Gloria J. Davis

**** ****** *****, ***** ********, GA 30083 615-***-****• ad0y2z@r.postjobfree.com

Goals To obtain a challenging position utilized my fifteen plus years of managed care experience and credentialing in a growing industry, and environment to assist in the health care market. EXPERIENCE NorthStar Anesthesia (Epix Healthcare)

Provider Enrollment Specialist December 18, 2018 to January 27, 2023

• Following-up on and gathering credentialing documentation, ensuring required information is obtained from the provider;

• Obtains required credentialing applications and enrollment protocols from insurance companies;

• Completes paperwork with required information from credentialing files and/or in conjunction with the physician or non-physician provider;

• Upon completion of paperwork and after ensuring accuracy, forwards paperwork to insurance companies to be assigned the necessary provider identification numbers;

• Responds to telephone and/ or written inquiries, questions and concerns from insurance companies, operations or billing department regarding the status of provider identification numbers and approval dates and other related requests;

• Provides backup support for Credentialing staff when team members are away from the office;

• Complies with Compliance Program.

Sound Physicians Hospitalist

Provider Enrollment Coordinator •July 24, 2017, to September 27, 2018

• Responsible for researching payer credentialing and billing issues and will work in conjunction with the Manager of Payer Credentialing in order to identify issues with the external Provider Enrollment vendor and the internal payer credentialing team.

• Additionally, will utilize a variety of proprietary and external tools in order to research and resolve provider enrollment issues.

• This may require contact with the Hospital Coordinators, operation personnel and/or insurance companies via phone, email or website.

• Works closely with external payer credentialing vendor on notification of a provider's start, welcome packets, provider documentation and ensuring the provider is in all systems.

• Responsible for completing enrollment for commercial, Medicare, and Medicaid for the following states, Hawaii, Idaho, Nevada, New Mexico, Oregon, and Oklahoma.

• Enrolling Locum and hospitalist with contracted insurance plans.

• Create/update CAQH profiles for all providers.

• Verify NPPES registry to ensure taxonomy code match certification to prevent claim denial/rejection.

• Work all denied claims weekly from Hold Report.

• Assist Provider with setting up PECOS account.

Denial Resolution Specialist

• Complete Medicare revalidation for all states. Create/update CAQH for all Sound Physicians.

• Work all denied claims $25,000 and up.

• Submit enrollment applications for all claims that denied due to not being enrolled with the payer.

Positive Reinforcement ABA Therapy, Inc.

Remote Case Manager/Director of Enrollment • April 04, 2016, to June 30, 2017

• Complete intake forms on new clients to receive ABA therapy in their home or school.

• Maintain authorizations for current clients, by obtaining progress reports, and graphs from therapists.

• Contact patients regarding required standards documentation needed to maintain service.

• Receive call from new clients, Tricare, hospitals, Military Bases, and other providers.

• Submit faxes to insurance companies to obtain approval for ABA therapy.

• Credential all therapists with Medicaid and commercial insurance plans.

• Maintain therapist’s documents for credentialing and HIPAA guidelines.

• Prepare claims for commercial plans, and submission.

• Maintain three spreadsheets for client, provider and insurance follow ups. Vanderbilt Hospital

Provider Enrollment Coordinator August 20, 2007 to March 31, 2016

• Independently coordinate and maintain all data within a provider's file pertaining to payer enrollment with complete accuracy.

• Scan all applications, payer letters, and enrollment files into VISTAR system, and review/audit files for paperless filing.

• Distribute and follow up on all documentation requests approximately every 14 days from the initial request utilizing the Payer Enrollment excel spreadsheet function.

• Follow up with Providers and Senior Billing Managers via phone or email, to insure that any issues have been resolved with claims, payments, and other outstanding problems.

• Department Team Lead of 6 people when the Supervisor is absent or unavailable.

• Maintain six different specialties, in monitoring and updating over 600 providers file to ensure their enrollment is up to date with all contracted, and out of state plans. ALIVE HOSPICE, INC

Case Management Assistant/Credentialing Coordinator December 10, 2001 to August 17, 2007

• Credential employed, covering physicians, Social Workers, and the facility with all (23) contracted insurance companies.

• Verify benefits/eligibility on all hospice patients; Obtain authorizations from insurance company

(prior to admission for all inpatient admits.

• Retrieve all status changes through voice mail messages. Receive phone calls from other Case Managers, patients/family members, Clinicals Services, Billing Dept., hospitals, skilled nursing, covering physicians, Pull clinicals daily (including the residence).

• Cold calling providers (MCOs) for new contracts seeking new MCO's, Negotiate letters of agreement for non-par providers.

• Communicate daily with clinicals services in obtaining clinicals when the clinicals are not available.

• Liaison to all contracted hospitals, skilled nursing facilities and Liaison between the insurance company and the Alive Hospice staff.

• Educate potential referral sources and patient's family's regarding the different hospice services that Alive offers and how their insurance covers our services. EDUCATION DAVIDSON TECHNICAL COLLEGE

Diploma - Non-Invasive Cardiovascular Technician and Medical Office Assistant Dean's List, GPA: 3.5/ 4.0

TENNESSEE STATE UNIVERSITY

Respiratory Therapy

Minor: Psychology

Active member of Actors Guild.

NASHVILLE AREA VOCATIONAL SCHOOL

Certificate Program - Certified Nurse Technician

SKILLS Team Lead

Director

Travel Agent

Claims processing.

Administrative assistant

Customer Service Representative

Knowledge of CPT. and ICD-9 coding Alpha-Numeric Data Entry Word

PECOS

HIPPA Guidelines

Typing Speed: 55 WPM

Excel (pivot point)

10-Key Calculator

Hospital Medical Staff

Access

Power Point

Misys, VISTAR, One App, Epic, Primm, Salesforce

Notary for Georgia

LICENSURE Active state unarmed security officer license

REFERENCES AVAILABLE UPON REQUEST

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