Tiffany Rivers

Temple Terrace, FL

SUMMARY OF QUALIFICATIONS:

• Accomplished healthcare professional with 10+ years’ experience assisting, credentialing, and coordinating medical services for private and cooperate offices • Tracked and audited new contracts through Salesforce and Apex • Focused and dedicated to delivering high quality service to patient’s providers, and their affiliates • Knowledgeable in Medicare and Medicaid • Proficient with Microsoft Office Suite (Word, Excel, Outlook, PowerPoint)

PROFESSIONAL EXPERIENCE: ***currently working as a Behavioral Health Provider Services as Administrative Support at Humana – January 2022 - contract ending this month HealthFirst via Kolter Solutions Provider Credentialing Specialist – August 2021– January 2022

• Reviewed new applications and supporting documents in a virtual environment and apply policy and criteria required for credentialing processing • Contacted hospitals, licensing agencies, malpractice carriers, and medical schools to obtain credentialing verifications • Reviewed malpractice history, regulatory and disciplinary action reports issued by state and federal agencies invoking appropriate processes as defined in policies and procedures • Reviewed the CAQH system and download applications or supplemental documents as appropriate • Performed outreach to providers and facilities via phone calls and fax/email correspondence • Demonstrated knowledge of credentialing regulatory and accreditation requirements (NCQA, CMS, Medicaid, etc.) Quest Diagnostic – Tampa, FL Sept 2019 – Sept 2021 Sales Support Coordinator

• Receive requests from sales representatives to speak to clients • Set up new accounts • Run credentials and send to providers • Update and modify client demographics • Add/remove providers that are no longer using the clients’ account

Quest Diagnostics – Tampa, FL Sept 2019 – Aug 2020 HR Service Center Representative (contract)

• Manage support requests that can come through a range of networks, such as email, chat, and telephone from company Employees, Candidates, and Contingent workers • Utilize a ticket from ticket management software in order to report a specific issue, present status and other important data • Presents status updates, and handles tickets, which have a unique identifier, for users in the self-service intranet, updates requirements, and look up the position of requests • Accountable for gathering information through a client conversation, log on to support tools, and additional support staff (service resources) if needed

Coast Dental and Orthodontics – Tampa, FL Mar 2019 – Jul 2019 Senior Credentialing Specialist

(Contract)

• Reviewed new applications and supporting documents in a virtual environment and apply policy and criteria required for credentialing processing • Contacted hospitals, licensing agencies, malpractice carriers, and medical schools to obtain credentialing verifications • Reviewed malpractice history, regulatory and disciplinary action reports issued by state and federal agencies invoking appropriate processes as defined in policies and procedures • Reviewed the CAQH system and download applications or supplemental documents as appropriate • Performed outreach to providers and facilities via phone calls and fax/email correspondence • Demonstrated knowledge of credentialing regulatory and accreditation requirements (NCQA, CMS, Medicaid, etc.) WellCare Health Plans – Tampa, FL Jun 2018 – Jan 2019 & Provider Credentialing Specialist (Contract) May 2016 – Nov 2016

• Responsible for recording, analyzing, organizing, storing and maintaining incoming documents and information from HR and provider offices • Preliminary credentials verification upon receipt of credentialing or re-credentialing applications and accompanying documentation • Performed primary and secondary source verifications every 3 years for both Par and Non Par Providers and their healthcare affiliates • Prepared for and attends Credentials Committee Meeting queries necessary sources to verify information on applications • Data entry into credentialing database as needed including CAQH, Omni flow, Cactus and Salesforce • Supported the Provider Relations Field Representative to achieve department goals • Supported the Provider Relations Field Reps to resolve claims and payment issues • Reviewed and processed incoming and outgoing paperwork including directory updates provider credentialing applications, contract maintenance forms and other related forms • Tracked new contracts through Salesforce • Audited configuration loads on new contracts • Provided office, project management, provider recruitment and data analysis support Envolve Benefit Options – Tampa, FL Jan 2018 – Jun 2018 Credentialing Specialist I (Contract)

• Maintained and update database for both practitioners • Verified professional dental and medical licenses (IE DEA, CLIA, DDS, CRNA, DMD), board certifications • Performed primary and secondary source verifications of credentials according to departmental policy • Served as the subject matter expert for activities related to credentialing in over 23 various markets • Resolved practitioner concerns in a timely manner • Efficiently credentialed all initial and re-credential applicants in a timely fashion • Worked with provider relations staff to ensure follow up when provider's applications are incomplete • Investigated and resolve complex credentialing issues • Credentialed 5-7 provider on a daily basis, 25 providers per week

Cigna HealthSpring – Tampa, FL Jul 2017 – Jan 2018 Provider Data Management Analyst (contrract)

• Responsible for completing the daily excel spreadsheets of provider's claims and contract data to be reviewed and entered into QNXT system • Ensured that all demographics and contract dates are accurate according to NPI Registry-tracks (claim image), and Cigna resource page • Entered/uploaded in a timely manner Provider Data and contracts ensuring that the quality and production standards are met daily • Responsible for checking and updating HCFA 1500 and Ancillary Claims for claims errors 221

• Verified Sponsors, programs, PAR and NON-PAR providers, and contracts are entered into system accurately

Kepro Medicare Appeals – Tampa, FL Jan 2017 – Jul 2017 Customer Review Specialist (Contract)

• Logged, tracked, and processed health service appeals. • Served as a liaison in corresponding and communicating with providers and members or members' representatives as needed during appeal processing • Interacted with other departments including Customer Service, Claims, Provider Relations and Pharmacy to resolve member and provider appeals • Conducted general appeal research and filing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of case, documentation of the appeal resolution and sending completed case files to external review organizations as required by regulatory guidelines • Maintained all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database • Developed and presents ideas for performance and process management improvement within the department

Dental Staffing Solutions – Tampa, FL Jun 2009 – Jan 2016 - Patient Care Coordinator

• Oversaw workflow at front desk to ensure the smooth flow of patients and information • Greeted patients and checking in patients and gathering accurate information to schedule follow-up appointments • Collected co-pays • Verified patient's insurance prior to scheduled appointment • Obtained prior authorizations for all dental insurance procedures and record information quickly and accurately • Assisted patients with completion of dental history, consents, and financial forms • Coordinated financial payment plans and keeping timely and accurate records • Ability to determine patient eligibility

EDUCATION:

Associate in Dentistry Sanford Brown – Tampa, FL Graduated 2007 HS Diploma - Tampa Bay Technical High School – Tampa, FL Graduated 2001