GLENDA WILSON
Lutz,FL
Summary
Credentialing Specialist with extensive experience at WellCare Health Plans, Inc., specializing in high-volume application processing and improving turnaround times. Demonstrated expertise in relationship building and effective communication, ensuring compliance and accuracy in all operations. Proficient in database management with a strong commitment to professional integrity and continuous process improvement.
Overview
38
38
years of professional experience
1
1
Certification
Work History
Customer Service Representative / Data Entry
Northeastern US Health Care Company
04.2022 - 05.2023
- Verified the information in the computer system was up to date. Eliminate outdated records by sending the records to be scanned. Complied statistical information for special reports. Verified and logged in deadlines for responding to daily inquiries. Identified and resolved system and account issues.
- Collected customer feedback and made process changes to exceed satisfaction goals. Made reasonable procedure exceptions to accommodate customer requests. Provided accurate and appropriate information in response to customer.
- Demonstrated mastery of customer service call script within specific timeframes. Addressed customer service inquiries in a timely and accurate fashion. Maintained up-to-date records at all times. Developed effective relationships with all call center departments. Worked with upper management to ensure appropriate changes were improve customer satisfaction.
- Built customer loyalty by placing follow-up calls for customer who had product issues. Formulated and enforced service center policies procedures and quality assurance measures.
Credentialing Specialist Sr.
Bristow Medical Center
Bristow, Oklahoma
11.2019 - 01.2022
- Receives and reviews submitted applications for completeness and compliance with instructions for preparation; ensures the timely completion of applications by communicating with and assisting the applicants in submitting all documentation necessary to process the application; identifies deficiencies and follows up to gather missing or incomplete data.
- Uses discretion and independent judgement in determining the need for deviation from standard processes or more detailed investigation, including those involving fees, or that would cause processing delays to clarify, verify and/or confirm information contained in the credentialing application.
- Perform primary and secondary source verification of Practitioner’s and facilities credentials according to policy.
- Performs the appropriate (applicable) credentialing processes in a timely and complete manner.
- Uses, protects, and discloses medical group patients’ protected health information (PHI) only accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Responsible for processing provider and facilities applications and re-applications including initial mailing, review and loading into the database tracking system ensuring compliance with required standards.
- Ensures the files for clinicians and facilities due for credentialing/re-credentialing are available for review by the Credentialing Committee each month and resolves outstanding issues prior to committee review.
- Oversees primary source verification activities.
- Ensures timely processing of all credentialing requests.
- Perform outreach to providers and facilities via phone calls and fax/email correspondence.
- Responsible for audits and reports audit finding to the Credentialing Committee.
- Supports the Provider Relations, Credentialing Management, Quality Management and Regulatory Compliance with requested data reporting.
- Demonstrate respect and maintain patient’s and facilities dignity and confidentiality.
Credentialing Specialist Senior
WellCare Health Plans, Inc.
Tampa, FL
11.2004 - 07.2019
- Processes high volume credentialing and recredentialing applications and/or enrollment of health care providers.
- Reviews applications, prepares verification letters and maintains databases.
- Contacts medical office staff, licensing agencies, and insurance carriers to complete credentialing and recredentialing applications.
- Ability to work with health care acronyms and able to differentiate between provider titles, download the providers applications.
- Meet productivity standards as outlined in client metrics.
- Identify any issues or trends and bring them to the attention of the management team.
- Understanding of credentialing process.
- Familiarity with CAQH, DEA CSR Board certifications.
- Verifying and auditing other employee's work.
- Train other staff in credentialing.
- Auditor check staff work to go to review.
- Amenable for the development revision and institution of the policy and procedures.
- Facility and organizational files and reports.
- Facilitated and organized bi-weekly credentialing committee meetings for all major legal discrepancies and medical review.
- Review all legal discrepancy findings through the National Practitioner Data Bank (NPDB/HIPB).
- Improved current departmental processes for initial and re-credentialing turnaround time frame.
- Outreach to providers to ensure their timely renewal of expiring licenses and certifications.
- Credential and re-credential all nurse practitioners and physicians and facilities applications in accordance with The Joint Commission Providers.
- Staff Training, productivity.
- Tracking quality control and files auditing.
- Insurance credentialing processes.
- Adjusted compensable indene.
- Verifying Board Certifications, DEA, CSR, NPI, Practitioners Data Bank, Insurance, State and Federal OIG, Sam report for Medicare and Medicaid, Hospital privileging and onboarding process for new providers, Medicare OPT-OUT, entering all data into Cactus database, NCQA certifications, education and hospital privileges.
Data Entry Operator
Office Staffing
Tampa, Florida
04.2003 - 11.2004
- Verification for the credentialing and recredentialing team which entails verifying DEA, CSR, Board Certifications, Site Surveys.
- Gathering, collating, and preparing documents.
- Conducting research to obtain information for incomplete documents and material.
- Reviewing all documents and information for accuracy.
- Training staff in primary sources.
- Training in credentialing.
- Collecting data and input to spreadsheets and databases.
- Support including data entry, filing, copying, scanning, faxing is required.
Computer Operator / Data Entry Lead
Pierce County Services
Tacoma, Washington
03.1985 - 02.2003
- Gathering, collating, and preparing documents.
- Conducting research to obtain information for incomplete documents.
- Reviewing all documents and information for accuracy.
- Monitoring of systems and networks.
- Monitoring of the security and facility environment.
- Interacting with System Administration staff to report and resolve issues.
- Using a variety of tools and processes to determine the health of the systems and networks.
- Applying fundamental concepts, processes, practices, and procedures to technical assignments.
- Executing and monitoring a range of scheduled routines.
- Resolving common operating problems.
- Diagnosing and acting on computer output instructions and machine stoppage or error conditions.
- Applying standard operating and or corrective procedures.
Education
English, Basic Computers, Algebra, Business and Registered Nurse -
Hillsborough Community College
Tampa, Florida07.2025
WordPerfect and Excel Microsoft Word -
Bates Community College
Tacoma, Washington06.1976
Child Development and Business Machine - Sociology
Tacoma Community College
Tacoma, Washington06.1974
Skills
- Professional demeanor
- Strong written communication skills
- Strong oral communication skills
- Ability to learn systems
- Spreadsheet software
- Database software
- Interpersonal skills
- Customer interface
- Vendor interface
- Credentialing staff interface
- Administrative experience
- Organizational skills
- Follow up skills
- Customer service skills
- Communication skills
- Following instruction
- Patience
- Self-discipline
- Personal integrity
- Professional integrity
- Relationships
- Team building
- Decision making
- Critical thinking
- Government relations knowledge
- Cultural awareness
- Sensitivity
- Teamwork
Certification
- Care Coordinator, 2022-11-20, Alorica, Omaha, NE
- Certified Professional Credentialing Specialist, 2012-10-15, WellCare Health Plans, Tampa, FL
Programs
- IntelliCare'd
- Omni
- Citrus
- MedPro
- Optum
- Gensis
- Navigator
- WWIKT
- Iris
- Excel
- Alorica Connect
- Grid
- Alorica ECFR
- EIS
- Engage
- Alorica on Point
- Avaya
- Oracle
- Service Now
- Spectrum Kiosk
- Spectrum Staff
- Teams
- Knowledge
- Del Set-Up
- Genesis
- Intermediate in Cactus
- Intermediate in Microsoft PowerPoint
- Intermediate in Access
- Paradigm
- Diamond EMMA
- IBPS
- VPN
- Cactus
- IRIS
- QNXT
- PRMS
- Word
- Power Point
- PECOS
- NPPES
- CAQH
- NCQA Accreditation
- URAC
- HIPAA
- FERPA
- TJC
- CMS
- CPMSM
- Microsoft Access
- Outlook
- Microsoft Office Open Type form
- SharePoint
- Adobe Acrobat Pro
- Square POS
- Open Refine
<Enter your own>
Title: Credentialing Specialists Senior
Timeline
Customer Service Representative / Data Entry
Northeastern US Health Care Company
04.2022 - 05.2023
Credentialing Specialist Sr.
Bristow Medical Center
11.2019 - 01.2022
Credentialing Specialist Senior
WellCare Health Plans, Inc.
11.2004 - 07.2019
Data Entry Operator
Office Staffing
04.2003 - 11.2004
Computer Operator / Data Entry Lead
Pierce County Services
03.1985 - 02.2003
English, Basic Computers, Algebra, Business and Registered Nurse -
Hillsborough Community College
WordPerfect and Excel Microsoft Word -
Bates Community College
Child Development and Business Machine - Sociology
Tacoma Community College
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