Jessica Claire
Montgomery Street, San Francisco, CA 94105 (555) 432-1000,
Professional Summary

Credentialing Manager experienced at directing administrative and personnel matters Managed Service Organization. Strong problem-solver with excellent time management skills.

Education and Training
Expected in 1989 | Central Islip Senior High School, , GPA:
Skill Highlights
  • Staffing management ability
  • Conflict resolution
  • Sound decision making
  • Staff training and development
  • In-depth claims knowledge
  • Claims analysis and review specialist

Professional Experience
2012 to Credentialing Manager Ati Physical Therapy | Downers Grove, IL,

•Manage the Credentialing Clerk who's responsibilities include:

Receipt of materials and data base management.

Assembly of files.

Distribution of files to Credentialing Coordinators.

Preparation of various credentialing letters and other correspondence.

Maintenance of confidential provider contract/credentialing master files.

Completion of other administrative functions as may be necessary.

Satisfying all department required time frames or communication of obstacles that do not permit meeting those goals

•Manage the Credentialing Coordinator (s) who’s responsibilities include:

•Review and verification of credentialing/re-credentialing information.

•Maintenance of provider files so they contain the necessary and complete credentialing documentation.

•Data entry of new provider information into departmental database(s).

•Monitoring of websites for sanction actions and timely notification of findings to management.

•Ongoing acquisition of documentation required for credentialing of providers

•Management of delegation oversight audits as required by client health plan’s policies and procedures.

•Preparation of necessary correspondence to delegated entities, providers, and others as needed.

•Timely monitoring of providers who require re-credentialing.

•Participation in client health plan Credentialing Committee meetings as needed.

•Oversight of delegation oversight audits and result reporting as required by client health plan’s policies and procedures.

•Completion of other administrative functions as may be necessary.

•Satisfying all department required timeframes or communication of obstacles that do not permit meeting those goals.

•Provide the following administrative functions:

•Maintain on-going contact with Assistant Director on issues associated with aspects of the day-to-date operations of credentialing department performance.

•Ongoing oversight and training of staff on the utilization of technology that assists in credentialing and/or re-credentialing process (i.e., databases, CAQH)

•Regular contact with Chief Medical Officer or designee, to prepare Credentialing/Re-Credentialing and other materials relevant to the client health Plan Credentialing Committee Meetings

•Maintain contact with Delegated Entity administration on issues associated with performance of those Entities.

•Management of any Corrective Action Plans implemented by or for the health plan's credentialing program.

•Work with Senior Management in preparation for Audits, as may be necessary.

•Make presentations to Plan senior management on credentialing issues as needed.

• Participation in and reporting to the client health plan QA Committee, as needed Satisfy all department required time frames or communication of obstacles that do not permit meeting those goals.

2009 to 11/2011 Account Manager Walt Disney Co. | Kapolei, HI,

•Act as a daily point of contact for the client regarding issues pertaining to all the services performed by Royal on behalf of the client.

•Perform issue resolution and provide feedback to the client.

•Produce and perform quality assurance of all reports that are produced by Royal.

•Participate and lead as necessary, in all meetings between Royal and the client, including but not limited to management meetings, finance meetings and board meetings.

•Work closely with the Provider Relations Representative to coordinate services.

•Ensure that contractual obligations are completed timely and accurately.

•Coordinate the production of special reports as requested by the Plan.

02/2004 to 11/2008 Provider Relations Representative Archcare | Tarrytown, NY,

•Orient new providers and health center staff to Plan policies and procedures; conduct individual and group orientation sessions for private office providers and their staff and for center/hospital based providers, administrators and support staff.

•Conduct ongoing education of center/hospital and private office participating providers through on site visits, phone calls and mailings.

•Monitor accuracy of provider directory, provider database and HPN submission.

•Support credentialing process, including the entering of information on provider database.

•Represent the Plan and act as a liaison between the Plan and participating providers.

•Monitor provider compliance with participation agreement, policies and procedures, State and local requirements.

•Contribute to the development of provider orientation and training materials.

•Address provider inquiries and complaints; research / resolve provider problems and inquiries; track issues related to provider inquiries, problems and complaints.

•Assess provider network expansion needs; make recommendations to management; recruit and contract with providers, as appropriate.

•Maintain appropriate documentation of all provider contacts.

•Conduct provider surveys; assist with Quality Assurance studies.

•Act as an internal and external resource regarding provider development and relations.

•Conduct other duties as requested by management to ensure efficient company operations.

•Assist with Corporate QARR initiative as necessary.

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    School Attended

    • Central Islip Senior High School

    Job Titles Held:

    • Credentialing Manager
    • Account Manager
    • Provider Relations Representative


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