Credentialing Specialist Resume Samples - Page 3

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Credentialing Specialists are responsible for verifying the professional licenses and certifications of medical staff. Their duty is making sure that federal and state standards are met and they may also assist auditors and help keeping a facility's accreditation. The strongest example resumes for Credentialing Specialists emphasize health information expertise, organization, attention to details, teamwork and communication skills. Report writing skills are a must. Most sample resumes for Credentialing Specialists highlight an Associate's Degree in health information management.

For more information on what it takes to be a Credentialing Specialist, check out our complete Credentialing Specialist Job Description.

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21

Credentialing Specialist

Submitted providers credentialing application to all MCO's and PPO's

  • Reviewed applications and maintain up-to-date database
  • Verified and processed all credentialing information through a strict vetting process
  • Called insurance companies, universities and certification boards as well as cross-checking all information against government-regulated databases
  • Reminded providers when credentials are expiring
  • Attended new provider orientations, providing credentialing packets and answering questions as needed
  • Re-credentialed providers with MCOs and PPOs when necessary
Candidate Info
4
years in
workforce
4
months
at this job
22

Managed Care Contracting and Credentialing Specialist

Overseeing proposal plans, adjustments, biddings, preparing, revising and administration of contracts that involve the purchase of sale of goods and services. Collecting relevant and critical data to determine applicant's eligibility to contract with the organization by creating relationship with vendors. Managed the flow of information between the managed care payers and contracted MSO facilities. Record and tracked contract statistics for future reporting while performing verification of applications, data entry, and reporting. Ensure all expiable are reviewed, obtained and managed on a monthly basis according to rules and policies. Maintain the confidentiality of all business, work and contracting information to ensure contract execution in accordance with company policy.

  • Prepare contract briefs and revisions, summarizing contractual requirements and budgets. Tracking authorizations and correspondence with industry trends and produces member supply reports. Processed and communicated with practitioner additions, deletions, and/or changes to all contracted vendors. Negotiate pricing, terms and conditions, mutually agreeable solutions to identify compliance issue, work proactively and effectively to overcome and prevent internal and external compliance problems from inception to completion. Conducts market competitive analysis, promotes best practices across membership, development of contract maximization strategies. Research complete and submit credentialing, re-credentialing and change of information applications for Medicare and other insurances. Review, maintain and update department contract and Medicare files, and application databases to keep information current and accurate. Analyze and mitigate risk.
  • Prepare and disseminate information to appropriate employees regarding contract status, facilitate contractor meetings. Ensure that contractor is in compliance with legal requirements, owner specifications and government regulations. Gathered and conducted verification of provider credentials for internal & external communications regarding all payer and vendors. Researched, completed and maintained compliance with facility and delegated payers through audit processes and procedures. Responsible for maintaining contracting system upgrades/enhancements and preparing for managed care contracted MSO facility audits. Prepared, payer relations & facility delegate at internal and external meetings and documents to be reviewed for contract approval and execution by senior management. Monthly reporting to Revenue Cycle Operations of Contractual Status. Maintain detailed and organized files.
  • Perform closing activities as needed. Track payments and deadlines to sales department by proving support to resolve open accounts receivables, credit approval, deductions and other outstanding receivable issues. Assisted/support customer service policies and procedures, to improve customer service and provide timely resolutions by requesting for proposal and quotation. Provide creative ways to refine customer history reports, DSO summaries by customer, product and region by analyzing business metrics data to Director of A/R. Obtained updated fee schedules for proposals and payment methodology from various contracts and contractual documents. Prepare contract change notices, monitor contractor performance, including the reporting and status of contractor and owner deliverables, while maintaining an audit file for each contract.
Candidate Info
9
years in
workforce
9
years
at this job
BA
Business Administration
23

Credentialing Specialist

Responsible for oversight and supervision of provider enrollment for [company name], as well as the practice management organization of [company name].

  • Responsibilities include the initial enrollment of all providers with all payers, ensuring CAQH, NPI and PECOS information is current, maintaining internal Access database of all provider information.
  • Communicate with all levels of the organization, from front-desk team members, billing team members, practice managers, directors, senior executives, and all providers.
  • Complete credentialing and re-credentialing applications. Complete or assist in the completion of all government applications including licensure, Medicare and Medicaid.
  • Send notification to payers regarding new office opens and changes of office information.
  • Maintain company wide information related to service offices including current address, phone/fax numbers, licensure, accreditation, government provider numbers, zip codes, counties serviced, services provided, etc.
  • Maintain integrity of all credentialing files.
  • Maintain and cultivate positive, long term relationships with contract/credentialing representatives and service/support office staff.
  • Complete special projects as assigned.
Candidate Info
13
years in
workforce
5
years
at this job
BA
Business Management
24

Credentialing Specialist

Review provider files for appropriate documentation required for the credentialing process.

  • Coordinate credentialing and re-credentialing applications and conduct document research.
  • Collect and maintain files in relation to credentialing of network providers, including application, contracts, current physician licenses, DEA licenses, malpractice insurance, board certifications and other pertinent forms.
  • Forward applications to providers and ensured accuracy and completeness of information.
  • Interface between providers and hospital staffs to collect required information.
  • Processed adds/changes/terms for provider demographic updates
  • Assessed and investigated provider data issues
  • Review provider files for appropriate documentation required for the credentialing process.
  • Coordinate credentialing and re-credentialing applications and conduct document research.
  • Interfaced with providers, internal departments to verify provider demographics.
Candidate Info
9
years in
workforce
6
years
at this job
25

Provider Enrollment and Credentialing Specialist

Entering/logging/scanning information into credentialing system for initial, updated, add on applications and maintenance processes

  • Manage the completion and submission of provider enrollment applications.
  • Perform tracking and follow-up to ensure provider numbers are established and linked to the appropriate Cogent group entity in a timely manner.
  • Establish close working relationships with credentialing coordinators, contracting department, medical management, and payer contacts.
Candidate Info
9
years in
workforce
2
years
at this job
BS
Sociology
26

Credentialing Specialist

Review applications and prepares verification letters.

  • Review initial and reappointment applications for Ancillary/Facility
  • Audit initial and reappointment files
  • Contacts medical office staff, licensing agencies, hospitals, and insurance carriers to complete credentialing and re-credentialing applications.
  • Conducts primary source verifications in accordance with CMS, NCQA, and DOI standards.
  • Identifies and obtains missing information.
  • Communicates with providers by phone, fax, email, and mail regarding credentialing status and information.
  • Communicates with internal staff members, physician offices, academic entities or other health related organizations in a professional and concise manner.
Candidate Info
8
years in
workforce
3
years
at this job
BS
Business Management
MA
Business Administration
27

Credentialing Specialist

Verify Physician Board Certification, Technician Certification and Equipment information

  • Update OptiNet Incomplete Spreadsheet, Retrieve documents for Customer Service, Claims and Providers Relations upon request, Test software environment for OptiNet
  • Perform monthly audits on selected BCBS & Anthem providers
  • Maintain audit spreadsheets for department, Perform monthly audits on selected providers
  • Assist Provider Relations and Claims in researching new participants who is not yet in our system. I verified providers TIN and physicians on CIGNA File to see if they are contracted with health plan. Receive and distribute department mail
  • Update provider information as requested in OptiNet & Provider Communication Management System (PCMS)
  • Provided training to Assessment, Provider Relations & Contracting departments
  • Maintain records of applications and verification letters.
  • Correspond with medical staff to obtain information or inform them of credentialing status or changes.
  • Trained (10) staff members on new scanning equipment
  • Test software environment for "OptiNet" before going "live"
Candidate Info
7
years in
workforce
2
years
at this job
MA
Technical Management / Healthcare Management
Medical Billing & Coding Program
28

Credentialing Specialist

Review all credentialing/re-credentialing applications from providers as received for 5 networks.

  • Distribute re-credentialing applications to providers as required based on re-credentialing timeframes
  • Maintain Database with provider information as received.
  • Submit a high volume of applications to CVO (MedAdvantage) for verification process.
  • Follow-up with CVO progress in order to prepare files for committee meetings.
  • Work closely with providers in order to obtain various documents/information as needed.
  • Assist with auditing of provider files to ensure compliance.
  • Generate various credentialing reports for upper management as requested.
  • Credentialing Committee Member: Assist with monthly preparations for the meetings
  • Work closely with the Provider Relations Dept. on provider issues as needed.
Candidate Info
17
years in
workforce
11
months
at this job
29

Credentialing Specialist

Submit and maintain provider and group practice applications and contracts.

  • Enter and maintain provider information and documentation into CAQH credentialing database.
  • Verify potential and existing provider's licensure, liability insurance, BNDD, CDS and DEA certificate.
  • Verify Provider's education, hospital privileges, Board certification and other criteria as required.
  • Verify accurate banking & billing information.
  • Assure all files have a Welcome, Denial or Term letter as appropriate.
  • Keep up to date provider enrollment process and records and track provider participation levels.
  • Update the system and the credentialing database to reflect approvals, denials and/ or terminations
Candidate Info
13
years in
workforce
1
year
at this job
BS
Business Admini Stration
30

Credentialing Specialist

Responsible for verifying the qualifications and certificates of providers that are training and or working in a Military treatment Facility.

  • Provide pre-qualified candidates credentials to the Military treatment facility in compliance with military guidelines and regulations.
  • Verify medical degrees through the National Student Clearinghouse for certifications, residency/training, board certifications, practice licenses and registrations.
  • Run queries through the National Practitioner Data Bank, Department of Health and Human Services and TriCare databanks.
  • Maintain the Centralized Credentials Quality Assurance System (CCQAS) military provider database.
  • Ensure provider information is entered accurately and prepare documents for scanning and uploading into the CCQAS database.
  • Track credit card charges and receipts and verify transactions for monthly reconciliation reports.
  • Provide administrative support to the credentials managers at the medical treatment facilities.
  • Ability to work with confidential information on a daily basis
Candidate Info
13
years in
workforce
1
year
at this job

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