Credentialing Specialist and Provider Enrollment
Resume:
Eunice Withers
Troy, NY *****
**********@************.*******.***
Professional Summary:
Highly organized, detail-oriented Credentialing Specialist with extensive administrative experience and a proven ability to manage complex projects, maintain accurate records, and meet tight deadlines.
Work Experience:
Credentialing Specialist
ELEVANCE HEALTH-Latham, NY
May 2019 to Sept 2024
Submit provider enrollment applications to government agencies in a timely manner.
Build and maintain strong working relationships with providers, office managers, billing teams, and payer contacts.
Participate in onboarding meetings.
Maintain enrollment data in the credentialing database and generate reports for clinic leadership as needed.
Prepare credentialing files for submission to government and commercial payers upon receipt of applications.
Identify credentialing red flags and escalate to managers/supervisors for review.
Maintain a tracking calendar for licensures, certificates of insurance, and network expirations.
Submit Annual Disclosure of Ownership and complete Medicare/Medicaid revalidations for providers and practices.
Manage credentialing and re-credentialing to meet contracted network timelines.
Educate providers and office staff on enrollment/credentialing processes and policies.
Manage provider CAQH and NPI accounts.
Credentialing Specialist
EMBLEM HEALTH-New York, NY
November 2010 to January 2015
Managed end-to-end credentialing and recredentialing for 500+ network physicians and allied health professionals.
Verified practitioner credentials, including NY State licensure, board certifications, and professional liability coverage.
Maintained accurate database records to ensure compliance with NCQA, state, and federal requirements.
Coordinated provider enrollment for HMO and PPO plans, improving turnaround time for new provider onboarding.
Supported the credentialing committee by preparing comprehensive provider profiles for review.
Education:
HIGH DIPLOMA
EDUCATION: HIGH SCHOOL - Orange, NJ
Skills:
Credentialed providers for both Initial and Recred, with knowledge of NCC and NCQA policies/standards.
Managed processes and requirements for Medicaid and Medicare compliance.
Knowledgeable in lines of business and contracting across all markets/states.
Strong research skills for provider credential verification using state websites.
Proficient in Network Connect, FlexCare, NPPES, and Medicaid/Medicare systems.
Willing to take on additional detailed processes and responsibilities.
Familiar with medical billing for both providers and facilities.
Detail-oriented with a strong focus on accuracy and deadlines.
Proficient in Microsoft Word, Excel, OneNote, and Adobe.
Contact this candidate