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Provider Credentialist

Harrisburg, PA, 17111
January 05, 2020

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Carmela Smith

*** **** ***, **********, ** *****

Cell phone: 717-***-****


UPMC Pinnacle, Camp Hill, PA October 2017 – Present AR Follow-up Specialist

● Responsible for performing claim research and follow-up work with insurance companies to resolve accounts which have been billed but remain unresolved.

● Responsible for claim denials and determining how to resolve the claim either by correction, re-billing, or if it was rejected authorization issues. Provide weekly reports on claims worked, re-billed, and submitted for write-off.

● Work from multiple computer systems simultaneously to verify and/or correct insurance carrier eligibility as well as associated claims follow-up functions.

Novitas Solutions, Mechanicsburg, PA September 2012 – October 2017 Provider Credentialist (June 2013 – October 2017)

● Responsible for processing provider applications for Medicare enrollment checking for completeness and accuracy.

● Ensured healthcare professionals meet all federal and state standards as well as NCQA (National Committee for Quality Assurance) standards.

● Maintained and updated accurate databases for practitioners including licensure, experience, education and training. Claims Processor (September 2012 – June 2013)

● Processed all Medicare Part A claims from Medicare Certified providers via paper and electronic submissions, including party liability and Medicare secondary.

● Assisted on a regular basis with appeals, outside contractor adjustments as well as various other special projects to assist the supervisor and/or business coordinator.

● Determined if claim submission was completed correctly, verified data and entered into system for adjudication. CBHNP, Harrisburg, PA

Claims Adjudicator II (March 2009 – May 2010)

● Processed behavioral health claims for several counties in the state of Pennsylvania under the medical assistance benefit with the Department of Public Welfare.

● Worked to resolve billing issues, ensure proper processing of claims according to plan benefit design and provider contract.

● Provided accurate and timely data entry and adjudication of claims from providers. DST Health Solutions, Harrisburg, PA

Healthcare Claims Specialist (November 2005 – October 2008)

● Evaluated corrected health and dental claims for hospital and provider services.

● Manually reviewed and adjudicated claims suspended for concurrent issues, potential duplication of payment, manual pricing as well as those complex or unusual cases requiring individual correction. Penn Billing Services, Harrisburg, PA

Patient Account Representative (February 2005 – October 2005)

● Responsible for billing commercial insurance carriers as a third party administrator

● Performed both original as well as follow-up billing for a behavioral health hospital

● Ensured payment and billing accuracy through manual billing

● Billed workers’ compensation insurance carriers adhering to workers’ compensation laws. EDUCATION

School of Computer Technology Highspire, PA

Graduate Certificate in Computer Programming, October 1989 TECHNOLOGY CAPABILITIES

Experienced with Microsoft Office Suite


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