Livecareer-Resume
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(555) 432-1000,
Montgomery Street, San Francisco, CA 9XXX5
:
Jessica
Claire
Professional Summary

Reliable and highly skilled Credentialing Analyst with broad and deep knowledge of the healthcare industry. Extraordinary professional communication skills with staff, patients, and relevant government regulators. Able to function well as an independent worker or as apart of a medical insurance team, and clerical team. To expand my Credentialing Analyst Skills and enhance the company's productivity in the health field.

Core Qualifications
  • High familiarity with healthcare and credentialing industries
  • Superior skills in successful management of multiple tasks
  • Exceptional grasp of credentialing accreditation
  • Significant healthcare credentialing experience
  • Excellent customer service skills
  • Good written and oral communication
Education
University of Maryland University College , Expected in pursuing : Health Administration - GPA :

Health Administration

Morgan State University , Expected in GNA Certificate : - GPA :
Baltimore City Community College , Expected in Pharmacy Technician Certificate : - GPA :
Experience
Gw Medical Faculty Associates - Credentialing Specialist
Alexandria, VA, 11/2008 - 2012
  • Sending and receiving recredentialing applications for all providers including but not limited to Primary Care Physicians,Specialists, Ancillary Providers, Facilities and any Delegated Entity participating withCare First Blue Cross Blue Shield Health Care. Keep an accurate log of providers who have and have not sen in their recredentialing application.
Magellan Behavior Health Columbia MD - Prior Authorization Representative II
City, STATE, 2005 - 2008
  • Supported doctors and hospitals in obtaining prior authorizations.
  • Performs telephonic support for on-line authorization of routine services.
  • Provides direct support to primary care practices and specialty care providers regarding utilization, authorization, and referral for mental health.- Proficient in the use of ICD-9 and CPT codes for Mental health.- Data enters referrals for non-complex services including DME, inpatient and outpatient care, behavioral health services and testing as applicable, and special circumstance requests as defined by Utilization Management.- Assists in gathering information needed for coordinators/case managers to determine continued authorization.- Provides data entry for care which has been arranged by the Pre-Authorization Coordinators.- Contacts providers with authorization, denial and appeals process information.
  • Assists in educating and acts as a resource to primary care practices and specialty care providers.
  • Verifies eligibility of members and participating status of providers in Nasco and Flexx.
  • Determines member benefit coverage utilizing IDX or group coverage documents may receive pended claims reports on claims received without prior authorization to research and review eligibility and benefit coverage.
  • Upon decision of claim payment status, generates the appropriate referral with notification and exchange of information to the service organization for proper adjudication of claim payment.
  • Assists with the identification and reporting of potential quality management issues.
  • Responsible for ensuring these issues are reported to the Quality Management Department.
CareFirst Blue Cross & Blue Shield - Provider Credentialing and Networking Analyst I
City, STATE, 2002 - 08/2015
  • Analyzes and researches credentialing applications/provider contracts to verify that appropriate information has been obtained.
  • Process applicants receive d via paper and via CAQH.
  • Responsible for technical maintenance, initial entry and update of data on Provider DataBase Files and the data that feed to the Nasco, Facets.
  • FEP Operational Data Store(ODS).
  • Mail confirmation letters to professional providers identify necessary provider numbers for proper billing.
  • Maintain and update all aspects of corporate database for network providers, including credentials, addresses, contracting status.
  • Process all terminations and cancellations request from professional providers.
  • Perform primary source verification on new practitioners to Care First and perform Re-credentialing of existing practitioners every 3 years in accordance with NCQA guidelines.
  • Assign provider numbers and update demographics information on the corporate database for publishing provider information in various directories Process applicants and updates in accordance with applicable state laws and guidelines.
  • Complete updates to the department inventory control system (IACS).
United Health Care - Pharmacy Service Technician Authorization Representative
, STATE, 01/2002 - 01/2004
  • Analyzed prescription benefit plan.
  • Work with under pharmacist to ensure the appropriate use of selected prescription drugs.
  • Prevented the improper prescribing or use of certain drugs.
  • Coordinated and communicated with doctors to prescribe an alternate drug beneficial for the patient.
  • Supported Doctors and hospitals in obtaining prior authorizations.
  • Rendered exceptional customer service and met volume deadlines and timetables.
  • Huge knowledge of Credentialing Accreditation Deep knowledge of health care and credentialing industry Familiarity with professional telephone etiquette Amazing ability to work with minimal supervision Outstanding ability to manage multiple tasks Superior customer service skills Excellent communication skills Demonstrates success in handling large volumes of work.
Skills

Credentialing, Delegated large groups, CAQH experience, behavioral health, billing, Excellent communication, contracts, CPT, customer service, customer service skills, data entry, DataBase, ICD-9, inventory control, letters, Mental health, exchange, Mail, network, Operational Data Store, ODS, outpatient care, Pharmacy Technician, primary care, Quality, Quality Management, reporting, requirement, research, telephone etiquette

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Resume Overview

School Attended

  • University of Maryland University College
  • Morgan State University
  • Baltimore City Community College

Job Titles Held:

  • Credentialing Specialist
  • Prior Authorization Representative II
  • Provider Credentialing and Networking Analyst I
  • Pharmacy Service Technician Authorization Representative

Degrees

  • pursuing
  • GNA Certificate
  • Pharmacy Technician Certificate

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