Customer Service Credentialing Specialist

GW

GLENDA WILSON

**************@*****.*** 1-813-***-**** Lutz, FL 33548 WWW: Bold Profile

Credentialing Specialist with extensive experience at WellCare Health Plans, Inc., specializing in high-volume application processing and improving turnaround times. Demonstrated expertise in relationship building and effective communication, ensuring compliance and accuracy in all operations. Proficient in database management with a strong commitment to professional integrity and continuous process improvement. Professional demeanor

Strong written communication skills

Strong oral communication skills

Ability to learn systems

Spreadsheet software

Database software

Interpersonal skills

Customer interface

Vendor interface

Credentialing staff interface

Administrative experience

Organizational skills

Follow up skills

Customer service skills

Communication skills

Following instruction

Patience

Self-discipline

Personal integrity

Professional integrity

Relationships

Team building

Decision making

Critical thinking

Government relations knowledge

Cultural awareness

Sensitivity

Teamwork

Northeastern US Health Care Company

Customer Service Representative / Data

Entry

04/2022 - 05/2023

Verified the information in the computer system was up to date. Eliminate outdated records by sending the records to be scanned. Complied statistical information for special reports. Verified and logged in deadlines for responding to daily inquiries. Identified and resolved system and account issues.

Collected customer feedback and made process changes to exceed satisfaction goals. Made reasonable procedure exceptions to accommodate customer requests. Provided accurate and appropriate information in response to customer.

Demonstrated mastery of customer service call script within specific timeframes. Addressed customer service inquiries in a timely and accurate fashion. Maintained up-to-date records at all times. Developed effective relationships with all call center departments. Worked with upper management to ensure appropriate changes were improve customer satisfaction.

Built customer loyalty by placing follow-up calls for customer who had product issues. Formulated and enforced service center policies procedures and quality assurance measures.

Bristow Medical Center Bristow, Receives and reviews submitted applications for completeness and Summary

Professional Skills

Experience

Oklahoma

Credentialing Specialist Sr.

11/2019 - 01/2022

compliance with instructions for preparation; ensures the timely completion of applications by communicating with and assisting the applicants in submitting all documentation necessary to process the application; identifies deficiencies and follows up to gather missing or incomplete data.

Uses discretion and independent judgement in determining the need for deviation from standard processes or more detailed investigation, including those involving fees, or that would cause processing delays to clarify, verify and/or confirm information contained in the credentialing application.

Perform primary and secondary source verification of Practitioner's and facilities credentials according to policy.

Performs the appropriate (applicable) credentialing processes in a timely and complete manner.

Uses, protects, and discloses medical group patients' protected health information (PHI) only accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

Responsible for processing provider and facilities applications and re-applications including initial mailing, review and loading into the database tracking system ensuring compliance with required standards. Ensures the files for clinicians and facilities due for credentialing/re- credentialing are available for review by the Credentialing Committee each month and resolves outstanding issues prior to committee review. Oversees primary source verification activities.

Ensures timely processing of all credentialing requests. Perform outreach to providers and facilities via phone calls and fax/email correspondence.

Responsible for audits and reports audit finding to the Credentialing Committee.

Supports the Provider Relations, Credentialing Management, Quality Management and Regulatory Compliance with requested data reporting. Demonstrate respect and maintain patient's and facilities dignity and confidentiality.

WellCare Health Plans, Inc. Tampa, FL

Credentialing Specialist Senior

11/2004 - 07/2019

Processes high volume credentialing and recredentialing applications and/or enrollment of health care providers.

Reviews applications, prepares verification letters and maintains databases. Contacts medical office staff, licensing agencies, and insurance carriers to complete credentialing and recredentialing applications. Ability to work with health care acronyms and able to differentiate between provider titles, download the providers applications. Meet productivity standards as outlined in client metrics. Identify any issues or trends and bring them to the attention of the management team.

Understanding of credentialing process.

Familiarity with CAQH, DEA CSR Board certifications. Verifying and auditing other employee's work.

Train other staff in credentialing.

Auditor check staff work to go to review.

Amenable for the development revision and institution of the policy and procedures.

Facility and organizational files and reports.

Facilitated and organized bi-weekly credentialing committee meetings for all major legal discrepancies and medical review.

Review all legal discrepancy findings through the National Practitioner Data Bank (NPDB/HIPB).

Improved current departmental processes for initial and re-credentialing turnaround time frame.

Outreach to providers to ensure their timely renewal of expiring licenses and certifications.

Credential and re-credential all nurse practitioners and physicians and facilities applications in accordance with The Joint Commission Providers. Staff Training, productivity.

Tracking quality control and files auditing.

Insurance credentialing processes.

Adjusted compensable indene.

Verifying Board Certifications, DEA, CSR, NPI, Practitioners Data Bank, Insurance, State and Federal OIG, Sam report for Medicare and Medicaid, Hospital privileging and onboarding process for new providers, Medicare OPT-OUT, entering all data into Cactus database, NCQA certifications, education and hospital privileges.

Office Staffing Tampa, Florida

Data Entry Operator

04/2003 - 11/2004

Verification for the credentialing and recredentialing team which entails verifying DEA, CSR, Board Certifications, Site Surveys. Gathering, collating, and preparing documents.

Conducting research to obtain information for incomplete documents and material.

Reviewing all documents and information for accuracy. Training staff in primary sources.

Training in credentialing.

Collecting data and input to spreadsheets and databases. Support including data entry, filing, copying, scanning, faxing is required. Pierce County Services Tacoma,

Washington

Computer Operator / Data Entry Lead

03/1985 - 02/2003

Gathering, collating, and preparing documents.

Conducting research to obtain information for incomplete documents. Reviewing all documents and information for accuracy. Monitoring of systems and networks.

Monitoring of the security and facility environment. Interacting with System Administration staff to report and resolve issues. Using a variety of tools and processes to determine the health of the systems and networks.

Applying fundamental concepts, processes, practices, and procedures to technical assignments.

Executing and monitoring a range of scheduled routines. Resolving common operating problems.

Diagnosing and acting on computer output instructions and machine stoppage or error conditions.

Applying standard operating and or corrective procedures. Hillsborough Community College Tampa, Florida

English, Basic Computers, Algebra, Business and Registered Nurse 07/2025

4 credits

Education

Bates Community College Tacoma, Washington

WordPerfect and Excel Microsoft Word

06/1976

2 credits

Tacoma Community College Tacoma, Washington

Child Development and Business Machine in Sociology 06/1974

Summer School

3 credits

Care Coordinator, 2022-11-20, Alorica, Omaha, NE

Certified Professional Credentialing Specialist, 2012-10-15, WellCare Health Plans, Tampa, FL IntelliCare'd

Omni

Citrus

MedPro

Optum

Gensis

Navigator

WWIKT

Iris

Excel

Alorica Connect

Grid

Alorica ECFR

EIS

Engage

Alorica on Point

Avaya

Oracle

Service Now

Spectrum Kiosk

Spectrum Staff

Teams

Knowledge

Del Set-Up

Genesis

Intermediate in Cactus

Intermediate in Microsoft PowerPoint

Intermediate in Access

Paradigm

Diamond EMMA

IBPS

VPN

Cactus

IRIS

QNXT

PRMS

Word

Power Point

Certifications

Programs

PECOS

NPPES

CAQH

NCQA Accreditation

URAC

HIPAA

FERPA

TJC

CMS

CPMSM

Microsoft Access

Outlook

Microsoft Office Open Type form

SharePoint

Adobe Acrobat Pro

Square POS

Open Refine

Title: Credentialing Specialists Senior

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