Credentialing Specialist Ii

Dorcina Sherman-Clark, MHA

Chicago, IL, ***** 630-***-**** **********@******.***

Profile

Highly motivated, well organized, and hard-working health care professional with track record of streamlining systems and procedures for physician practices to maximize productivity, minimize cost and directly contribute to the organizational goals. Resourceful in meeting challenging deadliness and solving problems in a professional and timely manner. Work well under pressure. Experience

CREDENTIALING SPECIALIST II/12/2020-Current/ERIE FAMILY HEALTH CENTER Chicago, IL

Manages and performs credentialing related activities for newly hired Providers and Representatives, and recredentialing activities for existing Providers. [Comprised total of 475]

· Initiate the credentialing process for all Providers who are required to be processed through the medical staff credentialing process. Establish working relationships with Providers or Representatives to facilitate the timely completion of the credentialing or recredentialing process through to approval by the Board.

· Thoroughly review applications and paperwork for completeness and accuracy. Reviews and processes more complex additions, updates, and deletions of Provider information. Maintain Provider information in Provider Database-Credential MyDoc/CredenitalStreams/Verity Stream CVO.

· Perform Primary Source Verification to Ensure compliance, apply for, and renew all Provider licenses including Professional, DEA, Controlled Substance, BLS, Board Certification, Hospital reappointment, CMS revalidations or redeterminations, and any other credentialing elements that are subject to expire.

· Work closely with Billing/Revenue Cycle department with identifying and resolving issues related to Provider credentialing including fees at hospital affiliates/Provider Enrollment. Serve as a liaison between the Hospital, Provider, Managed care-delegation process, IMPACT for onboarding/enrollment.

· Monitor/Maintain CAQH/Perform Provider Enrollment-Medicaid/PECOS/Commercial Plans/NPPES/NPDB/Primary Source Verification process.

· Review of Employment Agreements/Contracted Agreements for onboarding providers. Compiled Collaborative Agreements/IDPRF Delegated Authority process. MANAGER, REVENUE CYCLE/04/2019-12/2020/ERIE FAMILY HEALTH CENTER CHICAGO, IL

· Revenue cycle management of billing and insurance collection including claim rejection management, claim denial management, and ERA and manual posting.

· Provided insight into existing and emerging insurance coverage, reimbursement, and billing. Provided insight for pre-adjudication edits and follow-up/account resolution activities. Monitor productivity standards, quality improvement and metrics for outstanding accounts receivable. Identified and established rules and methods to eliminate back-end denials through an initiative-taking approach towards revenue management; by correcting errors before they are denied by payers. Ensured billing systems were fully optimized and meeting required benchmarks toward account receivables.

· Provided ongoing feed-back to physicians and support staff to improve clinical and operational performance.

· Developed and compiled On-boarding Provider Packages. Managed Enrollment for a total of (238) Providers, (13) FQHC's Health Centers/Site Enrollment. Managed the Provider Credentialing/Enrollment functions for Commercial/Managed Care/ State/Government Plans. Created and revised credentialing policies, procedures, and workflows to ensure compliance with all regulatory and contractual NAMSS/Joint Commission/HRSA/IMASS credentialing requirements. Conducted oversight of the delegated credentialing process for appropriate subcontractors. Responding to non- routine and difficult credentialing issues. Conducts oversight of the delegated credentialing process for appropriate subcontractors/CVO. Alliance/CENTRICITY EMR experience MANAGER, REVENUE CYCLE/09/2018-APRIL 2019/PRIME CARE COMMUNITY HEALTH CHICAGO, IL

· Responsible for Billing and Collections for Medicare, Medicaid, Insurance, and Self Pay Patients for all FQHC Medical and Dental clinics.

· Supervised Billing Specialists-Team. Ensured patient account billing process was performed according to Billing and Collections guidelines. Supervised Patient Service/Call Center Representatives.

· Established productivity/benchmark requirements. Proactively developed billing processes competencies, along with implementation of process improvements.

· Monitor/Maintain CAQH/Perform Provider Enrollment-Medicaid/PECOS/Commercial Plans/NPPES process.

· Provider Enrollment: Created and revised credentialing policies, procedures, and workflows to ensure compliance with all regulatory and contractual credentialing requirements. Conduct oversight of delegated credentialing for appropriate subcontractors. Responded to non-routine and difficult credentialing issues. ATHENA EMR experience/CAQH-Council for Affordable Quality Health Care Education

-MASTER OF HEALTH SERVICE ADMINISTRATION JUNE 2019 NATIONAL LOUIS UNIVERSITY, CHICAGO, IL

-National Honor Society of Leadership and Success-Alpha Sigma Pi

-TMG UNIVERSITY-CERTIFICATION PREP COURSE-CPCS/CERTIFICATE OF COMPLETION CREDENTIALING/CPCS, JANUARY 2022

-NAMSS-CPCS CERTIFICATION PREP/PENDING-FALL 2023

-ASSOCIATE DEGREE MEDICAL BILLING SPECIALISTS NOVEMBER 2005 TAYLOR BUSINESS INSITUTE

Skills & Abilities

· Credential Streams

· Verity Stream CVO

· NPDB-National Practitioner Data Base

· Credential MY Doc

· PECOS/NPPES/IMPACT

· CAQH-Council for Affordable Healthcare

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