Karen A Lofstrom
Nashua,NH
Summary
Network Data Specialist professional with track record in managing credentialing operations and ensuring compliance. Valued for collaborative skills and achieving results through efficient processes. Known for adaptability and reliability in dynamic environments and business mergers, with expertise in following complex work flows and Federal, State and Commercial Insurance regulations and requirements.
Overview
23
23
years of professional experience
Work History
Credentialing Specialist, Network Data Specialist
Elevance Health
11.2015 - 09.2024
- Scanned and entered applications for Solo, Groups and Facilities wishing to become enrolled in the network's Medicare, Medicaid and Commercial insurance plans.
- Provided pre-screening, outreach and development of a process to build and route clean files to credentialing inturn increasing the efficiency in post data and claims setup for rendering and reimbursing for services provided to plan members.
- Consistently met deadlines and delivered high-quality work, demonstrating a strong commitment to excellence in data management.
- Managed sensitive information responsibly, adhering to strict HIPAA, Federal and State regulations and maintaining confidentiality at all times.
- Enhanced personal goals by implementing efficient data validation and entry to automate manual tasks.
- Maintained flexibility with cross-functional teams by managing files in various work silos which, requires knowledge of credentialing and provider data for in and out of network contracts.
- Managed multiple priorities effectively (expedited, escalated and aging).
Data Entry III, QI Compliance Associate
Greater Nashua Mental Health
02.2002 - 09.2015
- Entered medical services rendered into the CMHC Facility database.
- Compiled weekly billing and electronically transferred claims to Medicare, Medicaid and Commercial insurances.
- Scanned medical records into EMR.
- Organized random selection of clinical staff and co-led internal chart audits, as directed by Compliance Manager.
- Identified compliance risks by reviewing medical charts by generating specific reports for Compliance Manager.
- Created Sentinel Event log fpr all high profile events - used in Psych Autopsies for identifying potential gaps and entered required data to the State Database for reports, reviews, additional audits (Suicides, Shootings, Overdoses, Child Abuse, etc).
- Engaged with external auditors by pulling requested records and organizing for compliance reviews and feedback.
Education
High School Diploma -
Nashua High School
Nashua, NH06-1971
Skills
- Microsoft Office proficiency (Outlook, Word, Excel, Access)
- Electronic Medical Record proficiency (EMR)
- Oracle Managed Care Database proficiency (Network Connect, Service Connect)
- Council for Affordable Quality Health Database proficiency (CAQH)
- Netshare experienced (workflows, Federal, State, Commercial Insurance grids, guides, rules)
- Credentialing Cycle flexibility (contracts, provider applications, provider and post data, in and out of network claims setup)
- Data entry, verification and quality management
- National Committee of Quality Assurance knowledge
- Adept in remote work (8 years)
Timeline
Credentialing Specialist, Network Data Specialist
Elevance Health
11.2015 - 09.2024
Data Entry III, QI Compliance Associate
Greater Nashua Mental Health
02.2002 - 09.2015
High School Diploma -
Nashua High School
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