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Credentialing Assistant Lead

Miami, FL
September 27, 2023

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Norma Flores

** ** ***** ******

North Miami, FL 33168



My objective is to work in a well-established company where I can grow as a professional. A company that will challenge my experience and let me expand my abilities, skills and knowledge. At the same time, make a comfortable working environment for my co-workers and myself.

Employment History

Credentialing Assistant/Lead

5/2012 to Present Compass Health Systems, PA North Miami, FL

Manage the credentialing/re-credentialing for 75+ providers in our groups in Florida, South Carolina, Colorado, Pennsylvania, Tennessee and formerly Texas, Nevada, and North Carolina

Complete and submit initial and re-appointment applications for providers to participate with multiple MCO’s/HMO’s and Hospitals/Clinics including but not limited to Medicaid, Medicare, Railroad Medicare in all 6 states

Assist providers on obtaining/updating their DEA Registration

Assist providers on obtaining/updating a state license (minimal task but done when needed)

Maintain credentialing software up to date (CredentialMyDoc)

Promptly respond to requests made by MCO’s/HMO’s

Assist providers on applying/updating their NPI record

Set up providers for Level II Background Screening online (AHCA portal)

Utilize Availity to apply to some networks or maintain groups information

Maintain a constant follow up on all applications submitted

Maintain a constant follow up on about to expire documents

Create, populate and maintain CAQH for each provider

Request additional/follow-up/missing information from our providers to maintain their files up to date and in compliance

Review Contracts/Negotiate fee schedules (minimal task)

Request Addendums to add additional products when available

Provide network participation updates to all of our staff on a weekly basis

Add/Delete/Change practice locations for our providers with the different HMO’s/MCO’s to maintain their files up to date

Link providers to the proper location with Medicaid and Medicare

Primary Source Verifications thru the EPLS, OIG, ABMS, AOA, ANCC, National Student Clearinghouse, ECFMG, NPDB, NPI, Medicare

Query the EPLS and FL DOH Administrative Actions database on a monthly basis.

Clear discrepancies found on our verifications and our providers credentialing applications.

Train new employees

Conduct interviews for candidates to join our Department

Distribute and assign work load between my peers

Prioritize and Organize work load

Multi-task to meet deadlines

Norma Flores Page 2


Credentialing Specialist

10/2010 – 5/2012 Medica HealthCare Plans, Coral Gables, FL

Process Practitioners credentialing and re-credentialing applications

Process Organization credentialing and re-credentialing applications

Communicate with providers to request additional/missing information

Maintain Licenses, DEA’s, Professional Liability, Board Certifications, ACR Certifications, AHCA licenses and Accreditations up to date

Verify Medicaid and Medicare numbers for participation and eligibility

Request and review Credentialing Policy and Procedures for applying or re- applying Organizations to assure compliance with CMS, State and Federal Rules and Regulations

Request Site Reviews

Perform Data Entry on approved files

Mail out letters for approved providers

Attend the Credentialing Committee once a month and review processed files with the Committee

Immediately notify the Credentialing Director and Manager of any information that should be reported to the appropriate governing bodies

Meet daily with Network Development and accept applications

Run primary source queries for licenses, DEA’s, EPLS, OIG, NPI, Board Certifications, AMA, AOA, ECFMG, Faimer, AHCA licenses, ACR Accreditations,, NPDB/HIPDB, FSMB, JCAHO, AAAHC, ABC, etc..

Meet deadlines


Maintain all information confidential

Customer Care- Marketing

5/2010 – 8/2010 Continucare Corporation, Hialeah, FL

Initiate/receive telephone calls to or from prospects promoting the advantages of receiving their medical care through Continucare Medical Centers

Complete appointment forms for representatives to visit interested prospect

Track and report daily leads that represented a business opportunity to the Senior Marketing Specialist and the Manager of Marketing Services

Follow up with every lead (call) that represented a business opportunity.

Worked with Strata Dial software

Receptionist/Front Desk

4/2010 – 4/2010 South Miami OB/GYN Assoc/ProMed Personnel, Miami, FL

Answer multi-line phone calls

Sign in patients and verify insurance information was correct

Provide patients with Patient Information forms and assure it was fully completed and signed

Have charts ready for physicians

Worked with Intergy software

Norma Flores Page 3

4/2007 – 4/2010

Gap on work history due to health problems

Credentialing Clerk/Assistant

2/2005 – 4/2007 Preferred Medical Plan, Coral Gables, FL

Processed Credentialing and Re-Credentialing applications

Processed Organization credentialing and re-credentialing applications

Communicate with providers to request additional/missing information

Maintain Licenses, DEA’s, Professional Liability, up to date

Request Site Reviews

Perform Data Entry on approved files

Meet daily with Contracting and accept applications

Run primary source queries for licenses, DEA’s, EPLS, OIG, Board Certifications, AMA, AOA, AHCA licenses, NPDB/HIPDB, JCAHO, AAAHC

Meet deadlines

Performed Audits for Delegated Networks


Maintain all information confidential


2004 The English Center, Miami, FL


1998 Miami Technical Institute Miami, FL

Computer and Business Administration

Other Experience

Bilingual – Read and Write English/Spanish

Typing 40wpm, Microsoft Outlook, Excel, Word

Volunteer for Disaster Reliefs or Construction projects References

Noralys Mallo 305-***-****

Paola Ley 305-***-****

Ismary Pichardo786-325-1793

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