Provider Credentialing And Networking Analyst I Present Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 9XXX5
  • Home: (555) 432-1000
  • Cell:
Professional Summary

Reliable and highly skilled Credentialing Anaylst 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 part 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 health care 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
Provider Credentialing and Networking Analyst I- Present, 2012 to 07/2015
Dignity HealthSan Andreas, CA,
  • 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 ProviderDataBase 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).
  • Prepared departmental contracts for attorney approval.Monitored multiple databases to keep track of all company inventory.Reviewed and provided comments on the adequacy of documents and took necessary steps to cure any deficiencies.
Credentialing Specialist , 11/2008 to 11/2012
CareFirst Care First BlueCross & BlueShieldCity, STATE,

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 with Carefirst Blue Cross Blue Shield Health Care. Keep an accurate log of providers who have and have not sent in their recredentialing application.

Prepare the recredentialing schedule that will work at the very least, 3 months in advance of when a provider will become up for recredentialing. Ensure that this schedule is adhered to at all times.

•Generate and prepare all recredentialing applications and cover letters to be sent out in a timely manner.

•Keep an accurate log of who has and has not sent back their recredentialing application.

•Initiate the termination process if it is deemed necessary by facilitating the written notifications to be mailed by the Credentialing Supervisor.

•Become familiar with CAQH web-based program used for housing Credentialing Information. Add, Delete and enlist providers to Citrus Health Care’s roster so that accurate credentialing and recredentialing files can be maintained.

•Keep current records such as: medical licenses, board certifications, DEAs, and proof malpractice insurance.

•Mail out any and all letters to request updated licensure information.

•Research and verify tax ID numbers, primary office addresses, office hours and provisions for after hours care, and all other necessary provisions for recredentialing.

Prior Authorization Representative II, 2005 to 2008
Magellan Behavior HealthCity, STATE,
  • 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/casemanagers 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.
Pharmacy Service Technician Authorization Representative, 2002 to 2004
United Health CareCity, STATE,
  • 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.
Bachelors: Health Administration, Expected in
University of Maryland University College - ,
Health Administration
: , Expected in
Morgan State University - ,

Geriatric Nursing Certificate

Pharmacy Technician Certificate: , Expected in
Baltimore City Community College - ,

Advanced skills credentialing ,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, prescribe, primary care, Quality Management, reporting, research, supervision, telephone etiquette

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School Attended
  • University of Maryland University College
  • Morgan State University
  • Baltimore City Community College
Job Titles Held:
  • Provider Credentialing and Networking Analyst I- Present
  • Credentialing Specialist
  • Prior Authorization Representative II
  • Pharmacy Service Technician Authorization Representative
  • Bachelors
  • Pharmacy Technician Certificate