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Credentialing Specialist Resume Example

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CREDENTIALING SPECIALIST
Professional Summary

Results-oriented professional, dedicated associate with high integrity, strong decision maker who understands the importance of compassion and patience.

Skill Highlights
  • Proven patience and self-discipline
  • Motivation techniques specialist
  • Confident public speaker
  • Effectively influences others
Professional Experience
Humana August 2008 to Current Credentialing Specialist
Cincinnati, OH
  • The Credentialing Specialist reviews and confirms the qualifications of a variety of health care professionals and facilities that contract directly with Humana or Choice Care, to confirm the qualification of these individuals and entities, the specialist goes directly to the source.
  • Among the information that is verified are the physician's licensure(s), malpractice history, sanction history, education/training, board certification, and Drug Enforcement Agency certificates.
  • The Credentialing Specialist also verifies the physician's practice experience, professional liability insurance and hospital affiliations.
  • The Credentialing Specialist ensures that all providers applying for participation with both Humana and Choice Care network are properly trained in their specialty and have not had any trends in malpractice or sanction history.
  • In addition to medical credentialing; I also assist with dental and pharmacy credentialing projects and give feedback as necessary.
  • Person in charge when the Manager is out of the office, solving any problems that may arise in the department.
Humana August 2007 to August 2008 Large Group Billing Specialist
Louisville, KY
  • Performed research and resolved issues for customers regarding their financial accounts.
  • Monitored accounts receivable to ensure accurate and timely collection of their premium payments.
  • Audited and reconciled premium payments resolving any discrepancies determined in the reconciliation process.
  • Worked closely with the Benefit Administrators to assure the groups satisfaction with Humana and gave guidance to the group on the best methods of making their premium payment to benefit them as well as Humana.
Anthem May 2006 to January 2007 Financial/Accounting Operations Specialist
Mason, OH
  • Responsible for performing diverse operational financial and policy activities of a non-routine nature.
  • Reviewed and signed off on all accounts receivables daily to abide by the Sarbane Oxley Act.
  • Interpreted and communicated departmental and organizational policies and procedures.
  • Essential duties included, received and validated and entered information into finance systems.
  • Adhered to maintained internal controls and tracking reports for reconciliations and analysis.
  • Monitored and updated controls to ensure compliance.
  • Conducted independent analysis for purpose of resolving complex and varied work process issues.
  • Performed insurance verification and assisted customers with their prescriptions; taking prescriptions over the phone and resolving all issues that pertained to the customer's specialty medicine.
The Zenith July 2001 to March 2005 Analyst II
Sarasota, FL
  • Analyzed bills from 25 states to ensure accuracy in coding, appropriate application of state/jurisdictional fee schedules and guidelines.
  • Approved, modified, and/or denied the bill in accordance with the applicable state mandates and/or department guidelines.
  • Answered questions to customer service, claims staff, and providers on issues regarding specific bills.
  • Acted as a resource for the customer service specialist in the department on a daily basis and for all other supervisors, nurses, analyst and coders seeking help within the department.
  • Mentored and assisted with training of analyst and coders as needed.
  • Performed quality assurance audits on analyst and coders to provide feedback to supervisors to assist in identification of quality issues and/or training needs.
  • Audited the bill review system Compadvisor to assure all fee schedules were downloaded correctly and that all 25 jurisdictions were meeting the Sarbane Oxley qualifications.
  • Handled all reconsiderations for these jurisdictions.
  • Worked on the error reports.
Installation Station January 1996 to July 2001 Manager
Sarasota, FL
  • Part time management of all aspects of business, accounts payable, receivable and customer service.
Policy Management Systems February 1996 to February 1997 Insurance Processor
Sarasota, FL
  • Printed claims checks and retrieved cancellation notices for customer service.
  • Data entry and rated homeowners applications for insurance.
Ameritrust August 1995 to January 1996 Administrative
Sarasota, FL
  • Filed and worked in the claims department assisting the adjusters with lost time cases and medical only cases.
Tops Temps January 1995 to July 1995 File Clerk/ Claims Assistant
Sarasota, Fl
Education
University of Cincinnati Associate of Science: Business Administration Cincinnati, OH

finishing up some coursework and considering changing my major to Medicine
Mount St Joseph University Business Administration Cincinnati, OH

3.33 GPA
Keiser University Business Administration Sarasota, FL

3.5 GPA
Tigers Lair Martial Arts 2nd Degree Black Belt Sarasota, FL
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Resume Overview

Companies Worked For:

  • Humana
  • Anthem
  • The Zenith
  • Installation Station
  • Policy Management Systems
  • Ameritrust
  • Tops Temps

School Attended

  • University of Cincinnati
  • Mount St Joseph University
  • Keiser University
  • Tigers Lair Martial Arts

Job Titles Held:

  • Credentialing Specialist
  • Large Group Billing Specialist
  • Financial/Accounting Operations Specialist
  • Analyst II
  • Manager
  • Insurance Processor
  • Administrative
  • File Clerk/ Claims Assistant

Degrees

  • Associate of Science : Business Administration
    Business Administration
    Business Administration
    2nd Degree Black Belt

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