Customer Service Credentialing Specialist

Professional Experience

Education

DORLINE MARIE TAYLOR

615-***-**** **********@*******.*** 333 Remington Avenue, Gallatin, TN 37066 Seasoned Credentialing Specialist and Claims Resolution Analyst with over 20 years of experience in managed care, offering a deep understanding of provider credentialing, claims processing, and issue resolution. Proven track record of applying strategic thinking and analytical skills to streamline operations, improve provider satisfaction, and ensure compliance with state and federal regulations. Recognized for exceptional problem-solving abilities, customer service excellence, and leadership skills, consistently driving efficiency across multiple operational areas. Adept in using various healthcare software systems to ensure accurate and timely results, while collaborating effectively with cross-functional teams. Area of Expertise

Provider Credentialing Claims Issue Resolution Healthcare Compliance System Analysis and Testing Cross-Functional Collaboration Strategic Process Improvement Customer Relationship Management Regulatory Adherence Leadership and Mentoring Data-Driven Decision Making

AMERIGROUP, CREDENTIALING SPECIALIST SENIOR 2016 - 2023 Conducted formal reviews of contracts and credentialing documents, ensuring compliance with regulatory and organizational standards.

Built comprehensive file documentation and prepared cases for review by the credentialing committee. Evaluated provider applications based on established criteria, identifying deficiencies and recommending solutions. Communicated status updates and resolution outcomes to providers, fostering transparent communication. Developed and distributed provider education and training materials to enhance process understanding. Conducted research on pended and probated applications, identifying and resolving discrepancies effectively. AMERIGROUP, CLAIMS RESOLUTION ANALYST SENIOR 2014 - 2016 Investigated complex claims issues, coordinating resolution efforts across multiple operational areas. Led reviews of state and federal complaints related to claims, ensuring compliance and resolution. Analyzed system processes and collaborated with programming teams to design and implement updates. Conducted user acceptance testing to validate system changes, ensuring new requirements were met. Acted as a liaison between operational teams and end-users, addressing software-related queries and issues. AMERIGROUP, CLAIMS RESOLUTION ANALYST 2010 - 2014

Investigated and resolved claim discrepancies, working closely with providers and health plans. Performed user acceptance testing on contract system updates to ensure proper functionality. Collaborated with stakeholders to address and resolve complex claims-related issues. Consistently met deadlines for resolving high-priority claims, improving overall operational efficiency. HEALTHSPRING, SENIOR CLAIMS PROCESSOR 2006 - 2010

Utilized advanced analytical skills to identify and resolve claims issues, ensuring customer satisfaction. Processed claims across various services, including medical, ambulance, vision, and home infusion claims. Coordinated benefits with primary insurance providers to ensure accurate payment and reconciliation. Assisted in training new hires on claims processing procedures and best practices. Glencliff Comprehensive High School Nashville, Tennessee High School Diploma

Professional Skills

Microsoft Word, Excel, Outlook Analytical Thinking Customer Service Excellence Facets Software CAQH (Council for Affordable Quality Healthcare) Problem-Solving Skills Leadership and Team Building Macess (Workflow Management Software) Cactus (Credentialing Software) Process Optimization