Credentialing Coordinator Medical Billing
Resume:
Cheryl O’Brien
** ****** ******, *******, ** *2382
Email: ***********@*****.***
Summary
Highly motivated professional with 25 year’s experience in the healthcare industry. Strong verbal and written skills. Comfortable interacting with all levels of personnel. Adept at multitasking to achieve individual and team goals. Customer focused both internally and externally. Committed to quality and excellence. Proficient with Word, Excel, Outlook.
Employment History
Steward – Credentialing Verification Office, Brighton, MA 2020 – Present Credentialing Coordinator
• Responsible for credentialing re-appointment applications for hospital privileges All Steward sites
• Work closely with provider during credentialing process in order to maintain and receive all required documentation
• Ensure all licensing, certification & malpractice documentation are up to date and on file in Verity
• Update Verity system with updated provider demographics
• Ensure all Licensing, certification, malpractice & hospital affiliations are verified Steward – Carney Hospital, Dorchester, MA 2016 – 2020 Credentialing Coordinator
• Responsible for credentialing initial & re-appointment applications for hospital privileges
• Work closely with provider during credentialing process in order to maintain and receive all required documentation
• Work with Employee Health to ensure all providers have passed employee clearance
• Ensure all licensing, certification & malpractice documentation are up to date and on file in CACTUS
• Update CACTUS system with updated provider demographics
• Ensure all Licensing, certification, malpractice & hospital affiliations are verified
• Present re-appointment & initial applications to the CCM, MEC & PCAC committees for approval of privileges
• Update document retention website with current privileges for newly appointed and re-appointed providers
• Maintain provider files
Plexus Management Group, Inc, Westwood, MA 2012 – 2016 Provider Enrollment Specialist:
• Responsible for enrolling & re-enrolling providers with various health plans in KS, MA, MD, MD, RI & WI.
• Work closely with clients during enrollment process in order to maintain and receive all required documentation.
• Assist manager with contract negotiations, calling insurance companies for process and procedures
• Create and maintain provider files within the CAQH website.
• Register new providers with NPI.
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• Work Task queues on outstanding claims.
• Call various insurance payers to follow up on outstanding claims.
• Call various health plans to verify patient eligibility.
• Notify appropriate personnel if claim information missing or invalid to ensure claim resolution with maximum reimbursement
• Re-bill claims denied in error due to provider eligibility.
• Research denied claims and submit appeals when needed.
• Work with insurance company / provider representatives during the enrollment process of new providers NHIC, Corp. a division of HP, formally known as EDS, Hingham, MA. 1997 - 2011 Blue Cross / Blue Shield of MA, Boston, MA (Transitioned to EDS). 1988 - 1997 Information Security Analyst: 2004 - 2011
• Responsible for managing Medicare claim systems and building access requests.
• Provide varying levels of administrative support to the Security team.
• Test, validate, monitor and process system security program activities.
• Identify, implement and report safeguards to mitigate security weaknesses.
• Work with web design team to create and test company websites to streamline requests and processes. Technical Support Analyst 2000 - 2004
• Trained, tested and assisted with the implementation of Medicare Provider Enrollment Chain Ownership System (PECOS).
• Manage difficult projects resulting from new regulations as well as system changes.
• Identify and resolve problems dealing with systems and reporting logic.
• Analyze and interpret technical procedures and government regulations.
• Developed desk level procedures related to technical support functions. Provider Certification Associate: 1994 - 2000
• Responsible for credentialing providers for both Medicare and Blue Cross managed care plans.
• Maintained inventory reports and provider enrollment files.
• Developed provider application manual and trained new associates.
• Assisted supervisor with daily functions.
Provider Services Associate: 1988 - 1994
• Handled provider calls for patient eligibility and questions on claims adjudication.
• Research complex issues for management pertaining to provider payments and denials.
• Adjusted medical billing claims due to over/under payment.
• Assisted training instructor on new claims system and providers on UB-92 claim form. Education:
• American Career Institute, Braintree, MA. Certificate in PC Network Design w/ Security. 2011 - 2012
• Clark University, Braintree, MA. Master certificate in Medical Coding and Billing. 2004 – 2007
References
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• Susan Smith – Plexus Management Group, LLC – Credentialing Assistant Provider Enrollment Phone # 781-***-****
• Jessica Harylciw – Former Team Lead Plexus Management Group, LLC Phone # 508-***-****
• Tricia Gallagher – Former NHIC, Corp – Business Analyst Phone # 781-***-****
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