Credentialing Specialist with 25+ Years Experience

Claressia Williams

(Forest Park, Georgia )

Professional Summary

Credentialing Specialist with over 25 years of combined experience in multi-state provider enrollment, credentialing, payer compliance, and healthcare operations across government and commercial health plans.

Proficient in key credentialing systems including CredentialStream, CAQH, PECOS, and Modio, ensuring accurate and timely processing of credentialing applications and re-credentialing tasks.

Strong knowledge of NCQA and HIPAA standards, skilled in primary source verifications, license renewals, and maintaining provider data integrity across multiple platforms.

Demonstrated ability to manage large volumes of credentialing and enrollment requests, prioritize urgent cases, and maintain regulatory compliance while meeting strict turnaround goals.

Effective communicator and collaborator with providers, payers, and cross-functional teams, adept at resolving documentation issues and supporting provider onboarding workflows.

Background in healthcare billing and claims processing complements credentialing expertise, enabling comprehensive understanding of healthcare operations and provider relations.

Skills

Multi-State Credentialing & Provider Onboarding

Payor Enrollment & CAQH Profile Management

Primary Source Verification & License Renewal

Credential Stream, Modio, & SharePoint for Document Management

Medicare, Medicaid, Commercial Plan Enrollment (GAMMIS, PECOS, 855 Forms)

Compliance with NCQA & HIPAA Standards

Provider Data Maintenance & Documentation

Strong Organizational & Time Management Skills

Microsoft Office Suite (Excel, Word, Outlook) & Google Workspace

Remote Work & Virtual Collaboration Tools

Audits & Regulatory Compliance

Provider Contract & Credentialing Coordination

Medical Billing & Coding Fundamentals

Attention to Detail & Process Improvement

HIPAA Compliance Training (10+ years)

Interstate Medical Licensure Compact (IMLCC) Knowledge

Medicare & Medicaid Credentialing Standards

Professional Experience:

HFS – Illinois Department of Healthcare and Family Services. Springfield, IL(Remote) July 2024 – Dec 2025

Medicaid Provider Enrollment / Medicaid Credentialing Specialist (Temporary Contract -Cogentinfo Tech)

Processing Medicaid Health Care Provider’ s enrolment applications and provider updates within the States approval system.

Verification of provider credentials through various government agencies and license boards, reviewing the accuracy of provider demographic and billing information within the States system, and various data entry functions.

Research, verify, and document provider credentialing information through various government agencies and license boards as part of provider enrollment regulations.

Assist Medicaid Providers on the processes, police, and procedures within the state.

Credentialing different medical specialties, understanding and adhering to specialty-specific rules and compliance standards.

Validated primary source documents including licenses, diplomas, certifications, malpractice history, and liability claims for delegated entity credentialing.

Maintained meticulous provider data records using MMIS State System.

Track record of accomplishments and ability to document communication and outcomes effectively

Excellent organizational, communication and interpersonal skills

Work with State Management Staff daily to ensure that all Medicaid providers, applications have been submitted and approve

Document communication notes and resolution outcomes. Review the application and update submission in its entirety and confirm that all data is accurate, and all revalidation documents are completed and upload, ensuring that all verification documents are complete.

Transitional Care DBA Chronic Disease of Georgia – Monroe, GA (Remote) Oct 2024 – July 2025

Credentialing Specialist & Payor Enrollment

Managed multiple credentialing and administrative healthcare tasks simultaneously, prioritizing urgent provider credentials and balancing new submissions with follow-ups to ensure timely processing.

Utilized credentialing-specific tools and platforms such as PCOS for Medicare and various state Medicaid portals to track credentialing progress and submissions.

Communicated effectively with healthcare providers and office staff to collect required documentation; escalated unresponsive cases to leadership when necessary.

Maintained high accuracy in handling provider data, regularly verifying licenses and insurance documents to prevent submission errors and delays.

Implemented and followed detailed credentialing checklists to ensure completeness of applications, proactively identifying and resolving missing or incorrect information.

Experienced in credentialing across different medical specialties, understanding and adhering to specialty-specific rules and compliance standards.

Onboarded providers via email and online application systems; ensured all credentialing checklist items were completed to confirm provider start dates.

Validated primary source documents including licenses, diplomas, certifications, malpractice history, and liability claims for delegated entity credentialing.

Managed and maintained CAQH profiles for delegated providers, including roster updates, expirable document updates, provider terminations, and 120-day attestations.

Maintained meticulous provider data records using Modio and Google Shared Drive.

Submitted applications for provider enrollment in government insurance plans such as GAMMIS (Medicaid), Medicare (PECOS – 855I, 855R, Part B), and various state and commercial plans; followed up for timely signature returns.

Requested and tracked hospital privileging status.

Ensured timely license renewals in alignment with NCQA standards.

AMSURG Anesthesia Group – Nashville, TN (Remote) Aug 2022 – Oct 2024

Credentialing Specialist & Licensure Payor Enrollment

Prepared and submitted provider applications for network participation across commercial and government payors, ensuring accurate and timely enrollment.

Collaborated with internal stakeholders to support provider onboarding and licensure validation processes.

Experienced in handling both front-end application submissions and understanding of back-end approval processes for major insurers, such as Centene.

Maintained and monitored credentialing documentation using shared drives and credentialing systems.

Processed and submitted initial anesthesia enrollment applications to Medicare, Medicaid, and commercial insurance plans across multiple states.

Managed IMLCC Compact license applications across various state medical boards; supported facility credentialing processes.

Validated primary source documents including licenses, diplomas, and certifications to ensure credentialing compliance.

Participated in periodic audits of credentialing files to ensure adherence to regulatory and organizational standards.

Monitored license and certification statuses, ensuring proactive renewals.

Maintained provider data and credentialing records in CredentialStream.

Ensured accuracy and completeness of provider profiles in CAQH.

Collaborated with internal teams on provider contracts and agreement processes.

Supported radiology credentialing and enrollment activities within the Essential Healthcare Group; assisted radiologists through licensing and handled miscellaneous credentialing duties as assigned.

CVS Health - (Temporary Contract, Remote) Apr 2022 – Jul 2022

CAQH Coordinator

Maintained and updated CAQH profiles for providers across multiple states, ensuring compliance with attestation cycles, expirable document management, and payer access authorization.

Ensured data accuracy and compliance with payer requirements, NCQA standards, and healthcare credentialing best practices.

Handled credentialing data with high attention to detail, identifying and flagging expired documents and proactively initiating updates.

Created and maintained CAQH profiles for all providers affiliated with CVS MinuteClinics across various states.

Facilitated timely provider re-attestations and ensured contracted payors received accurate, updated information.

Entered new providers into the CAQH system with precision and managed ongoing data integrity.

Collected and input provider data into the CAQH Provider Data Source, ensuring completeness and reliability.

Athens Heart Center – Athens, GA (Remote) Sep 2019 – Mar 2022

Credentialing & Provider Enrollment Specialist

Conducted end-to-end provider enrollment and credentialing for multiple specialties, ensuring accuracy and adherence to specialty-specific compliance requirements.

Applied a proactive approach to documentation tracking and follow-ups with payers, helping ensure complete, timely, and compliant submissions.

Engaged directly with providers to collect credentialing data, resolve issues, and escalate complex cases using established protocols.

Gained experience with NCQA compliance standards and maintained a high level of accuracy in all credentialing and re-credentialing applications.

Initiated credentialing operations from the ground up, managing full-cycle credentialing and enrollment processes, including commercial and government payors (Medicare, Medicaid).

Processed PECOS and CMS applications including 855A, 855B, 855R, and 855I; ensured data accuracy across PECOS, NPPES, CAQH, and other relevant systems.

Performed primary source verifications and monitored expirable documents (licenses, DEA, malpractice, etc.), coordinating renewals to maintain provider eligibility.

Managed provider data within CAQH, ensuring updates and re-attestations met CMS timelines.

Maintained credentialing files, licensing records, and documentation of provider onboarding and termination activities.

Supported payor enrollment contracting and hospital privileging by preparing, submitting, and tracking credentialing applications.

Utilized FSMB, NPDB, and other compliance tools for querying and verification as part of credentialing due diligence.

Healthcare Credential Solutions – Bradenton, FL Jul 2018 – Sep 2019

Healthcare Credential Consultant

Facilitated payer enrollment and provider credentialing to ensure timely and compliant outcomes.

Maintained and updated CAQH profiles, PECOS primary source verifications, and Medicaid waivers.

Collected and managed provider documentation for credentialing and licensing processes.

Completed credentialing for Medicare, Medicaid, Tricare, and commercial payers.

Implemented systems for uploading documentation during the licensure application process.

Researched and tracked licensing requirements across all 50 U.S. states for Home Health, Behavioral Health, and Hospice Care providers.

St. Petersburg Endoscopy Center – St. Petersburg, FL Jul 2013 – Jun 2018

ASC Medical Biller & Coder / Team Lead

Processed billing per procedure; handled insurance verification, scheduling, and claims submissions (electronic and paper).

Coded diagnoses and procedures using ICD-10 and CPT; applied appropriate modifiers and reviewed operative notes.

Managed provider credentialing and enrollment with Medicare, Medicaid, Humana, Commercial Payors.

Worked claim rejections via Zirmed, encoder systems, and ensured corrections were made promptly.

Created billing batches, posted charges in Advantx, and ensured timely claims filing.

Calculated co-insurance, deductibles, and contract-based fees; utilized EMR Provation for documentation.

Generated and maintained reports (AIR, ARCA State Report, and Excel/Access claim logs).

Responded to patient/provider billing inquiries and resolved issues with professionalism.

Computer Sciences Corporation – Atlanta, GA Apr 2012 – May 2013

Senior Medical Claims Processor

Processed high volumes of healthcare claims related to the World Trade Center Health Program.

Reviewed claim forms, medical records, and billing documents for accuracy and completeness.

Entered and corrected claims (837P, 837I, 835 files) using Plexis system; handled both institutional and professional claims.

Managed appeals, audits, peer reviews, and ensured compliance with federal and company guidelines.

Responded to customer inquiries and provided claim status updates, resolutions, and follow-ups.

Investigated claims to determine payment eligibility and coordinated approval processes.

Caduceus Occupational Medicine – Hapeville, GA Jul 2005 – Apr 2012

Workers' Compensation Coordinator – A/R

Handled end-to-end operations for workers’ compensation claims, including coding, billing, collections, and payment posting.

Acted as liaison between insurance carriers, nurse case managers, and providers.

Obtained authorizations, followed up on outstanding bills, and managed appeals and denials.

Maintained injury and treatment records, processed invoices, and resolved claim discrepancies.

Performed audits to ensure accuracy in claims and billing procedures.

Tenet Health (Atlanta RBO) – Alpharetta, GA Mar 1999 – Jul 2006

Healthcare Business Specialist

Processed medical, workers’ comp, third-party, legal, and government program claims using AS400 and EDI systems.

Worked denied claims, managed collections, and resolved clinical documentation issues.

Reviewed contractual agreements and ensured correct electronic billing submission.

Handled complex accounts including bankruptcy, probate, auto liability, inmate, and home health billing.

Prepared all necessary documentation for payer audits and appeals.

Education

Ball State University – Muncie, IN

Associate of Arts, Healthcare Administration

National Institute of Technology – Atlanta, GA

Medical Billing and Coding (Trade School)

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