Credentialing Specialist Data Entry
Resume:
Ann Thomas
Tampa, FL *****
ad2xia@r.postjobfree.com
Summary
10+ years’ experience as a Credentialing Specialist for Providers, Facility and Ancillary providers, with Customer Service experience: Managed and maintaining licensure including DEAs, CLIA, and Medical license as well as tracking continuing education for provider and physicians. Data Entry Skills and Very Detailed Oriented Great at Multi-Tasking Coordinate of Credentialing/Contract activities, Knowledge of Medicare & Medicare guidelines Extensive clerical support
Professional Experience
Argus Dental Vision Healthcare 7/2020 – Present
Credentialing Specialist
Review credentialing application packet to ensure completeness and accuracy.
Secure necessary documentation required to complete provider applications.
Performs primary source verification of providers licensing, training, and certifications.
Queries the SAM, OIG, NPDB, Medicaid and Medicare database to obtain any sanctions imposed against the provider.
Queries the NPDB to obtain any malpratice claims history on file.
Verifies clinical/hospital privileges as applicable.
Tracks provider appointments and conducts re-credentialing every 3 years.
Demonstrates problem solving and decision-making capabilities
Mission Healthcare Communities 1/2020 – 4/2020
Credentialing Specialist
Will review and submit credentialing or recredentialing applications based on the data provided. If data is not complete, the Analyst will make effort to contact the responsible parties and complete the applications within the specified time frames
WIPRO 7/2019 – 1/2020
Credentialing Specialist
Will review and submit credentialing or recredentialing applications based on the data provided. If data is not complete, the Analyst will make effort to contact the responsible parties and complete the applications within the specified time frames.
Wellcare Health Plans, Inc (Contract) 4/2019 - 6/2019
Configuration Specialist
•Loads professional contracts into the Diamond System through appropriate research and provider data load activities.
•Performs accurate and timely provider research, verification and analysis.
•Resolves provider load issues within established documented processes.
•Ensures the proper supporting documentation exists and is maintained on file for all load processes.
•Loads and maintains provider data.
•Loads new providers as a result of the approved Credentialing Committee Lists.
•Coordinates with Membership for member move requests.
•Assists in updating payable procedure codes, price rules and fee schedules.
•Resolves critical errors forwarded from the claims department.
•Updates tracking database.
•Responsible for building and maintaining positive business relationships with business partners.
•Assists in special projects.
•Maintains high quality work.
•Meets productivity expectations.
•Works Auto Analyzer Reports.
•Performs other duties as assigned.
Argus Dental Vision (Contract) 10/2018 - 4/2019
Credentialing Specialist
•Review credentialing applicantion packet to ensure completeness and accuracy.
•Secure necessary documentation required to complete provider applications.
•Performs primary source verification of providers licensing, training, and certifications.
•Queries the SAM, OIG, NPDB, Medicaid and Medicare database to obtain any sanctions imposed against the provider.
•Queries the NPDB to obtain any malpratice claims history on file.
•Verifies clinical/hospital privileges as applicable.
•Tracks provider appointments and conducts re-credentialing every 3 years.
•Demonstrates problem solving and decision-making capabilities.
Molina Healthcare 7/2017 – 10/2018
Provider Services Contract, Credentialing Specialsit
•Perform primary source verifications of licensure, board certification, DEA/CDS Certificates, Education and Training, Medicare/Medicaid Sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB and FSMB queries, NCQA, URAC, CMS.
•Performs and documents licensure updates as applicable
•Updates provider information and enters malpractice coverage limits into applicable database system (Amisys, Facets, CredTracker, Cactus), as appropriate
•Documents provider credentialing verifications in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decision
•Obtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizations
•Maintains current knowledge of the Credentialing Manual and applicable database system (Amisys, Facets, CredTracker, Cactus) changes
•Solves moderately complex problems on own
•Coordinates with Plan staff to obtain missing credentialing information from non-compliant providers
•Use CAQH to pull up provider applications
•Works with team to solve complex problems
•Maintains log of responses and in appropriate follow-up to obtain verification of information
•Review malpractice history, regulatory and disciplinary action report issued by state and federal agencies invoking appropriate processes as defined in policies and procedures.
One Call Care Dental & Doctor (Temp Contract) 1/2017 – 7/2017
Credentialing Specialist
•Performs and documents licensure updates as applicable
•Coordinates with Plan staff to obtain missing credentialing information from non-compliant providers
•Obtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizations
•Works with team to solve complex problems
WellCare (Temp Contract) 9/2016 – 1/2017
Provider Operation Coordinator
•Supports the Provider Relations Field Reps to resolve claims and payment issues
•Root cause analysis of operational and health services issues
•Review and processes incoming and outgoing paperwork including directory updates, provider credentialing applications, contract maintenance forms and other related forms
•Tracks new contracts through sidewinder
•Audits configuration loads on new contracts
•Provides office, project management, provide recruitment and data analysis support
•Performs special projects as assigned or directed
Amerigroup 1/2013 – 8/2016
Credentialing Specialist
•Perform primary source verifications of licensure, board certification, DEA/CDS Certificates, Education and Training, Medicare/Medicaid Sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB and FSMB queries, NCQA, URAC
•Performs and documents licensure updates as applicable
•Updates provider information and enters malpractice coverage limits into applicable database system (Amisys, Facets, CredTracker, Cactus), as appropriate
•Documents provider credentialing verifications in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decision
•Obtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizations
•Maintains current knowledge of the Credentialing Manual and applicable database system (Amisys, Facets, CredTracker, Cactus) changes
•Solves moderately complex problems on own
•Coordinates with Plan staff to obtain missing credentialing information from non-compliant providers
•Use CAQH to pull up provider applications
•Works with team to solve complex problems
•Maintains log of responses and in appropriate follow-up to obtain verification of information
•Sends second and third notices to those who do not respond to the first one.
•Completes rosters changes and provides data entry and data base management updates.
•Answers and resolve network provider calls and emails inquiries
•Skill in managing multiple priorities and deadlines with minimal supervision.
•Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners and ultimately bill and obtain reimbursement for services rendered
•Sometimes schedule and distribute meeting invitations to Medical Directors and participating external practitioners
•Review malpractice history, regulatory and disciplinary action report issued by state and federal agencies invoking appropriate processes as defined in policies and procedures
Freedom Health (Temp Contract) 8/2012 - 11/2012
Credentialing Specialist
•Perform primary source verifications of licensure, board certification, DEA/CDS Certificates, Education and Training, Medicare/Medicaid Sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB and FSMB queries
•Performs and documents licensure updates as applicable
•Updates provider information and enters malpractice coverage limits into applicable database system (Amisys, Facets, CredTracker, Cactus), as appropriate
•Documents provider credentialing verifications in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decision
•Obtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizations
•Maintains current knowledge of the Credentialing Manual and applicable database system (Amisys, Facets, CredTracker, Cactus) changes
•Coordinates with Plan staff to obtain missing credentialing information from non-compliant providers
•Use CAQH to pull up provider applications
•Review malpractice history, regulatory and disciplinary action report issued by state and federal agencies invoking appropriate processes as defined in policies and procedures
Amerigroup (Temp Contract) 1/2011 – 7/2012
Credentialing Specialist
•Perform primary source verifications of licensure, board certification, DEA/CDS Certificates, Education and Training, Medicare/Medicaid Sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB and FSMB queries, NCQA, URAC
•Performs and documents licensure updates as applicable
•Updates provider information and enters malpractice coverage limits into applicable database system (Amisys, Facets, CredTracker, Cactus), as appropriate
•Documents provider credentialing verifications in checklist format; tracking expiration dates to ensure currency at time of Credentialing Committee decision
•Obtains documentation pertinent to timely completion of credentialing process from provider offices, IPAs, hospitals, and other provider organizations
•Maintains current knowledge of the Credentialing Manual and applicable database system (Amisys, Facets, CredTracker, Cactus) changes
•Solves moderately complex problems on own
•Coordinates with Plan staff to obtain missing credentialing information from non-compliant providers
•Use CAQH to pull up provider applications
•Works with team to solve complex problems
•Maintains log of responses and in appropriate follow-up to obtain verification of information
•Sends second and third notices to those who do not respond to the first one.
•Completes rosters changes and provides data entry and data base management updates.
•Answers and resolve network provider calls and emails inquiries
•Skill in managing multiple priorities and deadlines with minimal supervision.
•Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners and ultimately bill and obtain reimbursement for services rendered
•Sometimes schedule and distribute meeting invitations to Medical Directors and participating external practitioners
Citrus Healthcare 3 /2007-11/2010
Credentialing Specialist
•Responsible for intake and tracking of all applications.
•Review for completeness of information, identify deficiencies.
•Confirm the completeness of all CV information.
•Managing and maintaining licensure including DEAs, CLIA, and
•Medical license as well as tracking continuing education for provider and physicians.
•Runs NPD Query, AMA reports on files.
•Confirm hospital appointments and credentials standings,
•Prepare data for process review (Medical Director, Credentials Committee).
•Facilitate the resolution of credentialing issue and coordinate and complete external and internal termination notification requirements.
•Us CAQH to pull up providers’ applications.
•Answer all provider call on claim status such as: how the claim was process, when the claim was process, why it was denied, appeal status, authorization, and reprocessing of the claim, what correct CPT codes and location code to use.
•Change provider information in the system when it needs to be updated with a W9 form.
•Load providers and contract into the system
•Review malpractice history, regulatory and disciplinary action report issued by state and federal agencies invoking appropriate processes as defined in policies and procedures
Past Positions
St Paul/Travelers Insurance - FNOL (First Notice of Loss) Processor/CSA 2000-2006
United Healthcare of Florida - Provider Relation Representative 1999-2000
Colonial Penn Insurance - Customer Service/Clerical 1998-1998
Travelers Property and Casualty - Workers Compensation Medical Bill Reviewer 1989-1998
Skills
Microsoft Words Data Entry Lotus Notes, Excel, Windows 98 Ten Key Cactus System, Health Trio Facet, Amisys, NCQA, URAC, Adobe Acrobat ProX Salesforce, Omniflow, CAQH, QNXT, Sharepoint, Core, Acurity, Aldera, Encompass, Aptrackeer
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