DAVIDA FRYE TAYLOR
Henrico,VA
Summary
Results-driven Customer Service Representative skilled in developing credentialing processes and workflows. Enhances customer satisfaction through strong organizational skills and effective collaboration. Manages administrative tasks with an emphasis on risk management and compliance. Recognized as a change agent in fast-paced environments, driving company success and improving employee engagement.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Credentialing Manager
Dominion Youth Services
Richmond, VA
03.2025 - Current
- Completed credentialing and reappointment applications for timely submission to payers and facilities on behalf of providers.
- Obtained essential documentation from providers, including state licenses, IRS documents, NPI Notification forms, DEA numbers, board certifications, and malpractice certificates of insurance.
- Track progress of outstanding applications and report progress to Billing Manager, LOB Directors and Providers.
- To perform this job successfully, an individual should have knowledge of Spreadsheet software and Word Processing software.
- Keep current provider records electronically in Credentialing software, electronic provider folders, and in provider hard copy folders.
- Understand how provider credentialing impacts billing, contracts, and EDI.
- Investigated unpaid and denied claims to resolve Credentialing/Provider contract issues effectively.
- Maintains confidentiality in compliance with HIPAA regulations for all client PHI.
- To perform this job successfully, an individual should have knowledge of Spreadsheet software and Word Processing software.
Part-time Front Desk Patient Services Representative
Master Center for Addiction Medicine
Glen Allen, VA
04.2023 - Current
- Checked in and out patients at the front desk to ensure smooth arrival and departure processes.
- Answered and responded to patient inquiries via phone, ensuring clear communication and timely assistance.
- Scheduled and confirmed patient appointments to ensure efficient daily operations.
- Facilitated new patient intake process by referring them to appropriate resources, enhancing their onboarding experience.
- Collected patient payments, including co-pays and deductibles, to ensure timely billing and revenue flow.
- Verified patient insurance information and entered structured data into medical records system to maintain accurate billing.
- Scanned and uploaded documents into patients' medical records to maintain accurate and up-to-date information.
- Delivered exceptional customer service to patients, employees, and vendors, fostering positive relationships and satisfaction.
Credentialing Specialist
Molina Healthcare
New York, NY
02.2024 - 02.2025
- Coordinated credentialing and primary source verification process for practitioners and health delivery organizations.
- Process initial and recredentialing applications from providers, meeting departmental requirements.
- Prepare and send out recredentialing groups, meeting departmental requirements.
- Complete 1st, 2nd and 3rd requests for recredentialing packets, meeting departmental requirements.
- Sent reports to state plans/departments identifying providers who hadn’t returned recredentialing applications or were past-due for credentialing.
- Requested missing credential information from providers via email.
- Email providers for missing credentialing information or to schedule site visits.
- Review daily reports for missing information to update in Salesforce.
- Completed data entry of applications and reviewed for errors before submitting provider files for quality review.
- Data entry of provider credentialing applications into Salesforce.
Credentialing Analyst
CVS Health/Aetna
Richmond, VA
11.2018 - 08.2023
- Participate in the development of credentialing processes and workflows.
- Identified improvement opportunities, recommending enhancements and solutions to optimize credentialing processes.
- Provide telephonic education to providers/producers on credentialing policies and procedures.
- Identify and communicate trends (quality of results, efficiencies of processes).
- Research and prepare risk-sensitive or complex business review/credentialing verification items for CPC.
- Supported department members by researching and analyzing complex issues raised by providers/producers and internal/external customers.
- Provide issue resolutions for providers/producers, during the credentialing or data management processes.
- Managed vendor online access to primary verification sources to ensure timely and accurate credentialing.
- Review completed investigative files of co-workers for completion and accuracy.
- Configured benefit plans using QNXT software to ensure accurate processing.
- Achieved subject matter expert status in QNXT software through comprehensive training.
- Gained extensive experience working with Medicaid regulations and processes.
- Directly contact providers/producers and/or outside entities to clarify data quality issues.
- Ongoing License Sanction monitoring and reporting to minimize corporate risk.
Provider Relations Rep
Aetna
Richmond, VA
06.2015 - 11.2018
- Provided telephonic education to providers on policies and procedures.
- Provided education and training to providers and/or internal customers on system-related policies and procedures.
- Performed intake triage and responded to network inquiries including provider requests (e.g., policy and procedures, credentialing status, claims status, provider leads, etc.), internal customer requests, and member requests.
- Supported department members by researching and analyzing provider and customer concerns/issues for resolution.
- Obtained delegated credentialing materials and coordinated processes.
- Coordinated production and distribution of provider communication and educational materials to enhance provider understanding.
- Verified, analyzed, and maintained all provider data in support of claim adjudication and production of directory and physician supplements.
- Reviewed provider maintenance requests for complete and accurate information.
- Provided training and/or ongoing feedback to claim processors, customer service representatives, and other staff (e.g., appropriateness of request, accurate completions of provider add/change forms).
Provider Services Rep 2
WellPoint - Anthem Blue Cross & Blue Shield
Richmond, VA
06.2013 - 06.2015
- Responded to customer questions via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility, and claims.
- Developed and maintained strong customer relations, coordinating with multiple departments to ensure timely resolution of customer requests.
- Sought, understood, and responded to the needs and expectations of internal and external customers.
- Analyzed problems and provided effective solutions to enhance customer satisfaction.
- Researched and analyzed data to identify and address operational challenges, improving overall customer service quality.
- Thoroughly documented inquiry outcomes for accurate tracking and analysis.
- Operated a PC/image station to obtain and extract information, document information, activities, and changes in the database.
- Used computerized systems for tracking, information gathering, and troubleshooting.
- Adjusted claims within my department on several systems.
- Provided external and internal customers with requested information.
- Required to meet departmental goals.
Education
Bachelor of Business Administration - Management
Colorado Tech University
Colorado Springs, COSkills
- Claims Experience
- Compliance
- Risk Management
- QNXT Experience
- EClinicalWorks
- Availity
- Change Healthcare
- ProviderNet
- Data interchange
- Ability to Meet Deadlines
- Problem-Solving
- Data management
- Communication
- Oral and written communication
- Customer Satisfaction
References
Available upon request.
Certification
Medical Billing Specialist
Timeline
Credentialing Manager
Dominion Youth Services
03.2025 - Current
Credentialing Specialist
Molina Healthcare
02.2024 - 02.2025
Part-time Front Desk Patient Services Representative
Master Center for Addiction Medicine
04.2023 - Current
Credentialing Analyst
CVS Health/Aetna
11.2018 - 08.2023
Provider Relations Rep
Aetna
06.2015 - 11.2018
Provider Services Rep 2
WellPoint - Anthem Blue Cross & Blue Shield
06.2013 - 06.2015
Bachelor of Business Administration - Management
Colorado Tech University