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

Nationally Certified Credentialing Specialist bringing over five years of specialized credentialing and privileging experience both in the Federal Government and private sector; looking to obtain a position where my extensive knowledge of the credentialing and privileging process, billing enrollment process, credentialing laws and regulations as well as my strong research, training and analytical skills can be utilized. Also, to be employed with an organization who understands the importance of maintaining compliance and where professional growth and development can be gained while working towards the mutual goal of making a difference in the health care industry.

  • Federal Government credentialing and privileging experience
  • Proficient in Microsoft Office (Word, Excel, PowerPoint, Access, Outlook, Visio,)
  • Understand the importance of maintaining compliance with credentialing accreditation standards and regulatory agencies (TJC, NCQA, URAC, CMS etc)
  • Experience reviewing contractual documents
  • Strong well developed written and verbal communication skills
  • Strong research skills
  • Experience in a trainer capacity (permanent and temporary employees)
  • Experience typing Welcome Letters, having employees complete direct deposit forms, federal and state tax forms, I9s, Appointment Affidavits, Selective Service Registration, and 306s (Declaration of Federal Employment)
  • Experience with provider enrollment and revalidations
  • Experience updating providers' CAQH information
  • Extensive knowledge of credentialing and privileging and appointing policies, regulations, standards and Medical Staff Bylaws
  • Experience tracking licenses and certifications
  • Experience coordinating the credentialing for various MTFs(Medical Treatment Facilities) with the DOD and US Coastal Guard
  • Experience writing and revising credentialing and privileging polices, procedures, and manuals
  • Auditing experience
  • Claims experience (EOBs)
  • Experience in Appeals and Grievances  
  • Quality Assurance experience pertaining to NCQA, CMS, and TJC
  • Ability to establish and maintain professional and beneficial relationships with medical staff, Service Chiefs, Contracting Officer Representative and others needed to assist in the credentialing process
  • Ability to produce accurate detailed reports on trends, assessment findings, and program effectiveness
  • Excellent time management, persistent follow up, organizational, problem solving, and analytical skills
  • Experience serving in a expert adviser capacity over the credentialing and privileging program
  • Experience with credentialing and government database software (VetPro, SharePoint, VISTA, Cred Queue, Provider Queue, IPD 5250, Onbase, DocTracker, CCD, Intellicred, Salesforce)
  • Knowledge of HR procedures and policies
  • Experience conducting payor research 
  • Experience reviewing TOPRs (Task Order Proposal Request) for various government contracts
  • Experience viewing documents that establish identity and employment authorization (passports, permanent resident cards, I-94s, birth certificates, U.S Military cards, social security cards etc)
  • Experience conducting Market Salary Analysis for proposal bids
  • Experience carrying out large scale projects related to the credentialing and privileging program and Market Salary Research required for bids
  • Experience developing criteria and metrics to evaluate the credentialing program process and effectiveness
  • Ability to manage demanding workload and schedule
  • Experience researching current laws and regulations and staying abreast on new laws and regulations pertaining to credentialing and privileging
  • Experience working with a CVO
Expected in | , , GPA:

Certified Provider Credentialing Specialist, CPCS

NAMSS Member

Currently studying for the Certified Professional Medical Services Management Certification, CPMSM

09/2016 to 08/2017 Credentialing Specialist Gw Medical Faculty Associates | Arlington, VA, Responsible for completing providers' applications for privileges at Surgery Centers and Hospitals.  Once applications are returned reviewed applications for accuracy and completeness.  Reached out to providers who have not returned applications and offered assistance.  Reached out to Site Leaders and informed them of outstanding applications as well as requested assistance with obtaining applications from providers.  Once applications were returned, responsible for forwarding applications, credentials, and credentialing fees to facilities.  Maintained correspondence with medical staff at the facilities to ensure privileges are granted as soon as possible.  Tracked credentialing status and credentialing committee dates.  Informed the team of credentialing committee dates when providers will be granted privileges.  Requested temporary privileges if necessary.  Responsible for the billing enrollment process including requesting enrollment paperwork, having providers complete in blue ink and submitting billing paperwork.  Tracked payor enrollment status with all carriers.  Maintained open communication with the scheduling department regarding enrollment and credentialing status of all providers.  Assisted providers with writing explanations of employment gaps and NPDB inquiries.  Sent reports to the team once a week regarding credentialing and enrollment statuses.  Served as the point of contact for credentialing and payor enrollment. Maintained all in-house credentials and PSV information.  Sent 30, 60 and 90 day notifications to providers regarding expiring credentials.  Sent notifications to the scheduling department regarding providers that may need to be removed from the schedule due to not renewing required credentials.  Assisted patients with payments including quoting payment amounts using CPT codes with modifiers and taking credit card payments over the phone.  Provided excellent customer service to patients and providers.   
02/2016 to 09/2016 Clinical Administrator Elara Caring | Bingham Farms, MI, Liaison between the Clinical Services department, internal Evergreen Health departments, providers, and members. Responsible for streamlining the day-to-day functioning of authorizations, high level escalations and appeals and grievances as they pertain to Clinical Services. Provides administration and departmental support for utilization management, case and disease management, customer experience, and compliance through the processing of authorizations, Continuity of Care, member and provider escalations and appeals and grievances. Effectively communicates issues and assists in the coordination of resolutions for all stakeholders.  Assists in completing activities related to various cross functional projects in support of departmental goals.  Effectively handles authorization requests and inquiry phone calls from providers and accurately enters into the Medical Management Platform.  Utilizes online tools to determine authorization requirements based on the type of service requested, the location of the service, member’s plan type and the provider specifics.  Generate approval letters using MCG Guidelines (Millennium Guidelines) or send unfavorable decisions to the Medical Director for review. Communicates authorization specific to providers verbally on the phone and by written letter.  Serves as a liaison in corresponding and communicating with providers, vendors and Evergreen contacts and/or member representatives Coordinates with the Medical Director the submittal of unfavorable decisions and peer to peer reviews.  Acts as an administrative support to the Medical Director.  Interacts with other departments including Claims, Credentialing, Sales, Enrollment and Member Services to resolve member, provider and broker issues related to process or specific cases.  Research laws and regulations (Federal and State) pertaining to timelines of claim submission, payment, and appeals etc.  Works with Case Managers to insure potential case management referrals are appropriate for the program.  Applies state, federal laws and regulations and accepted criteria in pre-screening cases, educating providers and members of the utilization management process.   Manages the UM Escalations mailbox and Valence SharePoint ticket system De-escalate angry/irate members and providers while maintaining the integrity of Evergreen.  Participates in the evaluation of comprehensive quality management programs.  Responsible for the logging and researching of all appeals and grievances and assisting the compliance nurse while being the first point of contact.
02/2015 to 02/2016 Credentialing Specialist Gw Medical Faculty Associates | Silver Spring, MD,

Responsible for activities associated with credentialing and recredentialing of physicians and providers. Process provider applications including receipt, reviewing and loading data into the tracking system. Review provider Interest Forms and CAQH applications to ensure all internal, state, accrediting and regulatory standards are being met. Send out "In Process" or "Incomplete letters" to providers within the 30 day timeframe as well as ensure all providers are credentialed within the required 120 days. Maintain provider information in online credentialing databases, systems and excel spreadsheets. Oversee primary source verification activities with all delegated entities and ensure all PSV verifications(licensure, board certifications, education, training, hospital affiliations etc) are being completed within compliance of Maryland State Law and NCQA standards. Review credentialing reports once received from CVO. Run Clean File Report for all providers with no adverse actions to submit to the Chief Medical Officer for review and approval. Pull all files with adverse actions, build file documentation and prepare files for credentialing committee review. Manage agenda and take the minutes for the Provider Advisory and Credentialing Committee (PACC). Ensure that Robert's Rule of Order is being followed in the credentialing committee meetings. Assist with NCQA audit by ensuring all 21 credentialing elements are being met. Train interns on the credentialing process to assist the credentialing department.

2014 to 02/2015 Credentialing Operations Specialist (Full-Time) Maximus, Inc. | Baltimore, MD,

Responsible for all aspects of credentialing operations. Developed a written credentialing process and stored on a shared drive for viewing. Communicate with project managers and physician recruiter regarding criteria for credentialing with various positions at Medical Treatment Facilities with the Department of Defense and US Coastal Guard. Review Task Order Proposal Requests to analyze credentialing requirements for various Army and Naval Hospitals and Medical Centers. Primary Source Verify all required credentials (CV, licenses, education,employment history,BLS,NPI etc) and verify all site specific forms are completed and signed by provider. Communicate with site regarding establishing a start date for provider once security check is clear. Review NPDB for any reports as well as review any explanation letter from the provider regarding any reports found. Produce a weekly status report on credentialing files for both new hires and current employees. Advise supervisor on any issues concerning credentialing operations. Recommended procedural changes by bringing all credentialing in house (even with joint bids) to ensure compliance and consistency. Review Health Form for immunizations (MMR, HepB, Varicella, PPD, and Flu Shot). Run criminal background check using a 3rd party vendor to screen applicants before security clearance is denied to minimize a delay in the hiring process. Verify privileges held for physicians at previous employers. Monitor expiring credentials (licenses,BLS, immunizations etc) sending notices out to providers as well as their assigned project manager. Run report for expiring credentials at 30 and 90days. Conduct Market Salary Research for all positions both privileged and non privileged.

03/2013 to 2014 Credentialing Program Assistant (Full-Time) John D Dingell VA Medical Center | City, STATE,

Responsible for the credentialing as part of the appointment process at the medical center, including full-time, part-time, independent, dependent practitioners and other allied health professionals. Responsible for the enrollment of new employees into the VetPro system (electronic credentialing program/system). Coordinates the collection of information and documents used to primary source verify credentials. Ensure all applications submitted are complete and accurate. Manage the credentialing and privileging for health care providers. Assist practitioners and other health professionals with entering their information in the system. Responsible for verifying references, education, verify supplemental attestation questions have been answered, employment history, licenses, certifications and registrations by national or professional organizations including DEA and CDS. Verify NPI numbers, screen through HIPDB and LEIE. Ensures all applicants are credentialed in a timely manner. Act as a resource for credentialing responding to outside inquires. Monitors licenses and certifications daily. Produce 30 and 45 day reports of expiring licenses and certifications. Assist employees who request to view confidential information contained in their credentialing and privileging folder.Use government purchase cards to order verifications create purchase orders and reconcile purchases on a timely basis. Transfer files and grant shared access to VAs requesting access. Keep track of deadlines including grace periods for licenses and certifications. Conduct final appointments after researching, analyzing, and validating all data and info required. Responsible for the Without Compensation Program (WOC). Ensure all applications and paperwork is complete with student and service ensure correct signatures are on the WOC Appointment Requests. Ensure identification documents and investigation paperwork are included in student's file. Tracks incomplete applications as well as unsigned applications. Type and create welcome packets. Explain process to applicants as well as services. Interact with recruiters to monitor number of applicants and paperwork. Inform Protection and Support and Police and Security of employee's/student's who appointments are expiring. Assist with HR functions.

01/2012 to 03/2013 Credentialing Specialist II (Full-Time) Magellan Health Services (Kelly Services) | City, STATE,

Timely and accurately entered data of all providers' demographic information including tracking of applications and contracts in system. Performed reviews and analysis of incoming documents to determine completeness of applications and contractual documents. Completed primary source verifications based on the requirements of each provider's state and professional level. Conducted verifications including license; licensing board, federal, state and professional sanctions, general risk/liability assessment, malpractice coverage, malpractice history, clinical hours, education and experience, professional and board certifications. Provided status reports on providers. Maintained compliance with HIPAA, URAC, NCQA Credentialing Standards, and Federal and State Guidelines. Sent correspondence to field reps, providers, and all others needed to obtain information/documents needed to complete the credentialing process. Managed credentialing and privileging functions. Developed monitoring and tracking strategies for reports. Responsible for reporting changes and updates to CVO Director. Ensured accuracy of TINs, service addresses, office hours etc. Trained temporary staff as well as conducted refreshers for current employees on the credentialing process.

04/2010 to 11/2010 Credentialing Specialist (Full-Time) BlueCross BlueShield Of Michigan (Bartech) | City, STATE,

Maintained Compliance with HIPAA, NCQA Credentialing Standards, and Federal and State Guidelines. Processed and tracked the status of credentialing applications and updated and maintained the credentialing database in accordance with internal policies and procedures. Collected and maintained files in relation to the credentialing and re credentialing of network practitioners including applications (CAQH),DEA, CDS, licenses, malpractice insurance, education, hospital privileges, current physician license, board certifications, and other pertinent forms. Prepared documents for credentialing committee review. Responded and resolved inquires from practitioners regarding status of application, communicated with hospitals, malpractice insurance companies, licensing boards, office managers and practitioners via email, phone, and fax. Produced detailed credentialing reports (demographics, board certified, type of provider)

09/2009 to 2012 Human Resource Specialist Creative Hands Early Learning And Child Development | City, STATE,

Maintained employees personnel files in compliance with applicable legal requirements. Explained provisions of employee benefits and services programs; interpreted and analyzed regulations, policies and procedures. Assisted in the hiring process by coordinating job postings on websites (CareerBuilder, Indeed, Monster), reviewed resumes, performed telephone interviews and reference checks. Classification of all positions. Coordinated health, life and disability insurance enrollments. Reviewed worker's compensation claims, conducted investigations and reviewed medical for completion. Conducted research on various federal programs and grants pertaining to the childcare sector. Recruited childcare professionals by attending job fairs and local community colleges. Handled all human resource functions for both the Westland, Michigan and Boston, Massachusetts offices.

05/2006 to 07/2009 Inquiry Specialist (Intermittent Employment) BlueCross BlueShield Of Michigan | City, STATE,

Responsible for the administrative duties required in the credentialing verification process and assisted in the general clerical functions of the department. Maintained compliance with HIPAA, NCQA credentialing standards, and federal and state guidelines. Reviewed practitioner's applications for appropriate documentation required and completeness for the credentialing and re credentialing process and sending correspondence for missing information/documents. Responsible for scanning documents into system. Responsible for the data entry of all practitioner's information into system. Verified legitimacy of practitioners Information (education, licensing, certification, etc). Responsible for contacting practitioners to update information absent from CAQH Application. Acted as a resource to inform practitioners of their status in the credentialing process.. Ensured all information entered into the system was accurate and up to date. Responsible for credentialing and privileging.

  • Developed and revised various credentialing and privileging processing documents, checklists, manuals, policies and procedures
  • Obtained National Certification as a Certified Provider Credentialing Specialist
  • Contributed to the success and pass of many Joint Commission and NCQA Audits
  • Selected to participate in Business Process Review Meetings as a Expert Credentialing and Privileging Process Specialist
  • Recognized for Passing and Exceeding all external and internal audits
  • Selected to participate in the Breakfast and Mingle with the CEO
  • Considered a expert at credentialing and privileging (Full Cycle) 
Expected in 2018 | Business Administration Oakland County Community College, Royal Oak, Michigan GPA:
Currently attending, will graduate the summer of 2018 

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Job Titles Held:

  • Credentialing Specialist
  • Clinical Administrator
  • Credentialing Specialist
  • Credentialing Operations Specialist (Full-Time)
  • Credentialing Program Assistant (Full-Time)
  • Credentialing Specialist II (Full-Time)
  • Credentialing Specialist (Full-Time)
  • Human Resource Specialist
  • Inquiry Specialist (Intermittent Employment)


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