Lucia Aponte
Summary
Health systems professional with a solid track record in credentialing and compliance; played a key role in achieving NCQA accreditation through meticulous file audits and documentation improvements, leading to better provider compliance. Focused on initiatives that enhance credentialing workflows and elevate organizational performance while advising decision-makers and offering management support. Proficient in managing provider compliance, conducting detailed audits, and resolving intricate enrollment issues while providing staff training on credentialing practices. Developed effective documentation and reporting systems that uphold compliance and drive operational success.
Overview
39
39
years of professional experience
Work History
Health Systems Specialist
Department of Veterans Affairs- Philadelphia VAMC
Philadelphia, Pennsylvania
04.2024 - Current
- Performing as the subject matter expert (SME) to Licensed Independent Providers (LIPs) and Service Chiefs regarding routine and complex matters related to C&P.
- Ensures current information is present on providers relative to state licensure, Drug Enforcement Organization (DEA) license, National Practitioner Data Bank (NPDB) Continuous Query (CQ) enrollments and renewals, Federation of State Medical Boards (FSMB), documentation of professional education, specialty medical training, certifications, adverse licensure or privileging actions, initial and renewal of privileges which may affect the status of privileges granted for medical practice. Informs C&P Manager/Analyst of trends identified, audit results and identified problems that may affect a provider's privilege status.
- Assisting the C&P Manager/Analyst in developing short- and long-term goals necessary to accomplish the mission of the C&P program.
- Assisting the C&P Manager/Analyst in drafting local credentialing processes and Medical Staff Bylaws in compliance with all applicable regulations.
- Receiving and reviewing reports detecting problem areas requiring further investigation and which are confidential in nature.
- Informing the C&P Manager/Analyst of trends identified, audit results and identified problems that may affect a provider's privilege status.
- Providing guidance and instruction to hospital staff in completing the required documentation of establishing privileges for LIPs.
- Assuring application packages and other documents meet technical requirements per specialty of provider and assures application folder and database account (VetPro or other internal databases and spreadsheets) meet technical requirements.
- Serving as technical advisor to the Executive Committee of the Medical Staff (ECMS) and if applicable the Credentials Committee.
- Developing and providing routine and special reports as requested by the C&P Manager/Analyst.
- Establishing and maintaining a variety of files and records pertaining to the C&P process.
Provider Credentialing Specialist
AmeriHealth Caritas
Philadelphia, PA
09.2019 - 03.2024
- Perform and collect primary source verification documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on NCQA standards, health plan requirements, and company credentialing policies using Virtual Cactus
- Accurately maintain both participating and non-participating provider records in multiple states in database, while diligently resolving complex provider enrollment related issues
- Effectively communicate notification of changes to appropriate providers, members, and other departments within the contracted time frame
- Clearly document and provide audit reporting within timelines for 100% of audits while collaborating with cross-functional teams
- Identify, monitor, and report discrepancies in information and conduct follow-ups when appropriate
- Completes special supervisor projects of data collection for escalated issues
Member Service Representative
AmeriHealth Caritas
Philadelphia, PA
11.2015 - 09.2019
- Offered courteous service to members and providers achieving 90% and higher first call resolution (FCR) and customer satisfactory surveys (CSAT)
- Educated members and providers with primary care physician assignments, eligible benefits, Risk Assessment Surveys, and claims processing practices
- Enforced strict HIPAA regulations when verifying and handling member information
- Handles transfers and releases, Special Needs PCP assignments process, returned checks and provider mail
- Managed customer conflicts and challenging situations by staying calm and accessing internal knowledge-bases to develop strategic solutions.
- Enhanced member relationships by providing excellent service during each interaction.
Customer Account Executive
Aqua
Newark, DE
08.2011 - 01.2013
- Excelled in high volume call center environment accurately troubleshooting both verbal and written inquiries with diplomacy, empathy, good judgment, patience, and professionalism
- Provided courteous customer service opening and closing accounts, educating customers on account information, generating service orders, and correcting billing discrepancies
- Effectively demonstrated a working knowledge of multiple company resource software including billing system, outage management system, and Automated Call Distribution (ACD)
United Stated Marine
MILITARY SERVICE, United Stated Marine Corps
01.1988 - 05.1996
- Meritorious Unit Commendation
- Certification of Commendation
- Good Conduct Medal with star
- Letter of Appreciation
- National Defense Service Medal
- Meritorious Mast
- Sea Service Deployment Ribbon with star
- Rifle Expert Badge
Education
High School Diploma - General Education
Murell Dobbins Area Vocational Technical School
Philadelphia, PA06-1987
VASP Leadership Course
TMS
ILEAD Leadership Course
TMS
Skills
- Support achievement of NCQA accreditation for health plans within timeline
- Training facilitation for new staff and cross functional teams
- Successful collaboration with providers to complete file audits
- Implantation of best practices and standardized processes across credentialing departments
- Construction of process flows and job aids to document audting process
- Facility and individual provider credentialing
- Eligibility Determinations
- Business Correspondence Writing
Languages
- English, fluent
- Spanish, fluent
Timeline
Health Systems Specialist
Department of Veterans Affairs- Philadelphia VAMC
04.2024 - Current
Provider Credentialing Specialist
AmeriHealth Caritas
09.2019 - 03.2024
Member Service Representative
AmeriHealth Caritas
11.2015 - 09.2019
Customer Account Executive
Aqua
08.2011 - 01.2013
United Stated Marine
MILITARY SERVICE, United Stated Marine Corps
01.1988 - 05.1996
High School Diploma - General Education
Murell Dobbins Area Vocational Technical School
VASP Leadership Course
TMS
ILEAD Leadership Course
TMS