Revenue Cycle Credentialing Specialist
Resume:
Omaha, NE *****
**********@*****.***
EDUCATION AND
TRAINING
Bachelor of Science
Marketing And Management
Purdue University, West Lafayette,
IN
Associate of Science
Nursing
Southwest Baptist University,
Bolivar, MO
SUMMARY
Efficient credentialing specialist with over twenty years of experience in all aspects of credentialing and compliance management. Proven track record of enhancing process efficiency and productivity. Strong communication and problem-solving skills facilitate effective collaboration with healthcare professionals.
SKILLS
EXPERIENCE
PATIENT ACCOUNT AUDITOR
Detego Health (Position eliminated 1/25) Omaha, NE May 2024 - January 2025 BILLING AND REVENUE CYCLE MANAGER
ENT Specialists, PC (Interim Position) Omaha, NE September 2023 - December 2023
REBECCA BOYD
• Credentialing and database
management
• Regulatory compliance - URAC
• Provider enrollment
• Attention to detail
• HIPAA compliance
• Multitasking capacity
• Conducted detailed analysis of complex financial transactions and accounts.
• Evaluated adequacy of internal controls over financial reporting processes.
• Performed comprehensive research and data analysis to support strategic planning.
• Resolved issues related to client accounts through strong problem- solving skills.
• Monitored daily cash flow activity, ensuring timely filing of claims and proper reimbursement for services rendered.
• Investigated any discrepancies that arise during the billing process and resolved them promptly.
• Developed strategies to reduce denials, improve accounts receivable, and enhance revenue cycle performance.
• Implemented new policies and procedures for streamlining workflow processes within the revenue cycle department.
• Performed data analysis to identify trends in denials or rejections from payers and develop strategies for resolution.
• Reviewed patient billing information to ensure accuracy and compliance RB
CREDENTIALING SPECIALIST
Methodist Hospital Systems Omaha, NE August 2021 - September 2023 OWNER
Surgical Billing, LLC Palm Springs, CA August 2002 - April 2021 with federal and state regulations.
• Oversaw training of staff on changes in insurance regulations and coding updates impacting reimbursement rates.
• Maintained detailed records of provider data in the credentialing database system.
• Interacted regularly with representatives from health plans and commercial payers regarding credentialing matters.
• Credentialed hospital facilities, clinics, and long-term care facilities.
• Conducted background checks on potential providers, utilizing various resources, including state licensing boards, the OIG and GSA Exclusion List, and the NPDB.
• Processed re-credentialing applications for existing providers according to contractual requirements.
• Ensured timely completion of credentialing processes by providing guidance to providers on the required documentation.
• Coordinated with internal departments, such as medical staff services or risk management, to resolve any issues identified during the verification process.
• Validated primary source documents, such as licenses, diplomas, certifications, and other related credentials.
• Participated in periodic audits of credentialing files to maintain compliance with applicable regulations and policies.
• Developed an understanding of Medicare and Medicaid rules and regulations as they apply to medical billing procedures.
• Performed data entry into electronic health record system for all relevant patient information including diagnoses, procedures performed, medications prescribed .
• Submitted claims electronically to insurance companies in accordance with regulations.
• Monitored regulatory updates from Medicare and Medicaid programs as well as private insurers.
• Participated in meetings with physicians and other healthcare providers regarding coding compliance standards.
• Maintained detailed accounts receivable aging reports on a daily basis to ensure timely payments from patients and insurance companies.
• Verified patient information, including medical history and insurance coverage, to ensure accuracy of coding and billing.
• Conducted audits of medical records to identify missing or incorrect documentation that could affect accurate coding and billing.
• Researched denied claims to determine the cause of denial and corrected errors as needed.
• Assigned appropriate codes using ICD-10-CM for diagnosis, CPT for procedures, HCPCS for supplies and modifiers as required by payers.
• Generated reports from software systems to track claim status and denials.
• Assigned additional diagnosis codes based on specific clinical findings
(laboratory, radiology and, pathology reports as well as clinical studies) in support of existing diagnoses.
• Added modifiers as appropriate, coded narrative diagnoses and verified diagnoses.
• Resolved coding discrepancies and denials to maximize reimbursement.
• Tracked licensure expiration dates and coordinated renewal activities with providers.
• Facilitated the appointment process by providing information on privileges requested.
• Participated in Joint Commission surveys by providing requested information on physician credentials.
• Resolved complex issues with insurers regarding payment discrepancies or rejections of claims.
• Managed a team of billing specialists responsible for processing claims accurately and efficiently.
Contact this candidate