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provider credentialing specialist resume example with 13+ years of experience

JC
Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000, resumesample@example.com
Summary

Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Self motivated Individual offering a concrete background in Healthcare Management/ Network Development. Great leadership abilities and dynamic team performer. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management, and problem-solving skills. Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.

Skills
  • Critical thinking
  • Team building
  • Verbal and written communication
  • Project support
  • Time Management
  • Solo practitioner credentialing
  • Contract negotiation
  • Problem-Solving
  • Microsoft Office proficient
  • Good work ethic
  • Organization
  • Multitasking
  • Decision-making
  • Staff training and motivation
Experience
03/2022 to Current Provider Credentialing Specialist Jefferson Health | Northeast Philadelphia, PA,
  • Conducted primary source verifications such as background checks and board certifications.
  • Completed enrollments into Medicaid, Medicare and private insurance plans.
  • Obtained NPI numbers for providers and facilities and updated existing profiles.
  • Compile appropriate information to make requested credentialing, contractual, and demographic updates and changes related to provider
  • Compile data into systems of record in an accurate, complete and timely manner.
  • Manage and sustain positive provider relationships.
  • Setup providers and networks in systems of record, assign provider numbers, and communicate with provider community.
  • Facilitate accurate financial claims payment and provider directory processes. Represent BCBSLA to external provider communities and internal stakeholder groups.
  • Checked applications for missing information and organized all paperwork.
05/2021 to 11/2021 Credentialing Analyst Amn Healthcare | Hickory, NC,
  • Maintained informational resources, tracking and documenting requests for updates, certification and credentialing.
  • Conducted primary source verifications such as background checks and board certifications
  • Obtained NPI numbers for providers and facilities and updated existing profiles
  • Enrolled providers and Medicaid, Medicare and private insurance plans
  • Collected and analyzed information to monitor compliance outcomes and identify and address trends of non-compliant behavior.
  • Responsible for maintaining and adding current and accurate data for all providers.
  • Completes provider licensing applications and state renewal applications as needed.
  • Completes providers credentialing and re-credentialing applications and monitors and follows up as needed and documents progress on daily basis.
  • Received and evaluated applications to look for missing and inaccurate information.
12/2019 to 01/2021 Provider Relations Advocate Amplifon Usa | Orlando, FL,
  • Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
  • Investigated concerns such as billing and claims questions on behalf of providers.
  • Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
  • Assisted with physician recruitment by identifying specific providers within designated territories, negotiating rates for new physicians, and distributing provider agreements, successfully recruiting 50 new physicians per year as a goal.
  • Identified network gaps and collaborated with senior manager to fill deficiencies.
  • Eliminated contractual risks by instructing providers and coordinating educational material distribution.
  • Gathered, organized, and input information into digital database.
  • Helped implement training and development of external providers through education programs.
  • Initiated physician and hospital orientations to support ongoing education of health care provider community.
  • Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
  • Displayed strong telephone etiquette, effectively handling difficult calls.
09/2016 to 12/2019 Network Development Coordinator The University Of Vermont Medical Center Inc | Essex, VT,
  • Partnered with business teams and IT personnel to align project goals with business strategy and define project milestones.
  • Produced reports, spreadsheets and trend forecasts to enhance decision-making processes.
  • Spearheaded entire onboarding and orientation process for new employees, providing education and information to facilitate learning and improve employee job satisfaction.
  • Negotiate single case agreements and rates with providers as directed by senior management.
  • Provide assistance to Director of Contracting to work to establish long term contracts with network facilities for new providers that are obtained by the company.
  • Participated in brainstorming sessions and team meetings to identify deficiencies and recommend changes to policies and procedures.
  • Provided responses to providers inquiries and or complaints to ensure open communication and prompt resolution of provider issues.
  • Research potential network participants to assist with development of state, regional, and national networks as directed by senior management.
  • Maintain internal and provider data integrity including provider databases.
  • Assist with provider education to ensure smooth transition into the network.
06/2013 to 07/2016 Contracts Coordinator Hilton Grand Vacations | Estes Park, CO,
  • Monitored all incoming contracts and service agreements for correct pricing and information.
  • Coordinated and attended meetings as company's main contact to review contractual obligations.
  • Administered contract change requests and resolution.
  • Provide support to contract negotiators to ensure successful completion of the contracting process for the providers.
  • Managing existing contracts while seeking additional entities to expand company profits.
  • Checked information in company's database for accuracy and updated data with current information to maintain records.
  • Created reports and models based on contract requirements to predict profitability and gross margin.
  • Creates contracts and manages the contracting process unitizing the Emptoris Contract Management System to ensure that the new business contract deadlines are met.
  • Review final contracts before they are sent out to each provider that joins within the network.
  • Obtained documents, clearances, certificates, and approvals from local state, and federal agencies.
  • Submitted project closeout documents in accordance with contract terms.
  • Maintained energy and enthusiasm in fast-paced environment.
12/2010 to 02/2013 Contract Management Analyst League Of Southeastern Credit Unions | Murfreesboro, TN,
  • Reviewed proposed contracts against established policies, guidelines and legal requirements to identify critical issues.
  • Worked with internal and external parties to maximize value of assigned contracts in company portfolio.
  • Established clear review process throughout contract period to assess performance against expectations and requirements.
  • Worked collaboratively with administrative staff in negotiation, correspondence, documentation, and compliance checks for service contracts.
  • Developed and followed processes to manage contracts and remain in compliance with company commitments and regulatory obligations.
  • Developed comprehensive medical service contracts with hospital, surgery centers, long-term care facilities, physicians, ect for inpatient, outpatient, and onsite services for Federal Correctional Facilities.
  • Negotiate competitive reimbursement Medicare/Medicaid rates with hospitals and specialists to meet cost containment needs.
  • Process claims at negotiated rates to fulfill cost containment needs, for the Federal Prisons we maintained.
  • Maintain positive, professional relationships with current participating providers.
  • Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
  • Gathered, documented and modeled data to assess business trends.
09/2007 to 06/2010 Front Office Manager Pyramid Hotel Group | San Luis Obispo, CA,
  • Established workflow processes, monitored daily productivity and implemented modifications to improve overall performance of personnel.
  • Held oversight of office inventory activities, including ordering and requisitions, stocking and shipment receiving.
  • Oversaw cash and credit card payment transactions at the front desk.
  • Managed files and records for clients and adhered to safety procedures to prevent breaches and data misuse.
  • Prepared reports to assist business leaders with key decision making and strategic operational planning.
  • Responsible to oversee the front office staff at all times within the clinic.
  • Supervised, trained, and guided new employees and responded quickly to questions to improve understanding of job responsibilities.
  • Communicated corporate objectives across divisions through regular correspondence and scheduled status updates.
  • Managing incoming and outgoing correspondence and physicians schedules.
  • Organized details of special events, travel arrangements, and agendas.
  • Corrected guest issues promptly with knowledgeable and friendly service.
  • Supported management and staff and assisted with major projects.
Education and Training
Expected in 2008 Bachelor of Science | Health Services Administration University of Alabama At Birmingham, Birmingham, AL GPA:
Expected in 1999 Associate of Applied Science | Applied Science Bevill State Community College, Sumiton, AL GPA:

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Resume Overview

School Attended

  • University of Alabama At Birmingham
  • Bevill State Community College

Job Titles Held:

  • Provider Credentialing Specialist
  • Credentialing Analyst
  • Provider Relations Advocate
  • Network Development Coordinator
  • Contracts Coordinator
  • Contract Management Analyst
  • Front Office Manager

Degrees

  • Bachelor of Science
  • Associate of Applied Science

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