Customer service Manager
Resume:
Chelsea West
St. Louis, MO *****
********@*****.***
Work Experience
Credentialing Manager
OSP
February 2022 to Present
• Individual manages 47 Doctors, 36 offices in 10 different states
• oversee credentialing/privileging program to assure credentialing processes are in compliance with professional standards and state/federal regulatory requirements
• Created an electronic way to store applications for all the payers/ providers
• Researched and organized all carriers & network of payer’s locations use
• Provides referral, authorization, medical review, and case management services for members covered through Managed Behavioral Health
• Assists with quality improvement program and the integration of QI processes into Medical Management as assigned
• Complete all Licensure and Licensing for providers and their locations
• Track license and certification expirations to confirm renewals
• Enroll new doctors into applicable insurance companies
• Ensure all OSP doctors are credentialed with all applicable insurance companies
• Work with providers/ office managers to compile all the information in our credentialing
• Maintain accurate information for all providers, updating their credentials as necessary
• Creating reports, analyzing data, identifying lost revenue and implement strategies to minimize losses.
• Confirm the education and work history of our providers
• Managing intake process improvements
• Assign them portal information for the new system I am Updating so that all information can be in one system.
• Maintaining a database of employee certifications and renewal dates, confirming that employee credentials match the requirements of their job, and helping employees renew their credentials on time by finding test dates and locations.
Credentialing Specialist
AEG Vision - Alton, IL
November 2020 to January 2022
• Complete enrollment/credentialing and re-credentialing applications
• Maintain a detailed log of all pending and completed work
• Communicate the results and status of the applications to physicians, payers, managers, and co- workers.
• Assure accurate and timely data collection and verification of information critical to the credentialing process, particularly for new providers, locations, and practices.
• Analyze doctor files for completeness, accuracy, consistency, etc.
• Serve as point of contact regarding the status of applications for all credentialed doctors.
• Maintenance of physician enrollment and CAQH profiles
• Documentation within enrollment database
• Coordinate signatures
• Payer processing and research
• Involves extensive phone work and internet.
• Research and resolve claim issues related to physician enrollment. Manager
Taco Bell - Saint Louis County, MO
May 2017 to December 2021
• Assist with store merchandising by facilitating and/or participating in staging, stocking and storage of merchandise; ensuring that merchandise is presented according to established practices and store manager direction; and properly utilizing merchandise fixtures, signing and pricing of merchandise.
• Assist in all aspects of inventory management (including proper execution of damages, markdowns, register scanning, paperwork and facility controls); prepare and conduct inventories.
• Follow prescribed ordering practices to ensure the meeting or exceeding of in-stock targets.
• Provide superior customer service leadership.
• Act as a role model by following company procedures and policies as outlined in the employee handbook, SOP manual and company communications.
• Participate in store opening and closing activities.
• Assist in ensuring the financial integrity of the store through strict cashier accountability, key control and adherence to company security practices and cash control procedures.
• Assist in the maintenance of clean, well-stocked stores; provide a safe environment for customers and employees.
• Operate store in store manager’s absence.
• Review operating statements to identify business trends (including sales, labor, profitability, and inventory turn), expense control opportunities, potential shrink, and errors.
• Complete all paperwork and documentation according to guidelines and deadlines. Provider enrollment Rep/ Application Analyst Associate Cognizant Technology Solutions - Earth City, MO
September 2017 to October 2020
Assisting new clients through the implementation and on-boarding process while owning the client experience to ensure client satisfaction. Troubleshooting, testing and resolving client issues regarding their enrollment. Maintaining and follow up on open customer reported questions and problems. Ensure all enrollments, set up and testing has been completed prior to the predetermined go live date. Verifying correct enrollment numbers and mailing completed agreements to the proper Health Insurance payer/ vendor for approval. Incumbent will develop, document and implement plans, which will provide the appropriate resources to address social, physical, mental, emotional, spiritual, and supportive needs. Daily follow ups with clients, Insurance payers and vendors to insure receipt of forms and approval by payers/ vendors prior to submission by client. Troubleshooting, diagnosing and resolving technical issues with high First Contact Resolution rates (FCR). Following established policies, procedures, processes and workflows to ensure appropriate resolution of issues of moderate scope. Documenting all issues, comments and resolutions in appropriate software system applications Provider Services Associate I
Magellan Health Services - Maryland Heights, MO
August 2016 to September 2017
Actively listens and probes callers in a professional and timely manner to process authorizations and/ or other customer service requests working towards first call resolution. Recognizes and develops relationships with provider groups through repeat calls, and recognizes provider sensitivities for different health plans. Assume responsibility for self-development and career progression. Insurance Coverage Representative
Express Scripts - St. Louis, MO
May 2014 to July 2016
Handle up to 80 inbound calls and written inquiries from pharmacists and doctors. Follows-up with insurance companies to ensure prompt and accurate payments. Screening and reviewing requests based on benefit plan coverage and accuracy.
Facilitate resolution of drug coverage issues and proactively address research, insurance appeals, and direct claims and resolve issues. Work closely with Insurance Payer Representatives to identify payer trends and internal processing challenges. Assists with departmental appeal's functions during vacations and absences also special projects and other duties assigned. Quality Analyst
Convergys's - Hazelwood, MO
February 2013 to April 2014
Uses logic and analytical methods to solve difficult problems with effective solutions; appropriately utilizes resources available to them to resolve issues such as test data and environment problems; has excellent objective analysis skills; provides next steps, recommendations and/or solutions. Practices continuous learning, acquiring new skills and knowledge frequently; keeps abreast of new technologies, processes and/or products; determines when and how to apply them using methodical, thorough, and accurate approach. Practices attentive and active listening; speaks clearly in meetings to get point across; has the patience to hear people out; can accurately restate the opinions of others even when he/she disagrees.
Home Health Aide
Thomas Business Enterprises - St. Louis, MO
November 2011 to February 2013
Performs personal care activities that assist the patient with activities of daily living. Administer Medications ordinarily self- administered that have been specifically ordered by the physician. Prepares meals and snacks according to dietary plans.
Performs patient-specific activities that are taught by a nurse such as physical therapy. Field Supervisor
Byers Cleaning - St. Louis, MO
October 2010 to November 2012
Recruit, train, motivate and oversee technicians on duty, and assist with work overflow. Coordinate with managers on daily responsibilities and any specific requirements requested. Account for all jobs and verify all daily duties have been met.
Coordinate with dispatch to ensure all jobs are within the appropriate time-frame. Multi-task in fast paced environment, setting, production, budgeting, efficiently solving issues with customers. Education
High school diploma or GED
Skills
• ICD
• Hippa
• Health Insurance
• ICD-10
• Medical Billing
• CPT Coding
• ICD-9
• Medical Records
• Medical Coding
• EMR Systems
• Analysis Skills
• Epic
• Physiology Knowledge
• Medical Office Experience
• Software Troubleshooting
• Operating Systems
• Insurance Verification
• CAQH
• Contracts
• Microsoft Access
• NCQA standards
• Database administration
• Accounts receivable
• Medical terminology
• Typing
• Managed care
• HCPCS
• Medicare
• Employee Orientation
• Anatomy Knowledge
• Databases
• Help Desk
• Transcription
• Quality Assurance
• SharePoint
• Talent acquisition
• Human resources
• Salesforce
• Behavioral health (4 years)
• Auditing
• Revenue cycle management (3 years)
Certifications and Licenses
Drivers License Home Health Aide
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