Credentialing Representative Resume Sample
Ellis Kozey
6767 Cameron Crest,
Boston,
MA
+1 (555) 920 9868
Work Experience
Senior Credentialing Representative
01/2018
-
PRESENT
Los Angeles, CA
- Facilitate the application process for all new and existing providers to include facility credentialing (HDO’s)
- Anticipate customer needs and proactively identify solutions. Solve complex problems on own; proactively identify new solutions to problems
- Process credentialing applications
- Performing primary source verifications (PSV)
- Data entry and maintenance into Access Database in accordance with internal policies and
- Communicate with committee members
- Proactively identify solutions to non - standard requests
- Positions in this function are responsible for all activities associated with credentialing or re - credentialing physicians and providers
- Includes processing provider applications and re-applications including initial mailing, review, and loading into the database tracking system ensuring high quality standards are maintained
Credentialing Representative
10/2014
-
12/2017
Houston, TX
- Responsible for the development of credentialing policies and procedures
- Help process provider applications and re-applications including initial mailing, review and loading into the database tracking system
- Demonstrate great depth of knowledge / skills in own function and act as a technical resource to others
- Demonstrate great depth of knowledge/skills in own function and act as a technical resource to others
- Act as a facilitator to resolve conflicts on team
- Perform as key team member on project teams spanning more than own function
- Credentials and re-credential providers
- Related, progressive experience
Senior Credentialing Representative
02/2010
-
08/2014
Chicago, IL
- Providing support to the Credentialing, Payer Enrollment team
- Assisting with completing and processing of CAQH applications and government applications such as Medicaid and Medicare
- Reviewing database and updating Payer information
- Process ongoing monitoring of Medicare / Medicaid Opt Out / OIG / SAM
- Negotiate single case agreements according to unit guidelines with focus on financial and service objectives
- Assist in training of new Associates in the Accommodation process
- Timely and accurate communication in executing single case agreements
- Consistently perform provider searches and meet turnaround time objective
Education
Amberton University
2005 - 2010
School's Degree in Arts
Professional Skills
- Database skills including querying, reporting, and document generation
- Advanced computer skills including: MS Word, Excel, and credentialing software knowledge
- Prior professional work experience
- Multitasking skill: Ability to perform multiple tasks in environment that changes daily based on incoming work
- Experience working with compliance workflows and processes including NCQA policies and practices
- Experience in researching and applying government regulatory information
- Experience working with compliance workflows and processes including NCQA policies and practices
How to write Credentialing Representative Resume
Credentialing Representative role is responsible for research, database, software, government, travel, training, health, microsoft, adobe, multitasking.
To write great resume for credentialing representative job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Credentialing Representative Resume
The section contact information is important in your credentialing representative resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Credentialing Representative Resume
The section work experience is an essential part of your credentialing representative resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous credentialing representative responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular credentialing representative position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Credentialing Representative resume experience can include:
- Experience working with compliance workflows and processes including NCQA policies and practices
- Experience working with compliance workflows and processes, including NCQA policies and practices
- Experience working with compliance workflows and processes, including NCQA policies and practices
- Experience in researching and applying government regulatory information
- Experience working with compliance workflows and processes, including NCQA policies and practices
- Experience working with compliance workflows and processes, including NCQA policies and practices
Education on a Credentialing Representative Resume
Make sure to make education a priority on your credentialing representative resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your credentialing representative experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Credentialing Representative Resume
When listing skills on your credentialing representative resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical credentialing representative skills:
- Information.Intermediate level of research and analytical skills
- Experience in researching and applying government regulatory information
- Experience in researching and applying government regulatory information
- Experience in researching and applying government regulatory
- Experience working with compliance workflows and processes, including NCQA policies and practices
- Experience in researching and applying government regulatory information
List of Typical Experience For a Credentialing Representative Resume
1
Experience For Senior Credentialing Representative Resume
- Routine collaboration with supervisor/manager or experienced staff
- Experience with NCQA policies and practices
- Previous experience in a paperless healthcare office environment
- Previous (EDI) Electronic Data Interface experience
- Previous experience with Microsoft Excel (ability to sort, filter, data entry, export and import data)
2
Experience For Associate Credentialing Representative Resume
- Previous experience with Microsoft Word (ability to create and modify docs)
- Previous experience with Microsoft Outlook (ability to manage emails and calendars)
- Financial negotiation experience
- Data entry experience
- Healthcare Customer Service / Administration experience
- Help process provider applications and re-applications, including initial mailing, review, and loading into the database tracking system
- Screens incoming applications and paperwork for completeness and accuracy and sends necessary paperwork to credentialing vendor
3
Experience For Provider Enrollment Credentialing Representative Resume
- Provide oversight and compare application information to credentialing sources to ensure accuracy and completeness of provider application information
- Knowledge of credentialing procedures, policies, and terminology (e.g., NCQA; URAC)
- Update staff when new account information is provided that effects the workflow and negotiation process of the Accommodations
- Accurate data entry of all accommodation information in systems
- Estimated 30-40 applications on a weekly basis
- Oversee, facilitate and complete analysis and verification of provider credentials
- Support, monitor and oversee quality of network providers
4
Experience For Credentialing Representative Resume
- Receive and review application material to determine if system of care providers meet qualifying criteria for credentialing and have supporting documents to ensure compliance with the credentialing criteria
- Ensure verifications are completed within state, federal, and/or internally mandated timeframes (e.g., NCQA; CMS)
- Review reports (e.g., disciplinary reports; monthly reports; Medicaid reports) from state licensing bodies to determine if affected providers are within the system of care network and recommend appropriate follow-ups
- Contact primary sources, credentialing agencies, and/or reference on-line information sources in order to verify system of care provider credential information (e.g., licenses; education; Board certification; DEA and/or CDS)
- Tracks credentialing process and sends provider documentation that credentialing and re-credentialing processes are completed
5
Experience For Senior Credentialing Representative Resume
- Runs reports from provider databases to track credentialing and re-credentialing activities for the variety of provider types
- Verify that appropriate signatures on credentialing applications have been obtains and follow corporate and/or state signature procedures
- Attend and participate in meetings to achieve departmental and interdepartmental goals, objectives, and handle follow-up activities
- Documents communication with system of care providers and/or administrative organization in the designated databases; assists in managing the integrity of databases by using contacts with providers to verify and update provider files
- Help process provider applications and re - applications including initial mailing, review and loading into the database tracking system
6
Experience For Associate Credentialing Representative Resume
- Lead Team (dependent on level)
- Manage accuracy of the team’s work so that team members meet the established QC standards
- Manage inventory at acceptable levels
- Mentor/coach staff to achieve established goals and meet compliance dates
- Coordinate information and activities with other departments
- Proficient computer skills in Microsoft Office including Microsoft Excel (manipulating data and spreadsheets), Microsoft Word, Microsoft Outlook, Microsoft Access, and Adobe
7
Experience For Provider Enrollment Credentialing Representative Resume
- CPCS or CPMSM Certification
- Close and continual supervision
- Intermediate level of proficiency with Microsoft Excel and Microsoft Word
- Previous experience with ANY of the following: CAQH, PECOS, internal credentialing, NCQA Standards related to credentialing, or CMS Regulations related to credentialing
- Previous experience with ANY of the following: Microsoft Access (ability to create and edit forms), Adobe Acrobat Pro, Crystal Reports
- Experience in the Managed Care industry
- Experience using a computer and MS Word (created & edit documents), MS Excel (filter & sort data), MS Outlook (emailing & calendar scheduling), and MS PowerPoint (creating presentations)
8
Experience For Credentialing Representative Resume
- Healthcare Customer Service/Administration experience
- Proficiency with MS Excel (sort & filter data)
- Proficiency with MS Word (create & edit documents)
- Knowledge of industry terminology (e.g., medical; dental; behavioral health)
- Knowledge of applicable state and federal laws, policies, and regulations (e.g., state-specific license requirements; Controlled Dangerous Substances license requirements; DEA)
- Knowledge of provider information storage and retrieval systems (ie: CAQH, National Practitioner Data Bank (NPDB) or similar)
- MS Excel (pivot tables and vlook ups)
9
Experience For Senior Credentialing Representative Resume
- Intermediate level of proficiency with MS Excel and Word with the ability to edit, create, save and send spreadsheets and documents
- Applicant’s principal owners and/or officers
- Federal, state and local regulatory agencies
- Trans Union Sales Representatives, Vice Presidents and/or GVPs
- Sales force background
List of Typical Skills For a Credentialing Representative Resume
1
Skills For Senior Credentialing Representative Resume
- Experience researching and applying government regulatory information
- Knowledge using data analytics of key operating indicators (e.g., quality percentages; turnaround time) or performance standards experience
- ) of experience working with compliance workflows and processes, including NCQA policies and practices
- Experience working with compliance workflows and processes, including NCQA and CAQH policies and practices
- Multi-tasking skill: Ability to perform multiple tasks in environment that changes daily based on incoming work
- Experience of Medical Credentialing processes
- Health care provider credentialing experience
- Work experience using Microsoft Excel (sort & filter data)
2
Skills For Associate Credentialing Representative Resume
- Work experience using Microsoft Word (create & edit documents)
- ) of health care provider credentialing experience
- Decision-making skill: Ability to render recommendation on membership approval/declination based on predefined parameters and established procedures/rules
- Demonstrate knowledge of credentialing processes, tools and regulations
- Experience in a paperless healthcare office environment / (EDI) Electronic Data Interface
- Experience of Payor Enrollment Processes
- Previous healthcare office environment experience
3
Skills For Provider Enrollment Credentialing Representative Resume
- Experience with MS Excel the ability to sort, filter, data entry, export and import data
- Experience with MS Word the ability to create and modify docs
- Experience with MS Outlook the ability to manage emails and calendars
- Experience in a paperless healthcare office environment / (EDI) Electronic Data Interface
- Experience with NCQA Standards related to credentialing
- Experience with CMS Regulations related to credentialing
- Medical / Provider Credentialing experience
4
Skills For Credentialing Representative Resume
- Experience with credentialing
- Previous experience with NCQA policies and practices
- Basic experience with Adobe Acrobat
- Previous experience with Microsoft Word (ability to create and modify documents)
- Experience within Healthcare
- Health care provider credentialing experience
- Experience working with compliance workflows and processes
- 2-5 years of credentialing experience is required, payer specific
5
Skills For Senior Credentialing Representative Resume
- Health care provider credentialing experience
- Previous experience in an office and / or corporate setting
- Experience with Healthcare accreditation and regulatory standards including NCQA requirements
- Experience with CAQH ProView
- Creating and distributing monthly reports as assigned and handling complex and unusual or high-level credentialing issues
- Credentialing file organization and archiving
- Adherence to Trans Union policies regarding credentialing
- Identify training needs and oversee the necessary training so that all team members work to their potential
6
Skills For Associate Credentialing Representative Resume
- Knowledge of Credentialing requirements from the state, AAAHC and NCQA
- Familiarity with Windows PC and ability to navigate and research using the internet
- Working in an environment that requires coordination of benefits and utilization of multiple groups and resources
- Oversee, facilitate and complete receipt and processing of provider applications
- Maintain provider credentialing documentation
7
Skills For Provider Enrollment Credentialing Representative Resume
- Monitor and process expirables on an ongoing basis
- Scan system of care provider credentialing information into applicable systems to follow document management and retention procedure
- Receive and/or gather information from applicable databases regarding provider quality and performance (e.g., disciplinary notices)
- Facilitates the tracking of providers’ malpractice insurance, DEA, and licensure renewals to ensures they are current/active
- Facilitates the resolution of credentialing issues and coordinates and completes external and internal notification requirements
- Oversee and organize provider files which are easily reviewed by staff, credentialing committee and external review bodies
- Performance of due diligence verifications
- Verification of FCRA permissible purpose, GLBA permitted use and general business certifications against business norms
8
Skills For Credentialing Representative Resume
- Verification of certified intended use of services and or products requested
- Investigations via Third Party tools and or resources
- Verification of applicant’s federal, state, city/municipal and other government regulatory requirements
- Verification of applicant’s business legitimacy
- Introductory level of proficiency in Microsoft Office (Word, Excel, Outlook, Adobe) as demonstrated by ability to sort/filter Excel lists, separate or combine pages in Adobe and manage emails in Outlook
- Experience in a Credentialing Office or a Surgery Center/Hospital Medical Staff Office
- Credentialing experience
- Experience working with compliance workflows and processes
9
Skills For Senior Credentialing Representative Resume
- Healthcare provider credentialing experience
- Experience of Medical Credentialing processes
- Basic level of proficiency with Microsoft Excel (working in spreadsheets) and Microsoft Word (create and edit documents)
- Intermediate level of proficiency with Adobe
- Proficient with Microsoft Excel (general spreadsheet navigation, data entry and data sorting), Microsoft Word (creating and editing documents) Outlook (email and calendar)
10
Skills For Associate Credentialing Representative Resume
- Medical credentialing experience
- Provider Enrollment understanding or experience
- Provider credentialing Healthcare / Customer Service experience
- Close and continual interaction with supervisor/manager and other team members as needed in priority setting
- Facility Credentialing or Quality Review experience
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