Credentialing Manager Medical Billing

Samantha M. Celestine

Email: ******************@*****.*** Phone: 337-***-****

Special Skills * Excellent Customer Service * Computer Literate * Communication Skills *

* Leadership Skills * Problem Solving * Quick Study * Detail Oriented *

* Excellent Work Ethic * Typing (70 wpm) * Multi-Tasking Capabilities *

* Displays Professionalism * Promotes Team Work *

Software / Systems Used Athena * Centricity * Misys * MSOW Solutions * Salesforce * Workday

Work Experience

Memorial Hermann Physician Network Houston, Texas

System Credentialing Coordinator – April 2020 – Present

Responsible for facilitating the credentialing and re-credentialing process for providers at the Memorial Hermann Surgery Centers by attending board meetings, running reports, creating agendas, providing rosters and reviewing/processing provider applications in an accurate and timely manner; Completed thousands of NPDB Queries; Completed hundreds of processes to red flag providers who had past and present board actions via Texas Medical Board actions and Texas Medical Board HCE List Results;

Privia Health Gulf Coast Houston, Texas

Senior Credentialing Specialist - August 2019 – March 2020

Completed Texas Medicare and Medicaid enrollment applications; Coordinated managed care credentialing and initiated file changes for new providers in multiple payer markets; Assured compliance with all health plan requirements as related to the provider certification and credentialing; Managed and monitored activities of the department to ensure compliance with all policies/procedures and regulations; Reviewed and streamlined processes and workflows for the on-boarding department, using automation, where appropriate; Worked with technical staff to develop tools and procedures for auditing and reporting with the goal of streamlining credentialing processes and communicating with company and external stakeholders; Oversaw special projects requiring knowledge of delegated and non-delegated health plan requirements; Interacted with varied levels of management, physician office staff and physicians effectively to accomplish credentialing and various elements of implementation and launch; Maintained up-to-date data for each provider in credentialing databases and online systems; ensured timely renewal of licenses and certifications and in addition, the Credentialing and enrollment specialist is responsible for all audits to ensure that delegated credentialing entities are compliant; Maintained confidentiality of provider information; Assisted in managing the flow of information between the payers, contracted MSO facilities and Privia Medical Group; Coordinated and prepared reports; Recorded and tracked credentialing statistics; Assisted Revenue Cycle Team with analyzing accounts, updating account information, and clarifying coding errors by contacting payers;

Memorial Hermann Medical Group Houston, Texas

Medical Staff Services Coordinator - February 2017 – August 2019

Processed a high volume of provider applications and re-applications including initial mailing, review, and loading of data into system ensuring high quality standards are maintained. All in accordance with bylaws, rules, regulations and policies/procedures; Provided administrative support to Credentialing Manager, such as managing meeting agendas, taking minutes, etc.; Served as leader, department resource and provided guidance and expertise to credentialing specialists; Reviewed and implemented solutions to facilitate the credentialing process; Trained and oriented new employees. Provided mentorship and guidance to staff; Promoted individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; Supported department-based goals which contributed to the success of the organization; Served as preceptor, mentor and resource to less experienced staff; Other duties as assigned.

Lead Credentialing Specialist - October 2016 – January 2017

Obtained effective dates for a high volume of providers, including the loading of data into SharePoint; Ensured credentialing issues were documented and resolved, all in accordance with bylaws, rules, regulations and policies/procedures; Provided administrative support to Credentialing Manager, such as managing meeting agendas, taking minutes, etc.; Reviewed and implemented solutions to facilitate the credentialing process; Promoted individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; Supported department-based goals which contributed to the success of the organization; Other duties as assigned.

US Oncology/Texas Oncology Houston, Texas

Team Lead / Insurance Specialist - September 2013 – September 2016

Reviewed reports, identified denied claims, researched and resolved issues, performed detailed reconciliation of accounts, resubmitted claims to payers; Reviewed payment postings for accuracy and ensured account balances were current; Worked with staff to resolve payment and billing errors; Contacted third party payers to resolve payer issues and expedite claim processing while maximizing medical claim reimbursement; Adhered to confidentiality, state, federal, and HIPAA laws and guidelines with regards to patients’ records; Assisted with the interviewing process when considering new candidates; Assisted with training co-workers/new hires; Audited/Reviewed Accounts; Other duties as requested or assigned by management;

Memorial Hermann Medical Group Houston, Texas

Senior Billing Representative - April 2013 – August 2013

Analyzed accounts for errors, adjustments and credits and corrected entries when necessary. Updated account information accordingly; Communicated with other departments to clarify coding or charges needed to complete the billing process; Called insurance companies and/or patients to obtain missing or necessary information to complete the billing process; Assisted with correspondence related to patient accounts and bankruptcy notifications; Assisted with all other duties assigned by management;

Sugar Lakes Family Practice Sugar Land, Texas

Accounts Receivable / Billing / Credentialing Specialist - August 2012 – April 2013

Provided excellent service for both patients and insurance carriers while being courteous and friendly at all times; Posted insurance payments and patient payments; Answered patient questions concerning statements; Identified and recorded problems related to billing and collections, including charge entry, insurance verification, demographics, and posting of receipts; Maintained updated managed care / insurance fee schedules; Initiated follow up on identified EOB problems; Pulled information and processed appeals on insurance payments; Identified past due accounts and reviewed with the business manager; Communicated as needed to maximize reimbursement and minimize the AR; Processed all insurance requests that needed clinical information in a timely manner; Assisted in researching and identifying all insurance refunds; Resubmitted claims to insurance companies as needed for collection; Prepared daily deposits; Assisted front desk and check out when necessary; All other duties as assigned by management;

CHRISTUS Provider Network Houston, Texas

Revenue Cycle & Credentialing Specialist - August 2010 – July 2012

Completed Medicare and Medicaid enrollment applications for Texas and Louisiana; Coordinated managed care credentialing and initiated file changes for new providers in multiple payer markets; Served as administrator for billing system and assisted practice locations with credentialing and billing questions; Updated NPPES files, credentialing database and billing system with current provider numbers and practice information; Monitored accounts receivable to maintain appropriate levels and reviewed payments to maximize reimbursement; Interacted with patients, insurance carriers, billing departments and practice personnel concerning patient accounts; Assured all appropriate licensure, certifications and/or accreditations were secured and maintained according to policy to include all credentialing issues related to the service; Performed all functions in a courteous and professional manner.

Advanced Billing Solutions, Inc. / Superior Revenue Management Lafayette, Louisiana

Billing Supervisor – August 01, 2008 – July 31, 2010

Billing Specialist – January 01, 2008 – July 31, 2008

Entered and balanced daily charges for occupational therapy clinics and physical therapy clinics; Called on claims that haven’t been paid or claims that were paid incorrectly; Sent appeal letters and reconsideration letters; Made collection calls and sent collection letters to patients; Made collection calls to insurance carriers; Set up payment arrangements; Handled billing inquiries and requests from clinics and patients; Submitted monthly attorney statements and quarterly discounts as well as lien letters; Organized monthly charges and payments received from facilities by creating spreadsheets to assist with monthly deposits and month-end reporting; Ran reports showing physician referrals for each physical therapy clinic; Performed other duties as requested by director of billing;

Credentialing / Billing Specialist - September 2007 – December 31, 2007

Filled out contracts and applications, as well as other forms; Verified information on forms submitted by occupational therapists, physical therapists and speech therapists; Answered questions from medical personnel regarding contracts, enrollment forms and applications (ex. Medicare, Medicaid, Private Insurances, Liability/Malpractice Insurance, Bank Accounts, etc.); Mailed contracts and applications to medical personnel and medical billing companies; Handled billing inquiries; Handled requests from clinics regarding contracts, billing and credentialing;

Billing Specialist - February 2007 - September 2007

Entered charges for occupational therapy clinics, physical therapy clinics and speech therapy clinics; Called on claims that haven’t been paid or claims that were paid incorrectly; Sent appeal letters and reconsideration letters; Made collection calls to patients; Set up payment arrangements; Handled billing inquiries and requests from clinics and patients;

American Family Life Assurance of Columbus (AFLAC) Louisiana

Independent Sales Associate – August 2006 - February 2007

Assisted businesses and individuals with the sale and service of supplemental insurance policies

The Schumacher Group Lafayette, Louisiana

Quality Control Specialist - May 2005 - June 2006

Data Entry, Prepped, Scanned & Verified clarity of medical charts; verified that all components of these charts were legible.

Provider Enrollment Specialist II - May 2003 - May 2005

Filled out application forms and verified information on forms submitted by physicians, physician assistants and nurse practitioners; Answered questions from medical personnel regarding enrollment forms and applications (ex. Medicare, Medicaid, Liability Insurance, Bank Accounts, City Business Licenses); Mailed applications to medical personnel and medical billing companies; Handled physician correspondence regarding claims, enrollment forms and applications; Responded to written requests, as well as telephone requests, for new physician enrollments and current physician re-enrollments.

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