SUMMARY

Driven and compassionate healthcare professional with 20 years hands-on, experience in fast-paced environments. Accountable and responsible with a strong focus on the credentialing process.

EDUCATION

Almeda College 2001

Bachelor of Arts

Psychology

SKILLS

Conflict Resolution Customer Service

Relationship Management Influential Leader

Sound Decision Maker Critical Thinker

Staff Training and Development Detail Oriented

Staff Management Effective Communication

EXPERIENCE

The Addison Group-- Crossroads Treatment Centers

Credentialing Specialist Charlotte NC

May 2023-February 2024

Works closely with the recruiting and onboarding team to ensure that provider documents are received and properly loaded into the Modio database in a timely manner.

Effectively communicates with the payor enrollment coordinator(s) when provider profiles are complete in Modio and ready for enrollment to begin.

Conducts primary source verifications on all provider expirable upon receipt of a new provider file.

Completes all provider CAQH profiles upon initial employment and maintains the profile every 120 days as required by payors. Ensures CAQH attestation information is properly loaded into Modio.

Monitors provider expirable (License, DEA, Board Certification, COI) monthly via Modio. Sends notices to providers to renew as appropriate, escalates to department and center management when providers are non-compliant.

Ensuring that Availity is kept current and up-to-date for all locations.

Manages data integrity in Modio by routinely (no less than quarterly) auditing the database for missing provider and location information.

Serves as the primary liaison between staff and the Modio support team to streamline database updates and new requests.

Family First Medical Center, PLLC*Credentialing Coordinator Charlotte, NC June 2021-Current (contract)

Maintain and perform a warm, friendly and welcoming relationship with all staff, all medical and non-medical professionals, vendors and visitors

Prepare, submit and follow up on all initial payer applications for providers and office locations

Prepare, submit and follow up on all re-credentialing applications for providers and office locations

Contact and/or respond to requests for verification of credentials, current licenses etc. ensuring credentialing and licensing processes are completed timely and notifications are sent timely.

Prepare, submit and follow up on revalidation requests for providers and office locations.

Review provider credentialing files and work with providers to obtain the necessary missing, incomplete, and expiring items.

Track status of applications, follow-up as necessary and document activity in an accurate and timely manner.

Maintain and update provider files and rosters including but not limited to internal provider and/or location roster lists, individual CAQH profiles, payer databases, NPI Database and Medicare database and any other as needed.

Prepare, submit, and follow up on all initial payer applications for providers and office locations.

Contact and/or respond to requests for verification of credentials, current licenses etc. ensuring credentialing and licensing processes are completed Prepare, submit and follow up on all initial payer applications for providers and office locations.

Track current status of applications, follow up as necessary and document activity in an accurate and timely manner.

Maintain and update provider files and rosters including but not limited to internal provider and/or location roster lists, individual CAQH profiles, payer databases, NPI Database and Medicare database and any other as needed.

Worked closely with third party payers to maintain current information on contract terms and conditions. Enrolled Providers in Medicare using PECOS data base, NC Tracks, and Commercial Payors.

Participating in weekly meetings.

L. H. Consultants, LLC * Credentialing Manager -Charlotte, NC

September 2017-March 2021

Maintain and perform a warm, friendly and welcoming relationship with all staff, all medical and non-medical professionals, vendors and visitors.

Prepare, submit and follow up on all initial payer applications for providers and office locations.

Prepare, submit and follow up on all re-credentialing applications for providers and office locations.

Contact and/or respond to requests for verification of credentials, current licenses etc. ensuring credentialing and licensing processes are completed timely and notifications are sent timely.

Prepare, submit and follow up on revalidation requests for providers and office locations.

Review provider credentialing files and work with providers to obtain the necessary missing, incomplete and expiring items.

Track current status of applications, follow up as necessary and document activity in an accurate and timely manner.

Maintain and update provider files and rosters including but not limited to internal provider and/or location roster lists, individual CAQH profiles, payer databases, NPI Database and Medicare database and any other as needed.

Maintain consistent contact with providers to ensure that expectations are clear, and requirements are completed in a timely manner.

Colonial Family Practice Credentialing Specialist – Fort Mill, SC

June 2017 – August 2017

Responsible for creating and maintaining provider re-credentialing files within the credentialing database, verifying that reappointed have met re-privileging requirements and are eligible for the staff/allied health category requested.

Prepares and tracks re-appointment documentation through the review and approval process, initiating and mailing approval letters and updating the database upon final approval by the Board of Trustees. `

Ensures maintenance of practitioner credentials within the database, including all expirable. Provides support to physicians and other members of the Medical Staff Services office in the application and credentialing process; acts as liaison with physician departments, practices and other departments. Maintains and distributes the monthly medical staff calendar; manages room bookings and catering arrangements for all medical staff meetings.

Aerotek Staffing Benefits Specialist – Charlotte, NC

November 2016 – January 2017

Participated in the development, implementation and administration of patient benefit programs.

Provided customer service and benefits communication support and droves wellness initiatives. Served as the point of contact for day-to-day operations of Health Plan administration including assisting with management of carriers, administrators, vendors and consultants.

Resolved benefit issues for partners by collecting information, analyzing data, determining root cause and communicating facts/conclusions clearly and concisely.

Provided responsive customer service support via phone and email; provided support as acted as subject-matter-expert and point of contact, responding to inquiries, conducting research and evaluating proper course of action for clients.

Palmetto Health Corporate Office Coordinator, Provider Enrollment –

Columbia, SC** November 2014– March 2016

Coordinated credentialing data needed for enrollment, contracting, and other related purposes,

Drug Enforcement Administration, (DEA) number, state license number, Board certifications, CV, malpractice insurance, and state insurance form. Maintained provider credentialing files electronically via provider enrollment software, shared computer files, and CAQH (Council for Affordable Quality Healthcare.

Prepared weekly internal Provider report the first day of every week for Vice President and Director. Worked Physicians AR Hold Reports.

Maintained National Provider Identification (NPI) numbers on all providers, using NPPES for updating for Medicare and searching NPI’s.

Maintained records of all providers’ and continued medical education for reporting to various agencies.

Worked closely with third party payers to maintain current information on contract terms and conditions. Enrolled Providers in Medicare using PECOS data base.

Eau Claire Health Center Senior Credentialing Coordinator – Columbia, SC

June 2013 – August 2014

Responsible for credentialing activities and supervision of the day-to-day process of credentialing the providers who were associated with all affiliated physician groups. Planed, developed, and coordinated activities/procedures to assure compliance to NCQA Credentialing Standards.

Communicated with the HMO and PPO contacts regarding the credentialing process, notification of additions, changes, and problem solving.

Oversaw the submission of provider credentialing information to health plans for inclusion in Prospect networks. Such as Behavior Health Providers, LCMHC, LCSWA.

Oversaw the notification to health plans of provider terminations and reassignment of membership, when applicable. Coordinated and prepared annual site visits and audits from the various health plans.

Planned, organized, and supervised the Credentialing department. Participated and took minutes at the monthly Credentialing Committee meeting. Coordinated the malpractice policy administration and any policy changes for employed physicians and audit quarterly invoices for payment processing. Responsible for payment processing of NC/SC Medical License and DEA renewals for the staff providers.

Coordinated hospital privileges for employed physicians with close follow-up with hospital staff services. Coordinated payment of the annual medical staff dues at the various hospitals.

Worked closely with the Physician Recruiter and the Chief Operations Officer to ensure accurate transfer of new physician information.

Supervises the function of credentialing specialists responsible for intake application review, payer application submissions and follow-up. Monitors provider credentialing status relative to reimbursement and communicates status and trends to organizational leadership as applicable.

Comprehensive Health Family Services Office Administrator – Columbia, SC November 2009 – October 2011

Credentialed Providers with the Insurance Carriers and ensuring their reappointment with the hospitals. Followed-up within 15 days for assurance of applications were received. Verified of all License, State, DEA, and CDS. Created spreadsheet for daily usage.

Midlands Neurology Pain & Associates Office Administrator – Columbia, SC April 2004- November 2009

Credentialed Providers with the Insurance Carriers and ensuring their reappointment with the hospitals. Followed-up within 15 days for assurance of applications were received.

Obtained pre-certifications and authorizations when needed. Follow-up on all applications for status up-dates. Supervising front and back office for daily activities.

Contracting for Revenue Reimbursements. Performed audits on Providers file.

Eden Gardens Assisted Living Business Office Manager – Columbia, SC June 2001- August 2003

Provided assisted to the Executive Director. Post Payments to accounts. Collaborated and partners to manage and maintain $1.5 million budget. Coordinated pre-employment orientation.

Provided customer service and benefits communication support and droves wellness initiatives. Served as the point of contact for day-to-day operations of Health Plan administration including assisting with management of carriers, administrators, vendors and consultants. Resolved benefit issues for partners by collecting information, analyzing data, determining root cause and communicating facts/conclusions clearly and concisely. Provided responsive customer service support via phone and email; provided support as acted as subject-matter-expert and point of contact, responding to inquiries, conducting research and evaluating proper course of action for clients.

Participated in the development, implementation and administration of patient benefit programs.

Contact this candidate