with direct care providers related to treatments, procedures, medications and continuing care

Led the Practice Coordinators to ensure that practice staffing was appropriate to support the patient care, patient flow, and customer service needs for efficient Clinical operations

Maintained quality service by establishing and enforcing organization standards

Maintained and update patient records

Scheduled appointments and procedures, collect co-pays, input of referrals in database system

Resolved all operational issues related to registration, admissions and financial services for outpatients

Handle all aspects of departmental billing(s) for department(s)

Developed management reporting system to track practice performance such as telephone access, billing, no-shows, etc., and utilized the data to make operational changes

Acted as intermediary between physicians and staff, sharing information and facilitating development of communication systems for administration, physicians and staff

Massachusetts General Hospital Boston, MA

Patient Services Coordinator Level II November 1999 to January 2004

Performed various receptions and/or scheduling tasks for the various divisions of Radiology Department

Obtained insurance pre-approval for patient exams

Scheduled patient appointments using an on-line registration / scheduling system

Entered, edited and/or confirmed all patient demographic, financial and clinical data

Verified routing of patient reports

Maintained the physical environment of patient Areas and examination rooms

Edited, canceled, confirmed patient appointments, received patients and directed them to the appropriate testing area

Completed documents and reports on EDI insurance and patient registration verification

Ensured the completeness of all forms

Acted as liaison between referring physicians and MGH imaging staff

Mattapan Community Health Center Boston, MA

Clinical Operations Assistant February 1998 to October 1999

Assisted Medical Director with the scheduling of appointments

Monitored phone calls and directed to appropriate staff

Handled all travel arrangements, created new spreadsheets and new forms for clinical staff

Responsible for all typing, creating filing systems, copying and ensuring proper messages were taken

Assisted Department of Social Services with monthly and yearly writing of grants

Supply information and services to AIDS patients

Assisted Department of Human Resources with input of payroll information and employee benefit packages

Skills

Communications Skills (listening, verbal, written), Analytical/Research Skills, Computer/Technical Literacy, Flexible/Adaptable/Managing Multiple Priorities, Interpersonal Abilities, Leadership/Management Skills, Multicultural Sensitivity/Awareness, Planning/Organizing, Problem-Solving/Reasoning/Creative, Team player, Honesty/Integrity/Morality, Dedication/Hard-Working/Work Ethic/Tenacity, Dependable/Reliable/Responsible, Loyal, Positive Attitude/Motivating/Energy/Passion, Self-Motivated/Ability to Work With Little or No Supervision, Willingness to Learn

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