Manage Care Credentialing Coordinator - US Texas Oncology
(2024-12 - 2025-05)
Responsible for managing comprehensive provider enrollment and credentialing processes across Medicare PECOS/Gateway and TMHP Medicaid platforms. Proficient in Medicare I&A access management and file updates. Participates in monthly Teams meetings and manages communications via Webex phone systems. Demonstrates strong typing skills (45–50 WPM) and excels in provider relations and medical administration.
- Completing CMS 855I individual and 855B group applications
- Overseeing Texas Board and NCCPA verifications
- Maintaining dual-state licensing updates for Texas and Oklahoma providers
- Revalidations with Medicare and Medicaid
- Utilizes systems such as Cactus, Symplr, IDX-Athena, and TOPA for provider data entry, billing, and credential housing
- Coordinates insurance verification, authorization checks, and prescription pharmacy status updates
- Handles high-volume member support, including over 75 calls daily, addressing escalations, payments, enrollment applications, APTC, credit card verifications, and urgent referrals
Medical Administration Provider Enrollment - Utica Park Clinic
(2023-02 - 2024-10)
Managed coordination of payer enrollment processes, including phone follow-ups and document handling (faxing, compiling), credentialing, and provider data management.
- CAQH: Profile creation, updates, and re-attestation
- NPPES/NPI: Provider lookup and updates
- OPPE/FPPE: JCAHO accreditation compliance
- File auditing for credentialing and Medicare (EMSI-DOS)
- Payer enrollment using payer systems: Medicaid (OHCA), PECOS, Medicare Gateway, Tricare Humana, AETNA, BCBS, Cigna, Global Healthcare, Health Choice, Healthcare Solutions, Humana Military Multiplan, United Healthcare, Community Care, Indian Healthcare
- Credentialing status verification and provider listing updates
- Database management and reporting using: Cactus (Symplr), Aiva, MedStaff (Parkland Hospital); Intellimed, COP, CAQH, NPDB, ECHO-One App, HealthStream
- Revenue cycle support, recycling unprocessed claims to ensure revenue recovery
Credentialing Coordinator / Facility Application Specialist - Bay Mark Health Services
(2022-04 - 2022-09)
- Submit applications for Medicare via PECOS, Medicaid (state-specific), and commercial payers (e.g., BCBS, AETNA, HUMANA)
- Coordinate and compile applications for Opioid Treatment Program facilities (OBOT centers) with required documentation
- Ensure provider education and licensing are current before submission
- Set up portal logins and update CAQH profiles, flagging documents for renewal 10 days before expiration
- Conduct follow-ups with providers for timely application completion per state guidelines
- Initiate new applications or renewals to maintain compliance with active assignments
- Maintain and update Excel spreadsheets to track provider application statuses for weekly leadership meetings
Credentialing/Contracts Coordinator - Parkland Hospital
(2021-09 - 2022-04)
- Collaborate with the Contracts Credentialing Analyst to review all incoming new client contracts or contract revisions for Credentialing requirements, for assigned facilities, to identify unique requirements
- Negotiate with the client facility to reconsider unusual or uncustomary requirements by emphasizing the value and experience of the Quality Services Department with client facilities to minimize disruption of placements and optimize fill rate
- Consult clients on Credentialing best practices by making recommendations on requirements, expectations, and realistic start dates to streamline submission and placement processes to increase the fill rate of qualified HPs
- Maintain an up-to-date and accurate facility database, including updated contact information, new requirements, and client correspondence, by following up regularly with clients to optimize service coverage and prevent gaps in service delivery
- Research new requirements (by The Joint Commission, OSHA, and others) that may impact the industry to present proposals to leadership that clarify appropriate action plans
- Review healthcare providers submitted requirements, including licensure, certifications, screens, and other critical documents, using the data platform system
- Communicate timely updates of HP document status with all internal stakeholders via the data platform system, email, phone, etc.
- Verification of providers using various licensing databases, demographics updates using PSV, and a Microsoft Excel Spreadsheet
- Create urgency with healthcare providers via email and phone, to encourage timely and accurate document submission
- Coordinate response to assigned client regulatory audits, TJC/TWSM/NCQA documentation, and other requests by client facilities
- Coordinate with 3rd party vendors to determine appropriate dates, times, and locations for HP candidates to complete necessary compliance steps
- Facilitate the QuickBooks (QB) process for assigned facilities by taking a lead role to collaborate with Account Managers, Recruiters, and the Housing department
Insurance Verification & Eligibility Specialist - One Share Health
(2020-03 - 2020-08)
- Conducted insurance verification and eligibility checks using systems such as iSolve, LOOMIS, and NX SonicWall Extender
- Utilized Nice Scheduling to manage and coordinate scheduled breaks and lunch periods efficiently
- Accessed remote systems securely via RingCentral for off-site work capabilities
- Performed bill overview discussions with members, including status updates on missing documentation required for finalized billing
- Logged escalation calls and follow-up tasks using SharePoint and Admin123 Noting Systems to ensure timely resolution and documentation
- Researched and processed membership cancellations and requests, ensuring accurate and timely updates
- Managed bill submissions, including directing and completing UB-04 and CMS-1500 forms in compliance with billing guidelines and payer requirements
Medicare Enrollment/Insurance Verification - Molina Health Care Enrollment
(2019-09 - 2020-03)
