Credentialing Specialist Resume Samples

Description :

1. Analyzed and verified immunizations, training certifications, and customer documents to ensure that representatives were compliant.
2. Maintained 20 queues simultaneously such as TB, Varicella, 7-panel drug screen, various hospital specific required documents.
3. Trained several employees on corporate accounts within SalesForce.
4. Processing and maintaining relationships with account managers and admins for corporate accounts.
5. Assisted in managing customer accounts via phone/email/SalesForce cases to ensure representatives were compliant with mandated guidelines Multi-tasked to maintain documentation during peak document seasons.
6. Maintaining document processing with 24-72 hours.
7. Spearheaded corporate training sessions and videos.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Responsible for coordinating, monitoring, and maintaining the credentialing and recredentialing process with accuracy and integrity of the credentialing database system and related applications for third party payer credentialing of medical staff, consulting physicians, facilities as well as allied health professionals.
2. Insuring interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statutes and laws relating to credentialing.
3. Compiles and maintains current and accurate data for all providers using CAQH applications or Wellcare applications.
4. Completes provider credentialing and recredentialing applications; monitors applications and follows-up as needed.
5. Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
6. Maintains corporate provider contract files and knowledge of current health plan and agency requirements for credentialing providers.
7. Set up and maintains provider information in online credentialing databases and systems Cactus, OmniFlow & Xcelys.
8. Tracked license and certification expirations for all providers to ensure timely renewals.

Experience

5-7 Years

Level

Executive

Education

Healthcare Management

Description :

1. Provider Application Specialist Responsible for completing provider credentialing and recredentialing applications in a timely manner.
2. Coordinates the application process for each client in conjunction with the Client Reimbursement Specialist.
3. Provide updates to insurers on additions and deletions on physician participation.
4. Liaison between the providers and the insurance companies regarding the status of the provider application.
5. Maintain physician files with accurate information and copies of completed applications.
6. Maintain a physician database on pertinent credentialing information.
7. Interact with physicians on a day to day basis.

Experience

0-2 Years

Level

Entry Level

Education

Organization Management

Description :

1. Coordinate and manage the credentialing process for approximately 275 new residents and fellows every year to ensure onboarding in a timely manner.
2. Monitor and provide services to approximately 1,400 residents and fellows.
3. Monitor licensing and certification of residents.
4. Process Visa applications and monitor status; verify National Practitioner Data Bank licensure; conduct Sterling background checks; log Quest drug screening results.
5. Serve as the liaison between residents/fellows and the Benefits department & Payroll Department to set up direct deposits.
6. Serves as a liaison between Learning Network and House Staff officers in regard to recertification of ACLS and BLS.
7. Prepare documentation, produce files and generate resident's contracts.
8. Investigate and respond to resident and faculty concerns in a timely fashion.

Experience

5-7 Years

Level

Executive

Education

Planning

Description :

1. Responsible for loading and managing accurate data in the credentialing database(s) and preparing reports and other documents to be presented to the Medical Management Committee.
2. Routinely updated providers on their credentialing status as requested and provided timely follow-up for requests of outstanding information.
3. Established and maintained a good working relationship with employees and providers.
4. Maintained and managed data accounts in database.
5. Proactively partnered with all departments to manage the timely satisfaction of client services obligations under all contract agreements.
6. Made observations and recommendations for process improvement to the Compliance Manager.
7. Maintained a strong working knowledge of credentialing operations and procedures.

Experience

5-7 Years

Level

Executive

Education

Healthcare Administration

Description :

1. Responsible for processing provider applications, credentialing/re-credentialing and primary source verification of providers (Commercial/Tricare accounts).
2. Perform and audit timely, accurate credentialing/re-credentialing of all providers.
3. Review systems to determine provider network status.
4. Contact providers for missing information were applicable, via Fax, Phone or letter.
5. Perform timely data entry of providers credentialing elements into the Vistar system.
6. Perform Primary Source Verification of practitioner credentials per NCQA standards.
7. Work with PSV Coordinator on establishing verification resources including NPDB, HIPDB and Criminal Background checks.
8. Prepare provider files for presentation to the National Credentialing Committee for approval or denial.

Experience

5-7 Years

Level

Executive

Education

Management Training

Description :

1. Point of contact for credentialing of the Texas Army National Guard.
2. Maintain provider files in accordance to Army regulations and HIPAA.
3. Recommend adverse action to the State Army Surgeon for providers in non-compliance with regulation.
4. Coordinate and conduct provider privileging / credentialing boards for the Texas Army National Guard.
5. Contact providers requesting help with missions and contact providers with orders for missions.
6. Coordinate missions and provider help with their respective units.
7. Help maintain database and track 68W (Healthcare Specialists) certifications and training for Texas Army National Guard.
8. Maintain medical records and their contents in compliance with HIPAA, file medical records, scan records into electronic database for department of defense.

Experience

7-10 Years

Level

Consultant

Education

B.A

Description :

1. Provide support to practitioners, facilities, groups being credentialed to help maintain credentialing work flow processes.
2. Departmental representative at various committee meetings.
3. Liaison between practitioners, health plans, hospitals and patient care facilities.
4. Obtain, review and complete practitioner's credentialing and re-credentialing applications while maintaining confidentiality of practitioner information.
5. Interact directly with medical practitioners to communicate documentation needs.
6. Prepare, submit and maintain provider information in online credentialing databases and systems.
7. Ability to track and meet all certification and license expirations for practitioners to ensure timely renewals.
8. Responsible for tracking and trending of all CAQH for all providers, including attestation for EHR incentive programs.

Experience

7-10 Years

Level

Management

Education

Medical Billing & Coding

Description :

1. Organize and review credentialing and re-credentialing of Medical and Allied Health Professional Staff applications for completeness and accuracy.
2. Perform primary source verification for initial and re-credentialing of assigned providers utilizing NCQA Standards and other federal and state regulatory requirements.
3. Ensure timely verification to prevent any negative impact related to compliance or regulatory requirements.
4. Maintains and monitors copies of current state licenses, DEA, CDS certificates, malpractice coverage and any other required credentialing documents for all providers.
5. Responsible for generating and monitoring credentialing reports via Cactus and QNXT.
6. Enter new providers into CAQH with accuracy and perform ongoing CAQH data input information into the credentialing database; generate reports as needed and track credentialing status of providers in the systems.
7. Research and evaluation on credentialing items for potential sanctions to be submitted to the Credentialing Committee.
8. Responsible for a variety of clerical duties in support of the credentialing process including filing, making phone calls, and mailing of correspondence.

Experience

5-7 Years

Level

Executive

Education

Bachelor Of Science

Description :

1. Reviewed provider files for appropriate documentation required for the credentialing process.
2. Coordinated credentialing and re-credentialing applications and conduct document research.
3. Collected and maintained files in relation to credentialing of network providers, including application, contracts, current physician licenses, DEA licenses, malpractice insurance, board certifications and other pertinent forms.
4. Interfaced between providers and billing company to collect required information.
5. Forward applications to providers and ensured accuracy and completeness of information.
6. Submitted applications to manager, medical director and Credentialing Committee for review.
7. Communicated with providers and field associates regarding credentialing status and information.
8. Received Managed Care and PPO provider applications and re-credentialing applications Communicated with providers and field associates regarding credentialing status and information.

Experience

2-5 Years

Level

Junior

Education

Public Administration

Description :

1. Reviewed provider applications and documents for accuracy and completion.
2. Performed verification of provider credentials, such as verification of licenses, medical education and internship/residency training.
3. Established provider files and maintained required documents as specified by each individual client.
4. Maintained and updated physician database.
5. Medical Staff Services Coordinator Credentialed physicians by written source verification of medical school, internship and residencies.
6. Maintained current and complete file documentation on each physician.
7. Assisted physicians in obtaining medical licenses in states that they were not currently licensed.
8. Completed applications for privileging physicians at the hospital for each locum tenens assignment.

Experience

5-7 Years

Level

Consultant

Education

B.B.A

Description :

1. Acted as liaison with nurse practitioners, human resources/recruitment, billing management departments and insurance companies/3rd party payors.
2. Completed reference checks and performed primary source verification of licenses and other certifications for new hires in 19 States.
3. Completed credentialing for employment as well as with all insurance companies and commercial payers in 19 states.
4. Obtained CLIA certificates and numbers for clinics in 19 states to ensure opening of clinic as scheduled.
5. Provided weekly credentialing reports to all levels of management to provide status of newly hired nurse practitioners to confirm clinic opening dates.
6. Coordinated with human resources to manage employee status including new hires, terminations and clinic/market changes.
7. Notified employees of expiring licensure and certification documents to ensure 100% compliance with credentialing policies.

Experience

7-10 Years

Level

Senior

Education

Business Management