Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • H: (555) 432-1000
  • C:
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary

Over 30 years of combined knowledge of Managed Care, Medicare and Medicaid, government regulations, policies and compliance, managing contracts credentialing coordination and provider maintenance. Great leadership, team growth and development, training, and administrative support in a corporation.

Core Qualifications
  • Report preparation and Documentation
  • Working Knowledge of PECOS, CAQH, NPPES, and I&A.
  • Government regulations, policies and programs.
  • Credentialing
  • Administrative support
  • Data entry
  • Knowledge of Managed Care, Medicare, and Medicaid.
Provider Enrollment Associate II, 01/2016 - 03/2016
Crown Castle Usa Inc Salt Lake City, UT,

Successful processed 150-188 application weekly, ensuring providers were enrolled with contracted health plans per the Health Plans requirements and applications.

Communicate with the various health plans and government agencies in response to their request for new enrollments, revalidation's and re-credentialing applications for new and existing providers.

Document all calls, correspondence, faxes received, with the pertinent information: person spoke with, date time of call/communication received, status updates, confirmation/validation of applications and documents received, effective dates, Kotana and Call Reference numbers.

Maintained provider data within CAQH, NPPES I&A, PECOS and Intellicred systems.

Maintain weekly productivity and daily assignment logs.

Cahaba GBA (Warren Averett), Birmingham, Alabama Provider Enrollment.

Provider Enrollment, 07/2015 - 11/2015
Cahaba GBA (Warren Averett) City, STATE,

Process enrollments (initials, changes, terminations, and revalidation's) applications, EFT and Par Agreements through PECOS.

Confirm the applicants, individuals and entities listed on the application were not presently excluded from the Medicare program by the Office of the Inspector General (OIG) or through the System for Award Management (SAMS).

Utilize the various state boards websites to verify the applicants license and certification.

Send approval, rejected or denial letters through PECOS for WEB applications and email for paper applications.

Document PEGA with the status of the application (pending missing information, application fee not received, required further direction from CMS and application resolved and work object closed).

Key information into MCS system based on application and option type.

Review and resolve Congressional inquiries.

Provider Relations/Recruiting , 07/2014 - 09/2014
Children's Medical Center Health Plan City, STATE,

Responsible for recruiting and credentialing of new providers and maintain current provider databases relating to facilities and physician information.

Assist with basic operations of policy and procedure interpretation, negotiation, reviewing, and preparing enrollment agreements.

Resolve administrative problems affecting network providers, patients, and plans within contracted guidelines.

Case Install Team Small Group Renewal and Reclass , 05/2013 - 10/2013
Jacobson City, STATE,

Process SBC and Material Modification Letters.

Research inquiries received from the Platinum Team (offshore), email Under Writing, Account Managers, Brokers and/or Group requesting the necessary documentation to continue processing the application or to update the information.

Address and Group Name Reports - Update the name and address in Facets per the name address perimeters.

Review applications via Midwest Enroll and Oper, once the requested information received would then route work item to the specified individual or department via Midwest Oper.

Provider Consultant , 2010 - 07/2012

Credential and process applications from individual, ordering and referring providers, sole owners and sole proprietors seeking to provider medical services to Medicare patients.

Ensure all necessary documentation received with application; verify medical/professional school, licensures, and certifications.

Document all correspondence, whom spoken with, time, date and summary of what information was given/or supplied.

Processed CMS 855IR, 855B group, CMS 460 Participating Provider Agreement Form, CMS 588 Electronic Fund Transfer Agreement Form.

Worked in office and from home.

Sr. AA Project Management Corp Sector National Acc, 01/2007 - 11/2008
Aetna City, STATE,

Processed/handled sensitive and extremely confidential data.

Successfully maintained daily, weekly, monthly, quarterly and annual reports, budget analysis, forecasting, cost centers, demographics and sales reports for the North Central and Southwest Regions.

Successfully coordinated the Employer and Consultant Seminars.

ernal and internal vendors, ordering supplies and a purchase orders.

Coordinated meeting and events seminars, luncheons and series of classes for local businesses and associations.

Rapidly learned and mastered various computer programs.

Interacted effectively with all levels within and across organizational lines.

Sr. PDS Network Analyst North Central/ West Region , 01/2004 - 01/2007
Aetna City, STATE,

Review new and existing contracts, determined most appropriate system methodology that facilitated accurate and consistent claim adjudication.

Processed and maintained contracted provider demographic data and negotiated reimbursement arrangements.

Educate and train providers on system related policies and procedures.

Reviewed and analyzed all documentation for PCP/Specialist adds, changes and termination request.

Collaborated and worked with internal and external constituents.

Utilized solid decision-making skills while executing national, regional and market level strategies.

Implemented and maintained National Provider Identification Numbers.

Contract Specialist, 2003 - 2004
Aetna City, STATE,

Contract interpretation skilled, assessed administrative and constituent impact.

Processed all incoming contracts accurately and in a timely manner.

Managed and maintained Strategic Contract Manager.

Manually loaded MOUs, OB enhancements, individual, provider groups, facility, ancillary, and amendments contracts into legacy system.

Conducts and manages on-going reviews of contract installations, partner with quality management in identifying, analyzing and reporting trends.

Ensure contract compliance and adherence to policy and procedures.

SBM Middle Market Key Accounts List Bill Analyst , 02/2000 - 02/2002
Aetna US Healthcare City, STATE,

Consulted with internal/external customers to identify accurate, account structure billing format method and payment arrangement to meet customer expectations.

Coded and structured rates on new cases and renewals/revisions in system to provide timely set-up of benefits, account structure, rates enrollment and confirmed all changes to ensure legislation and compliance.

Finances: accounts payable/receivable, invoicing, insurance billing, budgeting.

Inputted work into internal tracking system and measurement systems with established time frame to support management and business initiatives.

Analyzed financial information and reports, utilized available resources and standard reference materials.

Sr. Claims Examiner Specialist SBM/MM, 06/1997 - 02/2000
Prudential Healthcare/AETNA US Healthcare Inc City, STATE,

Researched and resolved compliance claims that have been identified in the eligibility, contracting and provider set-up departments.

Maintained customer files, including telephone call logs, documentation, and other related correspondence in support of department audits.

Completed subscriber eligibility files to manually calculate claims to ensure prompt and correct payment Trained new and current claims examiners on claim processing and new updates.

Reviewed examiners claims for quality, documented any corrections or updates as needed for accurate claims payment.

Actively and timely report results to management and claims examiner.

Indemnity/HMO/PPO Claims Examiner included processed, audited, and adjusted all professional and facility medical claims, appeals and prepayment audits; liaison between Providers and Subscribers to identify problems and resolved claim payments.

Maintained and updated all aspects of new and renewed customer benefits and contracts.

Associate of Arts: , Expected in
National Technical College - Los Angeles, CA
Skills and Company Systems

Access, Excel, Word, Outlook, Pagemaker, Quicken, PowerPoint, Diamond, and Facets.


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    Resume Overview

    School Attended

    • National Technical College

    Job Titles Held:

    • Provider Enrollment Associate II
    • Provider Enrollment
    • Provider Relations/Recruiting
    • Case Install Team Small Group Renewal and Reclass
    • Provider Consultant
    • Sr. AA Project Management Corp Sector National Acc
    • Sr. PDS Network Analyst North Central/ West Region
    • Contract Specialist
    • SBM Middle Market Key Accounts List Bill Analyst
    • Sr. Claims Examiner Specialist SBM/MM


    • Associate of Arts

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