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Credentialing Specialist Resume Samples
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Candidate Info
33
years in workforce
14
years at this job
HS
Business
AAS
Accounting
Senior Credentialing Specialist
Processed provider credentialing information, including verification of data in accordance with policies and procedures, to support network development and credentialing processes.
- Assisted in preparing and coordinating provider information to / from managed care quality committees and other internal departments and / or external entities.
- Exceeded production goals by 99% while maintaining quality.
- Maintained credentialing database while tracking all direct provider contract data.
- Performed primary and secondary source verifications of credentials according to departmental policy.
- Maintained all medical license, Drug Administration and malpractice insurance for physicians and mid-level providers.
- Ensured compliance with national standards of quality organizations.
Candidate Info
15
years in workforce
4
years at this job
Business Administration
Credentialing Specialist I
Supervised Payor Audits
- Audited, data entered, and preformed primary source verifications in accordance with various regulatory agencies for credentialing, recredentialing, and delegated accounts.
- Resolved practitioner concerns in a timely manner.
- Analyzed reports to ensure processing compliance.
- Produced canned reports and maintained Visual Cactus Database
Candidate Info
18
years in workforce
11
months at this job
BS
Education
Credentialing Specialist
Exceeded performance standards
- Promoted special projects to enhance operations
- Efficiently credentialed all initial applicants in a timely fashion
- Supported enterprise decision-making with subject matter expertise
- Provided excellent customer service to practitioners, managers and teams as evidenced by satisfaction surveys
Candidate Info
8
years in workforce
3
years at this job
HS
High School Diploma
C
Pharmacy Tech
BS
Business
Lead Credentialing Specialist
Assessed applicant skills and abilities to confirm suitability and make appropriate position matches for government contracts. Coordinated with administrative points of contact in each staff element to ensure pool of applicants matched open needs.
- Provided assistance and guidance to employees with resume preparation, health record requirements, and completion of the personal provider information sheet (PPIS), and SF85P forms.
- Provided written and verbal instructions throughout each step of the credentialing process.
- Performed primary source verification of provider credentials, education, and employment history.
- Conducted electronic queries using databases for verification and sanction information for the credential file and contract application. Researched salaries for salary survey and comparison.
Candidate Info
23
years in workforce
2
years at this job
C
Conflict Resolution
BS
Public Health Administration
MBA
Strategic Healthcare Management
Credentialing Specialist, Office of Medical Staff Affairs
Managed credentialing process for initial appointments and reappointments of medical staff working closely with department chairmen, faculty, and hospital administrators
- Increased productivity and improved efficiency by systematizing and creating a performance improvement plan for the re-credentialing process
- Lead the transition from paper to electronic application submission (in process)
- Verified the professional licensing, training, and certifications of professional medical staff to ensure healthcare professionals comply with all established regulations and guidelines
- Assisted in interpretation and enforcement of Medical Staff Bylaws and Joint Commission standards and provide guidance to Medical and Dental Staff when necessary
- Maintained and updated all practitioner databases
- Reviewed credentials files and ran reports for potential red flags
- Assisted in areas of budgeting, performance improvement, and compliance as needed
- Attended monthly Medical Executive Committee, Credentials Committee, and Quarterly Medical Staff Meetings with hospital administrators as required
Candidate Info
14
years in workforce
4
years at this job
Credentialing Specialist
I began this position without any knowledge after only being there for 6 months the other Credentialing Specialist gave her 2 weeks notice. At that point of time I took over and continue to be the only credentialing specialist for 9 different hospitals.
- I don't hold any certificates at this time, partly because I needed to have at least 2 years of experience in the field and once I had the 2 years of working knowledge I was so busy and continue to busy but I am willing to get certified.
- I am a member of NAMSS.
- At this time I currently do all aspects of credentialing for over 500 providers at 9 different hospitals.
- I prepare the Credentialing Agenda, Credentialing Report and provide the minutes for the Credentialing monthly meeting.
- I provide the Orientations for all new providers.
- Credentialing Software - Midas/Series
Candidate Info
5
years in workforce
2
years at this job
BS
Health Services Management
MS
Healthcare Administration
Credentialing Specialist
Enhance and conduct onboarding process for all new hires (Physicians, Nurse Practitioners, Physician Assistants and Scribes)
- Coordinate, manage, and maintain Scribe onboarding for the team
- Develop process improvement initiatives to improve operational efficiency and reduce onboarding turn over time
- Collaborate with new hospital clients and establish processes to facilitate onboarding for new hires by a strict deadline
- Generate and deliver onboarding process reports for hospital management by providing status updates on new hires
- Build and manage relationships with hospital clients, recruiting and physician leadership
- Developed and implemented onboarding workflows, hospital requirements paperwork, and best practices for onboarding team
- Received three "MedAmerica: All Star" awards for demonstrating accountability, providing exceptional service, teamwork and camaraderie
Candidate Info
10
years in workforce
1
year at this job
BS
Education
MA
Hr Management
Credentialing Specialist
Coordinate the credentialing process for a staff of 30 pathologists. Monitor and renew medical licenses and malpractice insurance.
- Execute applications and track the process for new State medical licenses for providers.
- Collaborate with insurance companies and process enrollments into Medicare and MassHealth.
- Maintains appropriate CME requirements for each State license for individual physicians.
- Resolve contracting issues with credentialing and continually initiate system and process improvements.
- Verify State licenses, Board Certificates using the National Practitioner Data Bank Report, online verification of medical licenses, Veridoc, Federation of State Medical Boards, Uniform License Application.
Candidate Info
15
years in workforce
11
months at this job
Business Management
Credentialing Specialist
Meet with Providers to discuss contracting and insurance requirements for participation with each insurance company.
- Prepare and submit all appropriate applications and required supporting documentation.
- Follow-up with insurance companies to insure timely processing of applications and contracts.
- Educate providers on credentialing and contracting guidelines and requirements
- Facilitate monthly and or weekly meetings with insurance provider representatives to insure escalated issues are handled and resolved in a timely manner.
- Run daily production and task inventory, discuss with management appropriate course of action to maintain work load and productivity requirements.
Candidate Info
2
years in workforce
1
year at this job
BA
Political Science
Credentialing Specialist
Promoted to Credentialing Analyst for largest client as a specialist.
- Worked within a specialized team to maintain provider profiles for over a thousand healthcare providers, as well as new enrollments for healthcare providers new to the system.
- Created a system to maximize workflow and communication within the team to increase efficiency, output, and quality of service by establishing new guidelines and procedures.
- Assisted in managing accounts by maintaining client relations and performing routine checks and audits for oversight.
Candidate Info
11
years in workforce
1
year at this job
Office Manager/ Credentialing Specialist
Completed provider enrollment applications and followed-up on the status of paperwork (Commercial Insurance carriers, Medicaid and Medicare )
- Provided administrative assistance to the CEO, CFO, and Director of Operations.
- Developed, drafted and reviewed office correspondences and forms
- Accounts payable and receivable
- Ordered office supplies
- Planned/ organized office events/parties
- Appealed denied claims
- Followed-up on unresolved medical billing issues
Candidate Info
9
years in workforce
9
years at this job
AS
Science
Nursing Assistant
Credentialing Specialist, Upi/triwest Provider and Institution Credentialing
Credentialed 5000+ UPI providers/Triwest Providers for 49 Managed Care Organizations that delegate the credentialing process to UPI.
- Credentialed 500+ Institutions that delegate the credentialing process to UPI.
- Performed criminal history checks for oncoming providers
- Ran queries on providers for any monthly sanctions
- Performed large mailings weekly
- Developed flow charts detailing steps for oncoming or recredentialing providers
- Composed file folders daily
- Compose detailed check sheets
- Extensively review physicians "Colorado Health Care Professional Credentials" application
- Insert completed and reviewed criminal history/background checks
- File completed files in high density filing system
Candidate Info
4
years in workforce
1
year at this job
HS
High School Diploma
Credentialing Specialist
Screened and validated information given by providers
- Verified information and credentials supplied by applicant
- Created enrollment records in the Provider Enrollment Chain Organization System (Pecos)
- Scanned electronic documents attaching them to correct files
- Verbally responded to telephone and written inquires daily
Candidate Info
5
years in workforce
3
years at this job
HS
High School Diploma
BA
History
Credentialing Specialist
- Assisted in credentialing vision, dental, and hearing providers to company network which administers various managed care plans nationally that included Medicaid, Medicare, UPMC, and etc.
- Frequent contact with vision and dental providers and practice managers to verify and obtain outstanding credentialing information including but not limited to Malpractice insurance policies, State Licenses, DEA certificates, and etc.
- Updated multiple internal software systems with provider and practice information
- Coordinated with supervisor to organize provider files for audit and HIPPA compliance purposes
- Assisted in maintaining physical credentialed provider files
- Scanned physical files to assist the departmental effort to transition to paperless records
- Assisted in large data conversion project that consolidated multiple internal software systems to one dedicated application
Candidate Info
11
years in workforce
4
years at this job
AA
Associate of Arts
Credentialing Specialist
Reviewed and analyzed dental credentialing applications, ensuring completeness, accuracy and compliance with federal, state, and local accreditation agencies and company guidelines, policies and standards.
- Queries National Practitioner Databank and Office of Inspector General and SAM on all prospective dental providers.
- Organize and maintain credentialing files. Works with provider relations staff to ensure follow up when provider's applications are incomplete.
- Assists with the coordination of the credentialing committee review.
- Tracks Providers expiration dates, mail renewal documents and maintain records regarding providers liability insurance.
- Initiates correspondence to providers and clients when necessary to obtain requisite credentialing and re-credentialing information.
Candidate Info
6
years in workforce
5
months at this job
HS
High School Diploma
Medical Insurance
Credentialing Specialist
Maintain regular cooperation and compliance with all regulatory, accrediting, and membership-based organizations.
- Create and carry out various credentialing processes in relation to physicians, medical assistants, and various other healthcare professionals.
- Ensure that all personnel and services adhere to facility and staff policies, department guidelines, regulations, and government laws.
- Process applications and reappointment paperwork, checking for full completeness and accuracy.
- Constantly collect and process significant amounts of verification and accreditation information
- Must constantly maintain and update accurate databases for both practitioners and facilities.
- Prepare their own records for regular auditing.
- Maintain close communication with all appropriate practitioners to ensure that records are up-to-date and consistent.
Candidate Info
15
years in workforce
2
years at this job
Medical
Credentialing Specialist
Coordinate and monitor the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
- Conduct thorough background investigation, research and primary source verification of all components of the application file.
- Identify issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
- Respond to inquiries from other healthcare organizations and clients on a day-to-day basis, regarding credentialing and privileging issues as they arise.
- Utilize the Cactus credentialing database, optimizing efficiency, run reports; submit and retrieve National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
- Ensured compliance with regulatory bodies (Joint Commission, NCQA, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
- Work effectively with other departments to ensure proper payment and claims processing.
- Contact all appropriate parties to obtain, verify and validate correct claim information claims by telephone, fax, email, and/or mail to resolve unpaid and denied claims with minimal errors.
Candidate Info
16
years in workforce
5
years at this job
AS
Medical Assisting
Credentialing Specialist
Complete hospital and DOD applications for appointment and the reappointment process
- Complete Medicare applications as needed for the client and [company name]
- Submit soft credentials to our clients, as needed for the Radiologists
- Prime Source Verify the Radiologists credentials.
- Completed hospital and DOD applications for appointment and the reappointment process
- Completed Medicare applications as needed for the client
- Submitted soft credentials to our clients, as needed for the Radiologists
- Prime Source Verified the Radiologists credentials.
Candidate Info
10
years in workforce
3
years at this job
English
English
Credentialing Specialist
Process re-credentialing applications and paperwork using CAQH database
- Check for full completeness and accuracy
- Collect and process significant amounts of verification and accreditation information
- Maintain and update accurate database for both practitioners
- Check and maintain pertinent education, training, experience and licensure content. Credentialing Maintain close communication with all appropriate practitioners to ensure that records are up-to-date and consistent
- Answer calls from providers regarding credentialing application status and credentialing criteria.
- Train new Administrative Assistant and Data Entry staff
Candidate Info
10
years in workforce
2
years at this job
AS
Arts
BS
Human Development & Family Studies
Credentialing Specialist
Assist in the implementation of a centralized system-wide credentialing program
- Develop, mail, collect, and process reappointment credentialing applications for the health system
- Communicate directly with physicians, allied health staff, and office managers regarding reappointment
- Notify medical staff when state licenses and malpractice insurance certificates on file will expire
- Collaborate with medical staff coordinators at all five St. Vincent's Health System entities
Candidate Info
4
years in workforce
4
months at this job
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
9
years in workforce
9
years at this job
BA
Business Administration
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
13
years in workforce
5
years at this job
BA
Business Management
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
9
years in workforce
6
years at this job
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
2
years at this job
BS
Sociology
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
8
years in workforce
3
years at this job
BS
Business Management
MA
Business Administration
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
7
years in workforce
2
years at this job
MA
Technical Management / Healthcare Management
Medical Billing & Coding Program
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
17
years in workforce
11
months at this job
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
13
years in workforce
1
year at this job
BS
Business Admini Stration
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
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
7
years in workforce
3
years at this job
HS
High School Diploma
Credentialing Specialist
- Performs initial and re-credentialing activities to assure each application met credentialing standards.
- Receives, researches and answers calls from provider offices regarding credentialing and other quality issues.
- Communicates daily with physicians and hospital medical personnel to obtain needed documentation for provider files; completes written correspondence and maintains organized files.
- Assists with preparing for monthly MAC by auditing files, pulling spec sheets, assembling binders and updating Cactus.
- Understands the use of Cactus, Word, Excel, and CareVu Systems
- Maintains all Credentialing turnaround times.
Candidate Info
6
years in workforce
9
months at this job
BS
Healthcare Administration
Credentialing Specialist
- Manage credentialing with third party contracts focusing on quality assurance and regulatory compliance.
- Analyze and identify discrepancies in the credentialing process and redevelop new policies and procedures to create a more consistent workflow in the department.
- Create and manage tracking tools to maintain workflow in the department, and provide recommendations and insights to executive leadership to justify workload and hiring additional staff.
- Process credentialing and re-credentialing application and/or enrollments of healthcare providers in a timely manner consistent with internal policies and procedures while meeting funder requirements.
- Review provider applications, prepare verification letters, and maintains database with accurate, up-to-date information.
- Responsible for collecting, entering, updating and maintaining NPI, CAQH, AHCCCS, Medicare and any other applicable provider numbers and information in the system.
- Responsible for communicating with medical office staff, licensing agencies, and insurance carriers/health plans on a regular basis, developing relationships benefiting the agency.
Candidate Info
16
years in workforce
14
years at this job
AS
Associate of Science
BS
Bachelor of Science
Billing/credentialing Specialist/ Payment Posting
Service external and internal customers with exceptional customer service
- Handle and maintain front and back office
- Verify patient insurance effectiveness
- Credential new and existing providers for network participation
- Patient Charting
- Review claims payment accuracy.
- Insurance/ Payment Posting
Candidate Info
16
years in workforce
7
years at this job
BA
Sociology / Criminal Justice
Credentialing Specialist
- Performed quality audits on and maintain practitioner profiles ensuring they are ready for Credentialing committee in accordance with office policy, Joint Commission standards, and State and Federal Regulatory guidelines.
- Quality audit review includes but is not limited to: review of all primary source verifications, all online verifications to include EPLS, OIG, NPI, NPDB, DEA, State Licenses, CDS, and ECFMG.
- Assist in the credentialing process by entering/logging/scanning information into credentialing system for initial, updated, add on applications and maintenance processes.
- Acts as liaison with MSO as point person for completing and ensuring compliance and delivery of required information to clients in a timely manner.
- Mentor probationary employees for various teams to ensure they were performing appropriately.
Candidate Info
16
years in workforce
4
years at this job
Medical Billing
Credentialing Specialist
Track and manage compliance based on JCAHO (Joint Commission on Accreditation of Healthcare Organization) policies and procedures implemented by the company
- Prepare credentialing and re-credentialing applications on behalf of physicians and Nurse
- Credentialing files to meet VMS standards
- Conduct monthly audits for file compliance report to JCAHO
- Interface with contacts from client facilities/hospitals on compliance requirements and updates
- Set up and monitor all background checks and drug screens
- Distribute and maintain all competency testing for candidates
- Obtain all required documents for facility specific on-boarding requirements
- Verify all professional licenses and certifications for all candidates
- Candidate submittal review for facility placement
- Ensuring all candidate files are compliant by pulling weekly reports to ensure all documents remain current
Candidate Info
5
years in workforce
7
months at this job
AS
Health Management
Credentialing Specialist/ Coordinator
Provide credentialing and privileging verifications, including all Peer References, Education, and Affiliations. Participate in the delegated credentialing audit process as needed
- Manage monthly Expired Credentials and Expiring Facility Privileges to ensure timely renewals.
- Validate and process acceptable documents such as medical records, background check results and certifications.
- Processing, auditing and review of credentialing and re-credentialing of allied Health providers.
- Building/maintaining relationships with field/branch employees
- Accurate completion of employee files including pre-employment screenings, credentialing, and testing
- Managing compliance in accordance with Joint Commission and MSN standards
- Working with existing field/branch employees to keep documents current, active and compliant.
- Providing back-up support (with additional functions as deemed required) to help assure all operational needs are met
Candidate Info
19
years in workforce
2
years at this job
Credentialing Specialist, Medical Billing
Timely and accurate data verification, electronic transactions, pay-to-address, commercial and state insurance enrollment
- Ability to maintain and monitor assigned client accounts and respond to client questions and changes regarding enrollment related issues
- Working cross-functionally to continuously improve our service
- Participate in client calls as needed. Evaluate enrollment requirements for new and prospective clients
- Coordination and project management of the enrollment portion of client implementations when needed to ensure all enrollment deadlines are met or surpassed
- Review claim notes, conduct supplemental research and analysis, and process large amounts of information in order to take appropriate next actions on claims
- Review payments and/or denials posted, Research and understand payor and posting issues, Identify, document, and communicate existing and potential problems
- Compile information regarding errors, complete reports on a weekly, monthly basis, resolve unpostable items
- Document client and product-specific posting procedures to ensure internal staff and vendor are provided with required training materials
- Cross functional investigation and resolution of enrollment related claim denials
Candidate Info
11
years in workforce
4
years at this job
AS
Business Management
BS
Business Administration
Credentialing Specialist
Maintain an excellent record of performance in quality assurance and data integrity to ensure accuracy and completeness of provider credentialing process.
- Responsible for reviewing, researching and primary source verifying provider credentialing and recredentialing practitioner and health delivery organizations to ensure compliance with CFHP policies and procedures, NCQA, and TDI and HHSC guidelines.
- Oversees the daily activities associated with the efficient operation of the provider credentialing process, in cooperation with the Network Management department, Quality Management department and the Medical Director.
- Organizes and maintains files, receives incoming and makes outgoing calls to providers to obtain missing or additional information for application completeness.
- Coordinates and attends the bi-monthly Credentialing Committee meetings. Works in conjunction with the Credentialing Manager in coordinating the credentialing committee activities.
- Prepares various monthly, quarterly and annual reports relevant to the provider credentialing process and performs other related duties as requested or assigned.
Candidate Info
10
years in workforce
1
year at this job
HS
Medical Assisting
Provider Enrollment/credentialing Specialist
Provider Enrollment/Credentialing
- Screen and analyze provider data forms: CMS 855I and CMS 855R (Reassignment of Benefits)
- Determine whether the applicant meets all requirements/qualifications of Medicare Part B and all applicable state requirements.
- Send notification of missing information that is needed to properly complete the enrollment process.
- Research and resolve provider problems and complaints.
- Maintain above average knowledge of medical practices as it relates to Medicare
- Organize time and workflow
- Answer telephone calls from providers and other Medicare Services area that are related to provider enrollment policies and procedures
- Strive to conduct daily operations in a professional manner, according to the values established by Medicare services operations.
- Identify fraudulent providers enrolling in the Medicare program.
- Understanding of Physician's Current Procedural Terminology (CPT) coding for determination of specialty billing.
Candidate Info
26
years in workforce
3
years at this job
Computer Networking
Business Administration
Credentialing Specialist
Credentialing of current and new hire staff
- Establish and update CAQH
- Prepare verification letters
- Maintain Insurance ID numbers and UPIN numbers
- Establish EFT's for all Insurance payors
Candidate Info
10
years in workforce
6
months at this job
BA
Bachelor of Arts
Technology
Provider Enrollment and Credentialing Specialist
Confirming provider's information with accrediting and licensing agencies.
- Maintaining a database of provider's and client's information.
- Verifying that providers are properly enrolled and credentialing is not expired.
- Utilizing company's database and variety of software.
Candidate Info
12
years in workforce
1
year at this job
HR Training and Credentialing Specialist
Member of the CPR Instructor team
- Ensure all new hires complete certification requirements
- Develops and maintains Human Resources data bases and filing systems
- Reviews training records for completeness and accuracy
Candidate Info
15
years in workforce
6
years at this job
BA
Advertising
Communication Design
Credentialing Specialist and Graphic Designer
- Credentialing specialist for a fast-paced, rapidly growing practice of 15 providers and 11 locations in Texas and California. Responsible for filing and maintaining the necessary paperwork, contracts and licenses in accordance with insurance company, hospital and state law guidelines.
- Handle all of the enrollments, prior authorizations and daily maintenance of over 150 patients on the specialty medication Xolair. This requires an in-depth understanding of the dosing schedule requirements, clinical documentation and insurance payments, as well as constant communication with insurance companies, specialty pharmacies, drug manufacturers, and patients. A special focus on the needs of the patient, act as a bridge between the patient and the insurance company and quickly respond to all patient
- Participate in the daily flow of office functions, including scheduling appointments, insurance verification, ordering, and training new administrative hires.
- Create all promotional materials, business cards, pamphlets and other various artworks for office use, advertisements and media distribution for a growing company covering five different regions.
- AdvancedMD and Healthfusion medical software.
Candidate Info
8
years in workforce
1
year at this job
AAS
Associate of Applied Science
BS
Criminal Justice
Physician / Allied Health Credentialing Specialist
Generate and process applications for membership
- Verified all information
- Organized and maintain credentialing files for initial/reappointment of Medical and Allied Health professionals
- Develop a timeline listing for each applicant
- Serve as a liaison between Senior Management and Medical Staff
- Monitor physician's expirables
- Applied principles to determine physicians eligibility
- Knowledge of JCAHO, NCQA standards
- Prepared correspondences for external and internal requestors
- Assist with special projects to include research
Candidate Info
13
years in workforce
2
years at this job
AAS
Business Management Program
AAS
Medical Secretary Program
Credentialing Specialist
The position comes with various responsibilities within the Revenue Cycle Management Department.
- It is important to maintain medical staff within the organization by verifying their credentials.
- It is part of the responsibility in my position to ensure that the hospital or health-care facility complies with federal and state regulations regarding licensure and certification of facilities and medical professionals.
- A liaison between hospital and clinic administration and the medical staff, including physicians, technicians and nurses by maintaining the data for various providers within the Allina Health organization to track the expiration of certifications and licenses. I also ensure that health-care providers update their certification or licensing on time to be able to process new applications, renewals to provide physician privileges to the facilities and for reimbursement from various third party payers.
- My position in affiliation and credentialing allows me to work independently, analyze data and conduct research while performing various demands of the job.
Candidate Info
6
years in workforce
2
years at this job
C
Medical Coding & Billing
Billing/credentialing Specialist
Billed Mental Health Claims With H-Codes and T-Codes( 75 claims daily)
- Worked with regional centers ( ALTA, CVRC, SRC, ATAP, )
- Worked with all major commercial insurances
- Got authorizations for mental health
- Helped families understand their co-pays
- Answered phones/Customer Service
- Worked aging reports monthly /billed reports daily
- Medi-Cal/TAR'S
- Credentialing for 5 offices and 10 BCBAs
- Letters of Agreement
- Billed Primary insurance/Secondary's
Candidate Info
14
years in workforce
3
years at this job
Credentialing Specialist
- Credential according to client's business model
- Works closely with client, facility, group and provider in order to make the credentialing and privileging process run smoothly
- Assists the facility or group with any outstanding items in order to complete the credentialing and privileging process
- Responsible for making sure the client hasrequired documentation to meet their credentials standards based on their business model prior to the provider starting his/her assignment
- Processes requests for initial applications, including data entry, application generation, and mailing and electronic delivery
- Conducts continuous outreach to providers with outstanding initial and reappointment applications, second- and third-request letters, and telephone calls.
- Processes initial and reappointment credentialing applications as assigned
- Reviews and organizes incoming credentials applications, including data entry, organizing files in file order, and distributing selected documents, forms and checks to clients
- Performs related and unrelated tasks as assigned
Candidate Info
13
years in workforce
7
years at this job
HS
Medical Billing & Coding Program
Credentialing Specialist
- Processes all physician information including on boarding processes, licensure with state boards and privileging and reappointments for hospital affiliation; tracks progress of applications
- Maintains client physician confidentiality while updating and tracking information in physicians' files; continuous maintenance of physician records; devoted customer service to both clients and physicians
- Implementing and completing various projects to maintain organization and compliance
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