Credentialing Specialist Resume Title: Credentialing & Compliance

Credentialing Specialist

Longmont, Colorado, United States, 720-***-****, ******.********@*****.***

PROFILE Credentialing Specialist with extensive expertise in managing provider credentialing for Medicare, Medicaid, and commercial payers. Streamlined processes to enhance efficiency, improving accuracy and compliance in provider data. Proficient in utilizing tools such as Credential My Doc, CAQH, and PECOS, with a solid background in medical billing and coding. Strong commitment to patient-oriented service, ensuring timely onboarding and adherence to regulatory standards. SKILLS Credentialing Expert

Medical Billing Expert

ICD-10 Expert

Medicare Expert

Medicaid Expert

Compliance Expert

Data Entry Expert

Microsoft Excel Expert

SharePoint Expert

Revenue Cycle Management Expert

EMPLOYMENT HISTORY

Nov 2025 Credentialing Specialist, Clinica Family Health & Wellness Oversaw credentialing for 300+ providers with Medicare, Medicaid, and commercial payers. Utilised Credential My Doc, DORA, CAQH, PECOS, I&A, SharePoint, Excel, and Word. Identified and resolved gaps in provider information, assisting with NPI applications as required.

• Streamlined credentialing processes to enhance efficiency.

• Improved accuracy of provider data through diligent verification.

• Facilitated timely onboarding of new providers, minimising delays.

• Maintained compliance with regulatory standards and payer requirements. Aug 2023 — Jan 2025 Medical Billing and Coding Specialist, Compassionate Concierge Physicians

Manage full revenue cycle, including month-end and year-end close processes. Ensure accurate MIPS reporting by collecting measure data over 12 months. Oversee credentialing for commercial payers and CMS, participating in required meetings.

• Submit 1500 and UB04 claims electronically and on paper as needed.

• Update unpaid claims activity and respond to appeals using payer templates or custom responses.

• Identify claim error trends, posting electronic payments and addressing patient EOB questions.

• Scrub claims, add modifiers, review medical records, and ensure proper billing for services. Jan 2023 — Jun 2023 Medical Practice Manager, Avista Womens Care Oversee daily operations of a large women's health clinic. Facilitate regular meetings with providers and staff to gather feedback and enhance teamwork. Foster a positive work environment, ensuring clinical compliance with industry regulations while hiring and training administrative staff.

• Develop and implement policies for efficient practice operations.

• Manage budgeting, billing, and accounts receivable.

• Handle medical revenue billing, payroll, and employee leave requests.

• Coordinate patient scheduling, referrals, and surgical logistics. Oct 2022 — Dec 2022 Medical Billing Specialist, CPSI/Evident Oversee billing operations for two California hospitals, managing accounts receivable and credentialing. Submit 1500 and UB04 claims electronically and on paper as needed. Maintain updated records of unpaid claims within the database. Respond to appeals using payer templates and custom written responses, ensuring timely submissions via various methods. Collaborate with providers throughout the appeal process, conducting research and providing necessary documentation.

• Submitted claims to all payers, ensuring accuracy and compliance.

• Updated unpaid claims activity, improving tracking efficiency.

• Drafted and submitted appeal responses, meeting tight deadlines.

• Communicated with providers to facilitate successful appeals. Aug 2017 — Feb 2022 Medical Biller and Coder, Colorado Pulmonary Associates Oversee billing department operations using Centricity and Athena for a five-doctor practice. Manage full revenue cycle, including month-end/year-end closings and MIPS reporting. Monitor credentialing for commercial payers and CMS.

• Submitted 1500 and UB04 claims forms electronically and via mail.

• Updated unpaid claims activity in the database and managed appeal responses promptly.

• Identified claim error trends and executed corrective actions.

• Conducted claims scrubbing and ensured compliance with billing standards. Apr 2017 — Jul 2017 Finance Manager, Foothills Urogynecology Managed surgical scheduling and front office operations at Foothills Urogynecology. Collaborated with Medtronic on Neuro Stim procedures. Coordinated Dr. Dunn's surgical operations with Swedish hospitals, ensuring seamless patient preparation and OR readiness. Oversaw insurance authorizations, securing approvals across multiple providers.

• Streamlined surgical scheduling processes, enhancing efficiency.

• Ensured 100% approval rate on insurance authorizations.

• Strengthened relationships with Medtronic and Swedish hospitals. Aug 2015 — Apr 2017 Advanced Medical Revenue Specialist, RT Welter and Associates Managed billing for 33 diverse doctors across multiple specialties including Neurology, Orthopedics, and Urogynecology. Utilised software such as Epic and Allscripts for efficient account management. Navigated complex appeals for insurance denials and established payment arrangements. Conducted detailed account analysis, restructured fee schedules, resulting in a 200% increase over Medicare allowable. Facilitated ICD-10 transitions and generated tailored reports for providers. - Streamlined billing processes, enhancing revenue recovery for multiple specialties. - Increased one doctor's fee schedule, recovering significant lost revenue. - Developed customised reports, improving provider insights on performance. - Acted as a key resource for Medicaid transitions and client revalidation support. Aug 2013 — Aug 2015 Advanced Medical Revenue Specialist, Physician Reimbursement Systems

Managed accounts for Oklahoma Multispecialty Group, overseeing monthly aging reports for 16 Urology specialists. Facilitated appeals for insurance denials, ensuring timely resolutions. Coordinated payment arrangements, preparing patients for collections as needed. Created tailored reports, including bar graphs and pie charts, based on provider preferences. Generated monthly scorecards reflecting individual physician earnings over the past 3-4 years.

• Streamlined payment posting processes to enhance efficiency.

• Responded to patient inquiries, improving customer satisfaction.

• Assisted with various administrative tasks to support end-of-month operations. EDUCATION Some in Medical Billing and Coding

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