Credentialing Specialist with 10+ Years of Experience
Resume:
Eugene Young, Jr.
**************@*****.***
Professional Summary
•Over 10+ years of experience working as a Provider Credentialing & Enrollment Specialist with different healthcare settings.
•Experienced in working with physicians on a daily basis in a hospital environment and the day to-day tasks are very detailed and can be very complex, since we must adhere to the Healthcare Standards set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in order for the organization to remain Accredited and approved by the Centers for Medicare and Medicaid Services (CMS).
•Experience in accurately populated and maintained credentialing databases (CAQH, MD Staff), consistently updating licensure expirables to remain compliant with NCQA/payor standards/requirements.
•Experience in developing a quality nationwide provider network that achieved a positive experience for OptumRx clients and participating network pharmacies while achieving and maintaining URAC accreditation status.
•Experience in preparing, submitting provider enrollment and credentialing applications for government & commercial health and vision plans such as Aetna, Anthem Blue Cross, Blue Shield of CA, CIGNA, HealthNet, Molina, UnitedHealth Group, Tricare, VSP, etc. for network participation.
•Acted as a liaison between contracted health/vision plans and NVISION providers, clinics and ambulatory surgery centers.
•Proficient in using MS Office Suite, Google Suite, and other computer applications.
Skills:
•Expert in preparing credentialing files (Pharmacies, Physicians, Nurses, other medical professionals) arranging application completion, verification of licenses, and obtaining necessary information to ensure that all requested documents are current and accurate.
•Knowledgeable in Medical terminologies, credentialing process, documentation and verification, and information processing.
•Proficient in using MS Office Suite, Google Suite, and other computer applications.
Education
•Bachelor of Science in Human Services, University of Oregon 1984
Professional Experience
L.A.Care Health Plan, Los Angeles, CA (Agreeya-Staffing Agency)
March 2022-August 2025
Credentialing Specialist/Provider Data Quality Auditor II
•Responsible for the timely and accurate uploading L.A.Care’s provider network data, including identification and remediation of provider errors, which entails fostering positive working relationships with internal and external business partners, including L.A. Care’s contracted IPA’s, Medical Groups, and Plan Partners.
•Responsible for making independent decisions to ensure data quality measures, timelines and organizational policies are met related to provider network data.
•Conduct ongoing quality auditing of L.A.Care’s provider network data, including working with their assigned provider network accounts to remediate provider data errors (databases: CACTUS, Symphony, Provider Data Management).
Emanate Health Medical Center-Covina, CA (TLC Staffing/The Lawton Group) November 2021 – March 2022
Provider Credentialing Coordinator
•Work directly with physicians on a daily basis in a hospital environment and the day to-day tasks are very detailed and can be very complex, since we must adhere to the Healthcare Standards set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in order for the organization to remain Accredited and approved by the Centers for Medicare and Medicaid Services (CMS).
•Provides general office support services (e.g., filing, telephones, word processing, etc.) as required or directed.
•Prepares a variety of documents using a number of databases, graphics, spreadsheets, and word processing software applications. Provides general office support services (e.g., filing, telephones, word processing, etc.) as required or directed. This position is accountable to the Medical Staff Manager but reports to the Director of Medical Staff.
NVision Laser Eye Centers, Aliso Viejo, CA
March 2021 – July 2021
Provider Credentialing & Enrollment Specialist
•Prepared, submitted provider enrollment and credentialing applications for government & commercial health and vision plans such as Aetna, Anthem Blue Cross, Blue Shield of CA, Cigna, HealthNet, Molina, UnitedHealth Group, Tricare, VSP, etc.) for network Ophthalmologists and Optometrists.
•Facilitated in obtaining hospital and ambulatory surgery center admitting privileges for aforementioned providers.
•Accurately populated and maintained credentialing databases (CAQH, MD Staff), consistently updating licensure expirable to remain compliant with NCQA/payor standards/requirements.
•Acted as a liaison between contracted health/vision plans and NVISION providers, clinics and ambulatory surgery centers.
•Reviewed initial and reappointment credentialing applications and conducted follow- up as needed.
•Performed primary source verification of all credentialing requirements: education, training, experience, certification and licensing.
OPTUMRX (Subsidiary of United Health Group), Irvine, CA
May 2011 – November 2020
Senior Credentialing Specialist
•Ensured consistent documentation and complete verification of Independent Retail pharmacy credentials (OptumRx network of over four thousand pharmacies) for the 3rd largest Pharmacy Benefits Management Organization in the U.S.
•Monitored, provided support on a variety of complex federal, state, county and city regulatory licensing compliance policies and procedures (Healthcare industry).
•Processed credentialing and re-credentialing applications utilizing NCQA guidelines credentialing standards and adhering to departmental policies and procedures
•Managed licensing compliance requirements and permits for all pharmacies (long term care, home health agencies and home infusion pharmacies) at all levels-federal, state, county and city, including but not limited to: State Board of Pharmacy, Drug Enforcement Administration (DEA), Medicare, Medicaid/Medi-Cal, County and City Business licenses, Clinical Laboratory Improvement (CLIA) information to assure that data is consistent, accurate, and current.
•Liaised between the Credentialing Department, contracted pharmacies and the Contracts Department to complete required/requested information and/or resolve credentialing issues, such as disciplinary actions taken against the pharmacy.
•Responsible for developing a quality nationwide provider network that achieved a positive experience for OptumRx clients and participating network pharmacies while achieving and maintaining URAC accreditation status.
AIDS Healthcare Foundation (AHF), Los Angeles, CA
September 2006 –December 2010
Credentialing Specialist
•Initiated credentialing and recredentialing process in compliance with federal, state, managed care, and regional regulatory requirement guidelines and accreditation standards (JCAHO, NCQA, AAAHC, CMS, OHS, Title 22) for CA and FL network providers.
•Maintained credential and peer review files (primary source verifications of provider licensures, certifications, etc.) to ensure completeness and accuracy.
•Completed AHF's provider enrollment applications and updates for governmental healthcare programs according to federal and state regulatory requirements, including Medicare Part B, and MediCal/Medicaid.
•Documented potential provider liability issues, presented completed files to the Credentialing Committee for review.
•Prepared agendas and minutes at monthly Credentialing Committee meetings, delivered particular information pertaining to providers with malpractice issues.
•Participated in Credentialing and Peer Review meetings, regulatory audits by network managed care plans, and maintained Continuing Medical Education (CME) files/spreadsheets for AHF clinic providers.
•Vocation required knowledge of Credentialing and claims Software (CACTUS, EZCAP), Access, Word and various Credentialing websites.
•Experienced with CAQH application completion and processing.
Kaiser Permanente-Pasadena, CA
November 2005–October 2006
Medicare Reimbursement Specialist
•Managed the EDI clearinghouse rejections.
•Researched medical coding ICD-9, ICD-10, HCPCS and CPT-4 to let client know the outcome of medical claim.
•Prepared and submitted accurate claims with appropriate HCPCS codes and modifiers on DME equipment and supplies to insurance carriers.
Contact this candidate