Provider Enrollment & Credentialing Specialist

Melinda R. Cooke

Williamsburg, VA • 757-***-**** • ************@*****.***

Professional Summary

Detail-oriented Provider Enrollment & Credentialing Specialist with 10+ years of experience in medical billing, insurance credentialing, and provider enrollment. Skilled in navigating payer systems, ensuring compliance with state and federal requirements, and streamlining credentialing processes for large provider groups. Strong communicator and problem-solver with a proven ability to manage high-volume workflows while maintaining accuracy and efficiency.

Core Competencies

• Provider Enrollment & Credentialing

• Medical Billing & Coding (ICD-9, ICD-10)

• Insurance Verification & Claims Management

• Compliance & Regulatory Standards (Medicare, Medicaid, Commercial Payers)

• Database Management & Reporting

• Process Improvement & Workflow Optimization

• Provider Relations & Customer Service

• Software: Availity, CMS, NPPES, Citrix, Smart Sheets, OneApp, PECOS Professional Experience

Knack RCM – Remote (Woodbridge, NJ)

Sr. Account Manager, Provider Enrollment Feb 2025 – Present

• Handle recredentialing processes for group practices and individual providers to maintain network participation and compliance.

• Oversee onboarding for new clients, including setup of CAQH, NPPES, and licensing documentation.

• Prepare and submit appeals for providers with commercial and government insurance carriers.

• Submit Medicare and Medicaid applications across multiple states, ensuring compliance with payer-specific requirements.

• Conduct daily meetings with offshore teams to coordinate provider enrollment activities and resolve application issues.

• Manage client accounts and serve as primary liaison between clients and offshore teams, ensuring smooth communication and timely project delivery. Ventra Health RCM – Remote (Dublin, OH)

Provider Enrollment Specialist Mar 2024 – Feb. 2025

• Submit and manage credentialing applications for providers across multiple insurance carriers, including Medicaid and BCBS.

• Conduct primary source verification of licensure, education, training, and employment history.

• Ensure compliance with credentialing guidelines, state, and federal regulations.

• Utilize systems such as Availity, CMD, AIMS, Citrix Workspace, and Smart Sheets to track application progress.

• Collaborate with providers and payers to resolve enrollment delays and maintain up-to-date records.

Lwell LLC – Williamsburg, VA

Credentialing Manager Dec 2022 – Mar 2024

• Managed credentialing for 40+ providers across Medicare, UHC, Humana, Tricare, and commercial insurance networks.

• Oversaw CAQH maintenance and ensured provider documentation accuracy.

• Developed and maintained Excel databases to monitor credentialing status and generate progress reports.

• Facilitated virtual meetings with providers regarding application updates and credentialing requirements.

• Implemented organizational workflows to improve application turnaround times. Mitchell Endoscopy – Richmond, VA

Billing Coordinator Jun 2015 – Nov 2015

• Managed patient financials, billing, and insurance claim submissions.

• Processed coding for patient visits using ICD-10 and transitioned records from ICD-9.

• Corrected claim errors and secured authorizations for procedures.

• Worked directly with payers (Anthem, UHC, Medicare, Medicaid, Tricare) to resolve disputes.

• Delivered excellent customer service, assisting patients with billing inquiries and payments. Riverside Medical Group – Williamsburg, VA

Medical Billing Representative Oct 2012 – Jun 2015

• Processed patient billing, coding, and claim submissions using ICD-9 (and introduced ICD- 10).

• Verified insurance eligibility and obtained authorizations for medical and vision appointments.

• Collaborated with providers to resolve claim denials and ensure timely reimbursement.

• Supported front office operations, including data entry, phone system management, and patient support.

Education & Certifications

• Thomas Nelson Community College, Williamsburg, VA – Coursework, 2015–2016

• Certified Makeup Artist, TreMendi, 2015

• Wallkill Valley Regional High School, Hamburg, NJ – High School Diploma, 1997

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