credentialing specialist resume example with 5+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:
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Highly motivated Sales Associate with extensive customer service and sales experience. Outgoing sales professional with track record of driving increased sales, improving buying experience and elevating company profile with target market.
  • Proofreading
  • Solo practitioner credentialing
  • Insurance procedures
  • Community health center credentialing
  • Application management
  • License verifications
  • Facility credentialing
  • Policies implementation
Credentialing Specialist, 12/2018 to Current
Chg HealthcareFort Lauderdale, FL,
  • Processed documents and status-change requests, conducting followup assessment regarding enrollment inquiries.
  • Confirmed facility and user credentials to initiate and maintain registration and enrollment processes.
  • Maintained informational resources, tracking and documenting requests for updates, certification and credentialing.
  • Addressed credentialing requests, overseeing compliance with governmental and organizational guidelines regarding tiered data access.
  • Performed database queries, compiling information according to requests and logging logistics changes.
  • Completed enrollments into Medicaid, Medicare and private insurance plans.
  • Performed primary source verifications such as criminal histories, licenses and board certifications.
  • Set up NPI numbers for providers and facilities and updated current profile information.
  • Checked applications for missing information and organized all paperwork.
Billing Manager, 06/2017 to 12/2018
Dayton FreightTomah, WI,
  • Developed improved standard operating procedures to increase billing accuracy and cash flow.
  • Managed billing calendar and scheduled claims for payments.
  • Built high-performance team by collaborating with new members on procedural, administrative, collections and compliance areas.
  • Conducted insurance verification and pre-authorization, coded spinal and joint procedures and managed patient charts.
  • Set up and maintained Greenway electronic billing system.
  • Resolved billing issues by applying knowledge and completing in-depth research.
  • Helped customers to bring accounts into good standing by implementing payment plans.
  • Oversaw daily collections and accounts receivable activities, developing robust strategies to maximize collections and reduce aged accounts.
  • Eliminated inaccuracies in accounts payable payments by verifying information prior to generating checks and electronic payment transfers.
  • Performed accurate and fully compliant monthly closing processes, accruals and journal entries.
  • Entered procedure codes, diagnosis codes and patient information into billing software to facilitate invoicing and account management.
  • Facilitated payment of invoices due by sending bill reminders and contacting clients.
  • Analyzed patients' encounter forms diagnosis codes to validate accuracy, completeness and specificity.
  • Submitted claims to insurance companies.
  • Identified professional development opportunities and delivered comprehensive, standardized and hands-on training to new staff.
  • Enforced compliance with organizational policies and federal requirements regarding confidentiality.
  • Processed check requests and invoices for 3 locations every 30 days.
  • Assessed medical codes on patient records for accuracy.
  • Reviewed medical records to meet insurance company requirements.
  • Expertly assigned charges and payments for medical procedures.
  • Flagged return claims and dealt with insufficient payments.
  • Used Greenway system to manage provider schedules and keep calendar organized for 5-person practice.
  • Reviewed account information to confirm patient and insurance information is accurate and complete.
  • Assigned CPT procedure and evaluation and management (E&M) codes for services to assure appropriate billing and reimbursement.
  • Contacted insurance providers to verify correct insurance information and obtain authorization for proper billing codes.
  • Interpreted medical terminology and pharmacological information to translate information into coding system.
  • Verified final claim submissions by comparing account charges with documentation.
  • Maintained knowledge of new or revised codes and industry regulations to complete accurate coding services, including local coverage determinations.
  • Remained up-to-date with all insurance requirements, including details of patient financial responsibilities, fee-for-service and managed care plans by participating in training programs.
  • Reconciled codes against services rendered.
  • Reviewed legal claims for accuracy and issues.
  • Checked claims coding for accuracy with ICD-10 standards.
  • Maintained current working knowledge of CPT and ICD-10 coding principles, government regulation, protocols and third-party billing requirements.
  • Reviewed and verified benefits and eligibility with speed and precision.
  • Contacted patients for unpaid claims for HMO, PPO and private accounts and performed friendly follow-ups to ensure proper payments were made according to contracts.
  • Prepared billing statements for patients, ensuring correct diagnostic coding.
  • Prepared and attached all required claims documentation including referrals, treatment plans or other required correspondence to reduce incidence of denials.
  • Oversaw regulatory and strategic initiatives to ensure accuracy of medical claims.
  • Determined prior authorizations for medication and outpatient procedures.
Procedure Coordinator, 05/2015 to 05/2017
Atrium HealthMint Hill, NC,
  • Conducted record searches and coordinated with other units on procedural problems involving complex cases.
  • Secured pre-authorizations and pre-certifications for minor surgical procedures performed in office settings.
  • Scheduled and confirmed patient appointments for diagnostic, surgical and consultation services.
  • Conducted patient intake interviews to collect medical information and insurance details.
  • Answered 50 average daily phone calls to schedule appointments and address patient inquiries.
  • Contacted other medical facilities to confirm medical histories and prevent inaccurate diagnoses.
  • Gathered information to file appeals for spinal and joint denials and minimized inaccuracies by maintaining accurate records of approvals.
  • Assisted patients in filling out pre-appointment paperwork.
  • Managed front office customer service, appointment management, billing and administration tasks to streamline workflow.
  • Answered phone calls to provide assistance, information and medical personnel access to maximize office efficiency.
  • Worked with Pain Management doctors to prepare correct equipment and supplies for over 80 daily pain management procedure appointments.
  • Addressed, documented and responded to incoming correspondences to address client queries.
  • Supported administrative and healthcare staff, providing order fulfillment and inventory management services to ease operations.
  • Managed physician calendar, including scheduling patient appointments and procedures.
  • Created and maintained accurate and confidential patient files according to regulatory mandates.
  • Called patients to schedule spinal or joint procedure appointments, consistently double-checking information and availability.
  • Reconciled clinical notes, patient forms and health information for compliance with HIPAA rules.
  • Determined correct ICD-10 and CPT codes for use in medical record.
  • Prepared paperwork for admittance and discharges to coordinate smooth patient movements.
  • Maintained understanding of all active patients in order to facilitate workflow.
  • Interpreted medical terminology and pharmacological information to translate information into coding system.
  • Input details about patient histories, physical examinations, medications and other information into physical or electronic charts.
  • Documented and initiated tests, scan and other orders.
  • Reviewed account information to confirm patient and insurance information is accurate and complete.
  • Evaluated charts, documents and orders, and made timely corrections.
  • Reviewed and abstracted relevant clinical data from electronic medical records to select appropriate code for procedures.
Education and Training
Certificate: Medical Assisting, Expected in 05/2001 to Long Technical College - East Valley - Phoenix, AZ

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Resume Overview

School Attended

  • Long Technical College - East Valley

Job Titles Held:

  • Credentialing Specialist
  • Billing Manager
  • Procedure Coordinator


  • Certificate

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