Management Specialist Services Analyst
Resume:
Dawnette Denton-Espinal
Philadelphia, PA 19150
***************@*****.*** (Email)
215-***-**** (Cellular)
Degree in Liberal Studies, Management Minor (Pending) – Current GPA 3.57
Certified Paralegal – GPA 3.86
Public/Business Administration – University of the West Indies
Software: MS Office Applications; CAQH ProView, Visual CACTUS, CPR, HC3 PROFESSIONAL EXPERIENCE:
INDEPENDENCE BLUE CROSS
Date: June 2020 to Present
Position: Credentialing Supervisor
Department: Credentialing Operations
Responsibilities: Credentialing Supervisor oversees day-to-day activities of staff that process credentialing and recredentialing applications for medical providers. Ensures that applications are properly verified and accurately uploaded into HC3, the on-line credentialing database. This includes, but is not limited to, monitoring the processes and procedures that support the credentialing, re-credentialing, primary source verification, and credentialing application management. The credentialing supervisor is responsible for the oversight of the credentialing staff, staff performance management, and staff inventory management. The role further entails:
Development and review operating policies and procedures, develops, recommends, and/or implements changes, revisions, and enhancements as appropriate to current operating environment.
Serve as primary contact for practitioner or credentialing entity for all internal and external inquiries.
Coordinate the management of HC3, CPR, and CAQH ensuring the accuracy of data and reporting.
Monitor inventory to ensure process is completed within defined goal and expectation.
Ensure process is followed to identify that credentialing files are reviewed for information for completeness, accuracy and any conflicting information.
Responsible for oversight of the quality management program that ensures that the credentialing team is accurately following all NCQA guidelines and requirements.
Ensure all contracted provider licenses and certificates remain current, ensuring appropriate notification prior to expiration.
Monitor and report turnaround times for processing of credentialing applications while continuing to produce accurate credentialing files in the least amount of time.
Prepare for and coordinate credentialing audits to ensure all files are in compliance.
Establish and maintain positive and effective work relationships with network providers, internal and external customers, management and staff.
Responsible for medical credentialing regulations, procedures and standards.
Supervises Credentialing staff, including manage day to day operation, performance evaluation and training employees.
Strong knowledge of NCQA accreditation standards desirable
Effective communication skills with external and internal sources to verify or clarify potentially sensitive information pertinent to the application and credentialing process with minimal guidance from manager.
Knowledge of files review to meet all state and federal guidelines.
Planning projects distribution, assigning, and directing work to the credentialing team.
Knowledge of and familiarity with accreditation and certification requirements.
Excellent verbal, written and interpersonal communication skills.
Proficiency in computer and software programs (Microsoft Word, Excel, Access, CAQH, HC3, CPR, Power Point, Visual CACTUS).
Experience in policy development and procedure documentation.
Ability to make independent effective administrative and procedural decisions. 2 P a g e
Date: September 2012 – June 2020
Position: Quality Management Specialist
Department: Credentialing Operations
Responsibilities: Subject matter expert in complex and sensitive matter as it relates to high profile group Credentialing. Works independently with minimal supervision from the initial request through to completion. Develop and maintain processes to facilitate the resolution of any and all issues found in the research process that may delay and/or prevent the implementation of the contract in the specified timeframe. Work with Provider Contracting/Contract Manager, PDA, Provider Network, Provider Roster and collaborate with Management including Vice President within and outside of IBC as part of process to facilitate the contract inception. High Performer in all tasks assigned with attention to details.
INDEPENDENCE BLUE CROSS
Date: March 2000 – September 2012
Position: Senior Network Services Analyst
Department: Contracting & Professional Networks
Responsibilities: Oversees, develop and maintain processes/systems which better meet departmental goals. Oversees, train and assign tasks to employees. QA employees. Acts as a liaison between Network Coordinators, Network Data Administration, Credentialing Department, Provider Network and Contracting, Provider Operations, Pre-Cert, Case Management, Legal Department and Internal Audit to ensure prompt, accurate and professional responses to all inquiries, in addition to timely provider set up in the system with Welcome Letter mailed. Prepare the SAS 70 quarterly contract audit for submittal to the Vice President and Internal Audit. Meet with Manager and Senior Director to report on processes and special projects. Develop methodologies to extract provider credentialing/recredentialing information from the various IBC/KHPE systems. Conduct data investigations and research to ensure accuracy of all analyses and to evaluate the credibility of existing databases. Handles initial credentialing and application intake function for targeted providers. Handle complex provider set up issues. Coordinate with various internal and external areas to resolve and complete analyses. Assist with par database for the research and termination of providers. Ability to interact with providers and network administrators at various professional levels. Train on any new systems applications. Prepare and forward to the Manager monthly and quarterly reports for the department.
INDEPENDENCE BLUE CROSS
Date: March 1998 – March 2000
Position: OPL Settlement Specialist
Department: Claims
Responsibilities: Acts as a liaison between claims processors, subscribers, providers, Legal Department, and outside counsel in developing subrogation files. This requires detailed investigations to develop the information necessary to decide if a file is subrogable or not. May involve discussions with police, other law enforcement officials, local and state government representatives, as well as the subscriber, their attorney and property and casualty insurers. This position requires knowledge of the current claims system and the ability to negotiate amicably with counsel to obtain settlement and explain the reasons for the acceptance or denial of claims and the payments made. ENVIRONMENTAL PROTECTION AGENCY (EPA)
Date: November 1997 – January 1998
Position: Paralegal
Responsibilities: Entering confidential information relating to files in the database within a precise time frame. Supervising the staff and attending weekly meetings with attorneys. EME USIM & COMPANY, Attorneys-at-Law
Date: July 1990 – May 1997
Position: Paralegal
Responsibilities: Drafting legal documents - Estate, Trusts and Wills, Divorce, Civil Pleadings, Criminal Complaints, Real Estate including Sales Agreements. Managing the office, interviewing clients, collecting attorney’s fee, filing pleadings in a timely manner, attending court.
3 P a g e
RESIDENT MAGISTRATE’S COURT/CRIMINAL COURT
Date: June 1986 - October 1990
Position: Clerk of the Courts
Responsibilities: Managing the office, prosecuting in court, signing bail bonds, assisting the public in the filing of claims and petitions and meeting with the Judge.
Education:
Date: Present Saint Leo University
Date: 1997 -1998 American Center for the Technical Arts and Sciences Date: 1990 - 1992 University of the West Indies
Date: 1984 - 1986 Meadowbrook High School – Advance Studies Date: 1979 - 1984 Meadowbrook High School - Diploma References: Available upon request.
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