A Credentialing Representative ensures that the medical staff is equipped with current licenses and credentials and that they are working legally in their specialty. The job duties commonly listed on the Credentialing Representative Resume include the following – monitoring upcoming renewal dates and working with medical staff to advise them on steps to maintain their credentials; reviewing information on potential new employees, ensuring all required licenses are credentials are current before hiring, maintaining compliance with all regulatory and accrediting institutions; monitoring staff credentials and licenses, advising staff on renewal procedures and participating in the development of internal credentialing processes.
For these positions, employers prefer to hire those with the following skills and abilities – the ability to manage the workload effectively and to meet set deadlines; strong computer skills, strong communication skills to interact with all types of medical professionals, and relevant work experience. Education beyond a high school diploma is compulsory.
Objective : Seeks to obtain a position where one can use knowledge and strengths while learning new skills to help others.
Skills : Excel, Word, Powerpoint, QNXT, OCC Quick order.
Description :
Mailed, emailed or faxing re-credentialing applications to providers that have reached their 3-year mark.
Ran the following verifications for each provider: License, DEA, NPPES, NPDB, OIG, SAM, AHCA, SDN, American Board certifications, and hospital affiliations.
Ensured providers have provided all the necessary documents required for re-credentialing including certificates, proof of practice license, proof of DEA license, and insurance.
Analyzed any issues found in provider's documentation that pertains to their insurance, licenses, malpractice reports, etc.
Reviewed all applications to ensure they are filled out correctly and have the provider's signature.
Updated credentialing status of providers to credentialed, un-credentialed, provisional, or not required.
Assisted in the termination of providers from the company by sending termination letters to the correct department, logging the changes of provider status onto a secured Excel spreadsheet, and retrieving and preparing files to be sent to the warehouse.
Experience
2-5 Years
Level
Junior
Education
MS In Criminal Justice
Credentialing Representative Resume
Objective : Possess a high degree of integrity and commitment to comply with policies, regulations, and codes of conduct governing all aspects of job responsibilities. Strong attention to detail with the ability to multi-task in a fast-paced environment. Superior communication and customer service skills.
Skills : Administrative/Management, Strong work ethic: Quality-driven.
Description :
Processed and maintains the confidential credentialing files for each associate; including evaluation for completeness.
Communicated with clinical management and clinical staff to obtain missing information.
Initiated the onboarding process by sending out a welcome letter to the new hires and meets the new associate in person during orientation to collect paperwork.
Employed the credentialing database program (Intellicred) in an effort to maintain current information on all clinical staff.
Distributed the published report weekly for outstanding credentialing documents to the appropriate director of operations and clinical managers.
Additionally contacted for credentialing requests and/or inquiries from operations and hospitals.
Set up vendor accounts for clinicians and business development personnel for submission of credentialing documents for regulatory compliance and internal access to the operating room.
Experience
2-5 Years
Level
Junior
Education
Medical Billing And Coding Specialist
Credentialing Representative Resume
Summary : A Credentialing Representative professional with over eighteen years combined experience in Medical Staff Services and Managed Care, including Credentialing Operations, Network/Provider Relations. Excellent interpersonal, problem-solving, and verbal communication skills. Effective supervisory, time management, and leadership qualities.
Team Leader of the credentialing staff for Pennsylvania and Mid-Atlantic region.
Reviewed and processed credentialing and re-credentialing applications of health care providers.
Performed primary source verification, prepared verification letters, and maintained database.
Entered accurate and current credentials for applicants into the database.
Responded to verification requests.
Provided status checks on the credentialed physicians to the Provider Relations department.
Audited files for consistency and accuracy.
Experience
7-10 Years
Level
Management
Education
BBA In Business Administration
Credentialing Representative Resume
Objective : Professional with over 10 years of administrative and business skills primarily in the Health Care Insurance Industry. Professional background and education allow applying the skills have acquired within customer service, systems analysis, project management, as well as health care administration and coordination.
Skills : Microsoft Office, Computer.
Description :
Managed all activities associated with credentialing or re-credentialing nurses.
Included processing provider applications and re-applications including initial mailing, review, and loading into the database tracking system.
Ensured high-quality standards are maintained.
Pointed of contact over online payments and assist with renewals.
Managed the request center on a daily basis.
Implemented the credentialing policies and procedures and oversees primary source verification activities.
Team player always willing to help co-workers in every area.
Experience
2-5 Years
Level
Junior
Education
Diploma
Credentialing Representative Resume
Objective : Credentialing Representative is responsible for the day-to-day tasks associated with customer service, including answering customer inquiries, providing product information, and processing orders.
Skills : Microsoft Office, Spanish.
Description :
Reviewed physicians, allied health professionals, and mid-level providers' files for appropriate documentation required for the credentialing process.
Collected and maintained files for physicians, allied health professionals, and mid-level providers, including application, contracts, verify current state physician licenses, DEA/DPS licenses, malpractice insurance, board certifications, education, training, OIG, and opt-out.
Interfaced between physicians and hospital staff to collect the required information.
Performed credential verification and request information from appropriate data banks.
Submitted processes to the Quality Team for review.
Responsible for the Credentialing and contracting for over 200 physicians that we serve.
Completed and reviewed applications and contracts for physicians with various insurance companies.
Experience
2-5 Years
Level
Junior
Education
BS
Credentialing Representative Resume
Objective : Seeks to continue the career as a Credentialing Representative professional in an environment where experience and abilities will allow being an asset to an employer.
Skills : Microsoft Office, Various Billing Software.
Description :
Followed up with the provider/ office manager on any issue that involves the re-credentialing process such as pending documentation or general inquiries that pertain to credentialing.
Answered any questions from provider's offices and walking them through the credentialing application process if necessary.
Helped the one person that was working in the department and help get things organized.
Setup referral authorizations to clinicians to have the appropriate vaccinations/blood work for compliance.
Created statistical data on target markets for service provider selection for clients.
Participated in the delivery, development, design and improvement of new/current training or workshop used in instructing grantees on program requirements, submission procedures, program interaction, capacity building and leadership development; and increase individual and program effectiveness.
Reviewed and conducted analyses of applications or performance reports for assigned CPD grantees and recommend to supervisor for approval/disapproval.
Experience
2-5 Years
Level
Junior
Education
Diploma
Credentialing Representative Resume
Objective : Credentialing Representative is responsible for managing the end-to-end credentialing process for new hires. This includes updating and maintaining current information on company guidelines, maintaining a database of credentials and issuing badges to employees.
Skills : Understanding of Laws, Regulations, and Procedures.
Description :
Followed NCQA and JACHO guidelines to credential medical providers for both plan placement and facilities.
Utilized Oracle to place dentists on plans.
Responsible for the credentialing for the entire Medical Staff.
Managed client accounts, updated company records on subcontractors to meet industry standards.
Handled heavy phone contact for clients and encouraged enrollment.
Identified disparities or deficiencies and bring to the attention of the senior staff with a recommended alternative for resolving or correcting the issue.
Identified issues, potential areas of non-compliance or opportunities for improvement or increasing effectiveness.
Experience
2-5 Years
Level
Junior
Education
BS In BBA
Credentialing Representative Resume
Objective : Credentialing Representative is responsible for interacting with internal and external stakeholders to help implement a variety of credentialing programs for our employees. This includes the creation of processes, policies and procedures to support the credentialing efforts of all employees with multiple credentials.
Skills : Writing Skills, Planning Skills.
Description :
Physician licensing applications to meet strict deadlines, physician and medical staff office interfacing, updating physician and staff profiles.
Credential and re-credentialing of providers for our in-network providers.
Managed compliance in accordance with Joint Commission and Utilization.
Reviewed Accreditation Commission (URAC) state licensing board, AMA.
Coordinated the processing of eye care providers by preparing and reviewing reports with accuracy.
Maintained communication channels with the provider.
Reviewed and assessed grantee performance through the analysis of grantee submissions, performance reports and other methods such as management and financial systems, provide written assessment of results.
Experience
2-5 Years
Level
Junior
Education
BS In BBA
Credentialing Representative Resume
Objective : Credentialing Representative is responsible for managing the credentialing process and ensuring compliance. This includes conducting credential reviews and adhering to all regulatory guidelines, ensuring that all parties are properly credentialed with the appropriate credentials, and maintaining the credentialing database.
Skills : MS Office, Customer Service, Interpersonal Skills.
Description :
Performed due diligence verifications.
Verified of FCRA permissible purpose, GLBA permitted to use, and general business certifications.
Managed credentialing services for Physician's Edge clients; that conform to current accreditation and regulatory standards as they pertain to the health.
Submitted and maintained provider contracts, and ensures completeness.
Responsible for all payer enrollment applications, maintaining and following upon.
Handled delegated credentialing applications in a timely and accurate manner.
Communicated daily with providers and insurance companies.
Experience
2-5 Years
Level
Junior
Education
BS In BBA
Credentialing Representative Resume
Objective : Credentialing Representative is responsible for obtaining, reviewing, and maintaining all necessary credentials for employees, contractors and vendors. This includes reviewing and processing applications from employees, contractors and vendors for access to the company's data centers, office locations and other facilities.
Skills : Documentation, Data Entry.
Description :
Initialized and maintained credentialing procedures for new providers.
Extensive, organized communication with 40+ insurance companies to establish providers with networks and maintain fee schedules.
Credential potential clients in the membership department.
Credentialing Representative (Hired Full Time): Responsible for coordination of initial/re-credentialing process, including primary source.
Reviewed credentialing and re-credentialing files.
Obtained all primary source verifications and completed compliant review.
Monitored community development activities on-site for compliance with program requirements and ensuring that program activities achieve the maximum utilization of funds.
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