Sr Credentialing Specialist

SYLVIA BISHOP GALLEGOS

adxjfh@r.postjobfree.com / 210-***-****

Senior Credentialing Coordinator-WellMed- San Antonio, Tx 78249 March 2022- to Present. Work initial and re-creds credentialing all new providers. Track and obtain demographic and contract documentation in a timely fashion, to include phone outreach to external customers. Maintain and report on the Health Plan(s) compliance with contract submission rules and exception. Support the contract submission process to ensure confirmation, provide support and ensure that appropriate internal controls are established to account for and secure hard copy or scanned images of contracts. (Emptoris, CAQH, NPPES, NSC, BC, DEA, Nurse system. PSV, SITE VISITS,PDF, PRAC local state license Credentialing rpt PDM status inquiry, Portico, OIG, DEA, Background check). Maintain and update on a routine basis the contract organization’s databases. Coordinate the data verification process for contracted providers. Update contract organization’s. databases, as necessary. Interface with the configuration, credentialing and provider data management staff to ensure all Health Plan data systems are congruent. Specialist to ensure that medical staff members' maintain current credentials and licenses to work legally in their field or specialty.

Contracts Credentialing Coordinator - Superior Healthcare Plan- San Antonio, TX 78230 - January 2016 to Present Work in preparing credentials for new providers and re-credentialing providers. Assist with the contract submission process and the auditing of provider information systems for consistency and best practices in Provider set up. Track and obtain demographic and contract documentation in a timely fashion, to include phone outreach to external customers. Maintain and report on the Health Plan(s) compliance with contract submission rules and exception. Support the contract submission process to ensure confirmation, provide support and ensure that appropriate internal controls are established to account for and secure hard copy or scanned images of contracts. (Emptoris, CAQH, NPPES, PRAC Credentialing rpt PDM status inquiry, Portico, OIG, DEA, Background check). Maintain and update on a routine basis the contract organization’s databases. Coordinate the data verification process for contracted providers. Update contract organization’s databases, as necessary. Interface with the configuration, credentialing and provider data management staff to ensure all Health Plan data systems are congruent.

Accounts Receivables Manager-Providers - Deer Oaks Behavioral, Psychiatric Facility -- December 2013 to November

2015 San Antonio, TX 78224 Manager Knowledge of Federal and state agency rulings regarding billing and reimbursement, and coding procedures contracted with Long Term Nursing Homes throughout the United States to service our patients. Responsible for all aspects of the collections, familiar with Medicare, Medicaid, Commercial, TX VETS. 25 States. Managing 25 employees to include 1 Correspondence Supervisor, 1 Billing Supervisor, 1 Posting Supervisor. Position involved electronic billing thru the Allscripts software. Participate in the training of staff. Collections department consist of clearing rejected claims, corrections Billing-validating claims electronically, paper claims, and secondary billing, appeals, authorizations. Insurance followup including. adjustments for end of month close out procedures. Interview, hired, evaluated, and counseled staff.

Care Minders Home Care, Home Health Care - San Antonio, TX - May 2013 to December 2013 Business Office Manager Responsible for all Admitting, Scheduling, Outreach & Marketing, including credentialing, verifications, demographics, precertification authorizations, referrals, coordination of benefits to ensure reimbursements. Interviews, hired, evaluated, and counseled staff. • Processed payroll. Orientation of staff, Human Resources for this company Health Wyse, MobileWyse, CallWyse Allscripts.

Leading Edge Temporaries - Assignments at Cancer Practice - San Antonio, TX - February 2013 to May 2013 Billing

Registration Manager - Southwest General Hospital - San Antonio, TX - November 2009 to May 2012 • Managed

Central Admitting, ER, Scheduling, outside clinic's and PBX areas. Managed activities of 45 personnel in all Registration areas. Supervised team leaders and Emergency Room Supervisor. Scheduling included appointments for MRI's, Cat-Scans, X-rays, etc. This included verifications, precertification authorizations, referrals, coordination of benefits, Interviewed, hired, evaluated, trained and hired. Developed policies effectively managed.

Carelink Outreach Manager University Health Systems - San Antonio, TX - May 2006 to November 2009. Outreach and managed 2 Clinics 10 employees to enroll the Bexar County residents for under priviledge community.

Manager/Outpatient Registration Clinics - University Health Systems - San Antonio, TX - September 2004 to April 2006 Managed clinic registration. Directed daily operations included supervising the registration of 15+ staff consisting of 11-13 clinics. Implemented structure of the registration, Commercial, Managed Care, replacements, Medicare, & Medicaid, pre-certification authorizations, referrals, coordination of benefits to ensure reimbursements from insurance and more accurate collections at time of registration. Scheduling, to include for MRI's, Cat-Scans, X-rays, endoscopy, wound care, vascular, walkin ER clinic, neuro surgery, cardiology etc. Also strongly emphasized structured notes in the system. The creation of procedures of the Vascular & Neuro Surgery clinics. The wait time for patients. Maintained all necessary websites. Insured hold bills were cleared on a daily basis for release of claims. Highly emphasized on collecting deductibles, co-pays, noncovered procedures.

Customer Service Call Center/Posting Manager – University Health System - October 2002 to August 2004 Structured our Posting & Customer Service departments Credited for bringing the turn-around time of posting from 8 weeks to 24-48 hours within 1 month of working to accomplish this goal. Maintained and implemented the IDX module system for patient accounts receivables for automated use to include outside collections agencies maintaining the automatic daily bank deposits from different payers. Medicare, TMHP, Insurance companies Process including credit card chargebacks as per protocol. Reports maintained for insurance payments adjustments, and write-offs. Managed the underpayments and overpayments for payers and patients. Managed the Customer Service call center for UHS in implementing structure to this area, responding to all billing inquires, EOB translations and statement follow-up reimbursements. Monitored old Medipac patient accounts system. Training of all staff, maintaining all employee records, PTO, LWOP, absenteeism, etc. Liaison to all outside Collections agencies

Billing / Customer Service Manager -University Health System - San Antonio, TX - July 1999 to October 2002

Commercial Collections department, Billing/Collections - Customer Service Manager, tmanaged all aspects of the Hospital Billing to contribute to Accounts Receivables and monthly goals. Managed 45+ employees to include 3 Team Leaders •

Handled all electronic billing thru the SSI software. Participated in the training of all Billing staff, primary liaison with SSI. Billing department consisted of clearing hold bills, validating claims electronically, paper claims, and secondary billing, claim rejections, appeals, and EOB request. Maintained coding requirements as per ICD9, CPT4, HCPCS. Medicare, Medicaid, Commercial, TX Veterans Affairs, Workers Compensation, HMO, PPO, Contract billing. Yearly SSI conferences for billing education and updates. Communicated with Medical Records and the Registration departments to resolve hold bills to release claims on a daily basis. Insurance follow-up including appeals. Performed end of month close out and procedures Handled productivity for 15 Billing staff, managed the collection area (Medicare, Medicaid, & Commercial) • Handled the Customer Service call center responding to all billing inquires, statement research as needed.

EDUCATION

Robert E. Lee High School - San Antonio, TX August 1973 to May 1977

San Antonio Community College 1 year

Equipment/Experience Policies/Procedures Charity Process Registration HIPAA Compliant ICD-9/CPT Coding Type 65 wpm Revenue Operations Cost control AS400, IDX, STAR Ex cel/Word Medical Terminology Insurance Verifications 10-Key by touch. Billing/Accounts Receivables Posting/electronic Call Center Behavioral Billing Admin Outreach Education ILE Scanner (electronic MR) PHS (Physician Health Scheduling) New Wave SSI CERNER (EMR) Medisoft (EMR & Billing)

Medipac software Mckesson EMR. Experience

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