Provider Enrollment Health Insurance
Resume:
LOVIE
TAYLOR
************@*****.***
Fairburn, GA 30213
Professional with in-depth experience in healthcare operations, credentialing and provider enrollment. Skilled in navigating complex regulatory requirements, ensuring compliance, and streamlining processes for efficiency. Strong focus on team collaboration and achieving results, adaptable to changing needs. Known for exceptional organizational skills, problem-solving abilities, and effective communication.
PROFESSIONAL SUMMARY
International Institute of the
Americas
Albuquerque, NM • 12/2006
Associates of Science: Criminal
Justice Administration
Metropolitan College of Court
Reporting
Albuquerque, NM • 05/2002
Associates of Applied Science:
Paralegal
EDUCATION
SKILLS
• Multi-Tasking
• Medicaid/Medicare (CMS)
• Medical terminology
• Healthcare regulations
• Strong communication skills
Proficiency in
CAQH,PECOS,CMS,NPPES,NCQA
•
Effective written and verbal
communication
•
BroadPath Healthcare Solutions - Provider Enrollment Representative Tucson, AZ • 09/2023 - 12/2024
Noridian Healthcare Solutions, LLC - Provider Enrollment Rep North Fargo, ND • 05/2022 - 08/2023
CareMetx, LLC (TalentBridge) - Reimbursement Specialist Charlotte, NC • 12/2021 - 02/2022
WORK HISTORY
Developed and maintained positive relationships with physicians, nurses, and other healthcare staff
•
Ensured compliance with HIPAA regulations and patient privacy standards at all times
•
Completes routine enrollment tasks in support of the provider enrollment team
•
Researches and controls over 12 incoming daily applications and correspondence to categorize the work properly.
•
Reviews and processes a high volume of prospective provider enrollment applications
•
Verifies credentialing information and completes fraud detection and prevention
•
Proficient in crafting clear, concise, and well-organized written content for providers/ team members across various formats(templates, emails,)
•
Completes routine enrollment tasks in support of the provider enrollment team
•
Researches and controls incoming applications and correspondence to categorize the work properly
•
Reviews and processes a high volume of prospective provider enrollment applications, processing 15 per day.
•
Verifies credentialing information and completes fraud detection and prevention
•
Conducted audits to assess compliance with regulations and standards
•
Proficient in crafting clear, concise, and well-organized written content for providers/team members across various
formats(templates, emails,)
•
Lash Group (Talentbridge) - Patient Access Specialist Charlotte, NC • 11/2020 - 05/2021
Aliera Companies - Member Service Representative
Sandy Springs, GA • 05/2019 - 01/2020
Homedepot Call Center (Apex Systems) - Compliance Auditor Smyrna, GA • 12/2018 - 03/2019
Secured patient information and confidential medical records in compliance with HIPAA privacy rules standards to protect patient's privacy
•
• Identified health insurance payment information and billing sources Listed payers in the proper sequence to establish a chain of payments into CRM
•
Gathered demographic information to research and review documents from patients' medical charts to determine patient qualification under Medicare Part B guidelines
•
Collected and validated patient demographics and health insurance information to input into the Epic system
•
Obtained patient's health insurance information and determined eligibility for specific services rendered. Managing over 65 incoming calls per day.
•
Conducted audits of provider files, ensuring all necessary documents were up-to-date and compliant with regulatory requirements.
•
Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient data security and confidentiality policies and procedures
•
Provided support in obtaining required documents to assist healthcare professionals in successfully submitting Prior Authorizations
•
Obtained patient health insurance information and determined eligibility for medical benefits for specific services rendered for billing purposes
•
Received patient deductibles and co-pay amounts and discussed options to satisfy the remainder of patient financial obligations; input data in the Epic system
•
Utilized knowledge of electronic medical record systems and medical terminology to perform diverse data entry tasks.
•
Learned and maintained an in-depth understanding of health insurance coverage and service information to offer knowledgeable and educated responses to diverse customer questions
•
Enhanced customer satisfaction by efficiently addressing and resolving inquiries and concerns.
•
Helped a large volume of customers daily with a positive attitude and focused on customer satisfaction. Managing approximately 30-60 incoming calls per day.
•
Maintained confidential patient, employee, and company information in compliance with company policies and regulatory requirements
•
Provided exceptional service through active listening, understanding member needs, and offering appropriate solutions.
•
Meet work standards by following production, productivity, quality, and resolving operational problems; identifying work process improvements
•
UCB Pharma Inc (Advanced Recruiting Partners) -
Chargeback/Medicaid Coordinator
Smyrna, GA • 06/2014 - 03/2018
Research and audit data to communicate with appropriate departments to formulate a plan of action
•
Prepare Excel reports for templates and maintained compliance database
•
• Performed over 164 compliance audits per month
Compiled general ledger entries on a short schedule with 100% accuracy
•
Manage and build relationships with Group Purchasing Organizations and Wholesalers for the Letter of Commitment program (discount pricing) to ensure proper contract pricing and tracking
•
Data analysis of chargeback submissions and resubmissions to comply with contractual terms of agreements.
•
Provide Group Purchasing Organizations with membership reports and rosters showing active members and members requiring intervention
•
Upload new and contracted customers into the SAP CRM system and make any updates to eligibility as needed
•
Process Class of Trade and tier-level changes for qualified Group Purchasing Organization members in SAP (CRM) and CAQH for quarterly review
•
Provide written direction and guidance to internal teams and stakeholders to achieve targets
•
Created Excel spreadsheets to compare data utilizing V-lookup and pivot table functions and analyzed data for Medicaid invoices
•
Maintains state files with current Reconciliation of State Invoices and Prior Quarter Adjustment Statements
•
Audit outstanding Medicaid rebate claims and discuss findings with appropriate States to resolve discrepancies
•
Experienced in writing for diverse purposes, including contractual documentation, and formal business communications
•
Contact this candidate