Credentialing Assistant Lead
Resume:
Norma Flores
North Miami, FL 33168
adzzp9@r.postjobfree.com
Objective
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
File/Fax/Scan/Email
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, Medicare.gov, NPDB/HIPDB, FSMB, JCAHO, AAAHC, ABC, etc..
Meet deadlines
File
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
File
Maintain all information confidential
Education
2004 The English Center, Miami, FL
GED
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
Contact this candidate