Alesha Bailey
Ewing,USA
Summary
Greater than 8 years of experience working as Credentialing Coordinator and Provider Data Analyst with Managed care clients such as Horizon BCBS, Maximus Healthcare, and Caresource. Experience in auditing, initiating, processing, and completing credentialing and recredentialing functions for practitioners and providers and responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise. Supported Enrollment for Commercial, Government Programs, Behavioral Health Networks and completed provider data reporting updates and conflict resolution. Processed requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions and refer NPI, License, Medicaid ID. Proficient in Microsoft office, enter PCM iServe Tickets to initiate provider data entry, NCQA Audit Preparation for State Audit and Maintain delegated provider entered.
Overview
13
13
years of professional experience
Work History
Provider Network Coordinator I
CareSource
01.2023 - Current
- Responsible for the integrity of the data in the provider database system
- Accurately load provider records for all products and markets into the provider database for use by various internal departments, providers, and our member community
- Ensure all participating providers have successfully completed credentialing and contracting prior to loading; work with the appropriate team to meet these requirements when necessary
- Ensure valid documentation is available prior to loading or performing maintenance on provider records and collaborate with various functions to resolve issues when necessary
- Meet aggressive Service Level Agreements (SLAs) for processing data
- Adhere to requirements established by external governing bodies such as various state or federal entities
- Accurately track daily activities through detail workflow queues to meet established productivity and timeliness standards
- Research and resolve provider data inquiries for various internal departments
- Respond to emails, phone calls and written requests from providers and internal customers while providing consistent and clear communication
- Serve as a subject-matter expert for the provider database system content and logic behind daily processing
- Communicate effectively with various internal departments to enhance cross-functional awareness, promote process improvements and to identify issues
- Continually evaluate current processes for improvement opportunities, submit potential enhancements to management, and participate in process improvement activities
- Assist in various mandatory projects such as data cleanup, workflow revisions, upkeep of maintenance and other projects as assigned
- Perform any other job duties as requested
Credentialing Coordinator
Maximus Healthcare Inc.
03.2022 - 01.2023
- Verify accuracy of credentialing packet application and documents for multiple vendors
- Responsible for On-Going Monitoring, organizing and coordinating with providers regarding missing information
- Handle Clinician on-boarding, compile and maintain current and accurate data for providers per medical staff bylaws and polices
- Complete, monitor and maintain, as required, all provider credentialing application, NPI licenses, DEA, and professional liability for appointed providers
- Perform proper loading of data in relevant healthcare systems to ensure accuracy in credentialing of providers
- Enhance all aspects of service delivery by adhering to Medicaid and Medicare regulations
- Expertly record and process data and generated reports through creation and maintenance of computerized record management systems
- Audit vendor applications for accuracy and discrepancies, while maintaining optimum quality scores
Certified EKG Technician
Capital Health System
10.2011 - 01.2023
- Knowledge and understanding of heart rhythms including mapping of strips and interpretations
- Responsible for notifying Nurses and Physicians of any advisory alarms and change of patient's rhythms
- Patient communication and interaction, bedside manner, adherence to Patient's rights and privacy
- Apply telemetry Holter monitors to patients
Provider Data Analyst
Horizon-BCBS - NJ
10.2019 - 03.2022
- Provider Credentialing and Re-Credentialing, Provider Enrollment, Provider Data Maintenance, Commercial and Government Program, preparation for NCQA Audit
- Initiated, processed, and completed credentialing and recredentialing functions for practitioners and providers
- Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions and refer NPI, License, Medicaid ID
- Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise
- Supports the provider credentialing/re-credentialing process for initial appointments, temporary privileges, reappointments, and other credentialing instances
- Credentialing for Commercial, Government Programs, Behavioral Health Providers
- Provider Enrollment for Commercial, Government Programs, Behavioral Health Networks
- Provider data reporting, updates and conflict resolution, enter PCM iServe Tickets to initiate provider data entry, NCQA Audit Preparation for State Audit and Maintain delegated provider entered
Network Operations Representative
Horizon-BCBS - NJ
10.2016 - 10.2019
- Credentialing, contracting, problem solving, claims, provider related investigations
- Creating workflow instructions for position responsibilities, new employee training
- Initiated, processed, and completed credentialing and recredentialing functions for practitioners and providers
- Provider credentialing projects, provider credentialing training and tracking
Provider File Systems Analyst
Horizon-BCBS-NJ
05.2013 - 10.2016
- Implemented inventory control for contractual documents within government programs
- Update and research provider inquiries Screening inquiries for referral to appropriate areas within the division or company
- Providing the department manager and/or other staff members with complete and timely background information on all telephone calls, correspondence, and individual assignments and reports
- Providing clerical support to departmental areas as needed; provide clerical support to departmental areas as needed
- Performing daily analysis on various internal audits to determine maintenance requires to ensure accuracy of data populated
- Participating in special projects and duties delegated by management; including but not limited to claims projects, data integrity projects and billing and remittance projects
- Regularly research and update information using credible search engines of Internet Explorer, PDMS (Provider Data Management System), and Facets
Education
High School Diploma -
Ewing High School
06-2004
Skills
- Microsoft Office Suite (Primarily Excel)
- Adobe Acrobat
- OnBase
- Cactus
- Power BI
- Keane
- Cerner
- Cornerstone
- PDMS
- CAQH
- Concur
- Medical & Behavioral Health
- Credentialing/Recredentialing
- NPDB Queries
- OIG
- SAM
- Medicaid
- NPPES
- License Verification
- Contract Execution
- QNXT
Timeline
Provider Network Coordinator I
CareSource
01.2023 - Current
Credentialing Coordinator
Maximus Healthcare Inc.
03.2022 - 01.2023
Provider Data Analyst
Horizon-BCBS - NJ
10.2019 - 03.2022
Network Operations Representative
Horizon-BCBS - NJ
10.2016 - 10.2019
Provider File Systems Analyst
Horizon-BCBS-NJ
05.2013 - 10.2016
Certified EKG Technician
Capital Health System
10.2011 - 01.2023
High School Diploma -
Ewing High School