Microsoft Office Credentialing Specialist

SYLVIA BISHOP GALLEGOS

*************@*****.*** 210-***-****

Credentialing Specialist- Texas Children's Health Plan August 2023 to May 2024.

Strong knowledge of credentialing processes, regulatory requirements, and accreditation standards. Prepare and maintain reports of credentialing and re-credentialing activities for Providers and also Facilities.

Focus on the detailed verification of healthcare professionals' credentials, licenses, certifications, maintain

licensing, credentials and insurance records on updated state and federal regulations and policies.

Attention to detail, and good communication skills. CRM software.

Run sanction checks, as required Credential MD, NP, PA, DT, PT, OT, LCSW, LPC, SPL, DC, Audiology, Supervising Physician and Facilities.

Training of Delegated Providers with MPF (Master Provider Files) to process.

Verisys / Apperture CVO/ Cactus and Portico, & AMISYS.

Senior Credentialing Specialist WellMed San Antonio March 2022 to August 2023.

Work in preparing credentials for new providers and re-credentialing providers. auditing of provider information systems for consistency and best practices to include phone outreach to providers.

Credentialing for Texas, Florida, New Mexico states.

Maintain and provide support and ensure secure hard copy or scanned images.

File folder setup with status inquiry Verify education, professional history. MD, NP, PA, DT, PT, OT, LCSW, LPC, SPL, DC, Audiology, Supervising Physician, Maintain and update databases. Run sanction checks, as required

Conducting thorough background checks, ensure they meet regulatory and organizational standards

Attention to detail, and good communication skills.

CAQH CVO

Contracts Credentialing Coordinator - Superior Healthcare Plan- San Antonio, TX 78230 - January 2016 to Feb 2022

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 to include phone outreach to external customers.

Maintain and report the Health Plan(s) compliance with contract submission rules and exception. Run sanction checks, as required. Support the contract submission

Provide support and ensure that appropriate secure hard copy or scanned images of contracts.

Maintain and update the contract credentialing and provider data.

Accounts Receivables Manager-Providers - Deer Oaks Behavioral, Psychiatric Facility -- December 2013 to November 2015

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,Medicare/Medicaid, Commercial, TX VETS. 25 locations from New York, New Hampshire, Texas, Minnesota, Vermont, Delaware, Missouri, Idaho, Iowa, Massachusetts, Wyoming, Nebraska, Arkansas, Maryland, South & North Dakota, & Oklahoma, Illinois, Montana, Pennsylvania, New Jersey,

Colorado, Florida, New Mexico, Arkansas.

Managing 25 employees to include Correspondence Supervisor, 1 Billing Supervisor, 1 Posting Supervisor.

Handled electronic billing. Monthly goals for each state.

The training of staff. Duties consist of clearing rejected claims.

Billing-validating claims electronically, paper claims, and secondary billing, claim rejection reports, appeals, Medical Records, and EOB request.

Maintain coding requirements as per ICD9, & HCPCS.

Continuing education of Medicaid guidelines for all the different states billed. .

Implementing structure and process and procedures.

Insurance follow-up, authorizations for extended, and appeals.

Responsible for underpayments, over payments adjustments, which include refunds to payers and patients.

Handled 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 enrollments. Verrifications, demographics,

precertification authorizations, referrals, coordination of benefits.

Interviews, hired, evaluated, and counseled staff. Processed payroll time sheets and keep time and attendance records. Reports.

Follow all HIPAA regulations. Maintained awareness of regulation and legislation changes.

Registration Manager - Southwest General Hospital - San Antonio, TX - November 2009 to May 2012 • Responsible for Central Admitting, ER, Scheduling of MRI, SCANS, outside clinic's and PBX areas.

Managed activities of 45 personnel in all Registration areas. Supervised team leaders and Emergency Room Supervisor, all registration staff. This included verifications, demographics, precertification authorizations, referrals, coordination of benefits.

Interviewed, hired, evaluated, and counseled staff.

Facilitated communication within the hospital departments

Maintained awareness of current changes, regulations and legislation. Participated in department committees, group meetings with a focus on providing input to improve the quality.

Completed monthly reports and worked closely with Medical Records on a daily basis Negotiated and approved patient payments which included the Charity Application process for final approval.

•Increased collections that were under 50%.

University Health Systems - San Antonio, TX - July 1999 November 2009 -

Billing / Customer Service Manager – July 1999 to October 2002 Billing/Collections to manage all aspects of the Hospital Billing to contribute to Accounts Receivables and monthly goals. Managed 45+ employees. electronic billing thru the SSI software. Billing department consisted of clearing hold bills, validating claims electronically

Customer Service Call Center/Posting - October 2002 to August 2004

Manager/Outpatient Registration Clinics - September 2004 to April 2006 Managed clinic registration. registration. Scheduling of patients for MRI's, Cat-Scans, X-rays, endoscopy, wound care, vascular, walkin ER, Vascular & Neuro Surgery, cardiology clinics.

Carelink Outreach Manager May 2006 to November 2009 Managed the member enrollment. Offered position with Southwest General Hospital

EDUCATION

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

San Antonio Community 1978-1979 College 1 year

Skills: Cactus, Macess, CVO, PEMS, Verisys/Apperture, CAQH CVO, SProvider, AMISYS, DEA, CAQH, Cactus and Portico, EPLS, LIABILITY MALPRACTICE, LICENSURE, NPDB, NPI, OIG, OPT OUT, TX OIG/AHCA,,CV EDUCATION, Supervising Physician.

Charity Process Registration HIPAA Compliant ICD-9/CPT Coding Type 65 wpm Bilingual. Revenue Operations Cost control AS400, IDX, STAR Ex cel/Word, Medical Terminology Enrollment Behavioral Billing Medicare, Medicaid HMO, PPO, Replacements Third Party Admin Outreach Education ILE Scanner (electronic MR) PHS (Physician Health Scheduling) New Wave Employee Evaluations Denials/Appeals Prior Authorizations/Referrals Recruiting experience SSI CERNER (EMR) Allscripts software. Medisoft (EMR & Billing) Medipac software Mckesson EMR. Experience with Medicare, Medicaid, Commercial, TX Veterans Affairs, HMO, PPO, Contract billing.

REFERENCE

Alexis Dimes 1-281-***-****

Richard Campbell 1-443-***-****

Tracie Rainey 1-210-***-****

Texas Children's Health Plan 800-***-****

6330 W Loop S, Bellaire, TX 77401

Wellmed 210-***-****

19500 W Interstate 10 Frontage Rd, San Antonio, TX 78257

Superior Healthcare Plan-Centene 800-***-****

7990 I-10, San Antonio, TX 78230

Deer Oaks Behavioral 888-***-****

7272 Wurzbach Rd Ste 404, San Antonio, TX 78240

University Health Systems 210-***-****

Contact this candidate