KRASHUNDA GILES
Birmingham, AL 35208-3203,AL
Summary
Claims Analyst with 8 years of experience in effectively communicating policy provisions to policyholders and responding to inquiries from insured customers, claimants, and attorneys. Skilled in reviewing and updating claim les, executing outstanding items, and expediting le closure. Adept at consulting with insurance companies, adhering to process procedures, and exceeding performance ratings. Proficient in creating medical records requests, updating claim-related policies, and working on provider claims research projects. Multitasking professional skilled in file efficiency and database integrity. A resourceful Credentialing Coordinator with a background in tracking the expiration of practitioner documents. Articulate Credentialing Coordinator with exemplary critical thinking and decision making talents. An energetic professional with more than 10 years' requesting credentialing documents from providers. Ready to apply talents in credentialing and document workflows with a new organization. Experienced Credentialing Specialist adept at conducting application reviews and primary source verifications. Excellent relationship-building, problem-solving and communication skills.
Overview
12
12
years of professional experience
Work History
Credentialing Coordinator
Molina Healthcare
04.2022 - 04.2023
- Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
- Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
- Enhanced the organization''s reputation through meticulous maintenance of accurate, up-to-date records on all affiliated providers.
- Collaborated with department heads to develop a comprehensive credentialing policy, ensuring compliance with industry standards.
- Reduced errors in documentation by thoroughly auditing provider files for completeness and accuracy.
- Performing provider credentialing activities including primary source verification, records review, and credentialing file preparation
- Performing provider outreach to support timely credentialing and recredentialing
- Monitoring provider licensure and sanctions via standard reporting databases
- Compiling required data and reporting in support of delegated credentialing agreements and external partnerships
- Assisting with accreditation survey and audit preparation
- Analyzing data and make recommendations for improvement to the credentialing and QI programs With guidance from the Credentialing Manager:
- Creating training materials, policies, and operating manuals
- Updated the quality assurance policies and procedures when workflow changes are made
- Minimized potential legal complications by ensuring adherence to federal and state regulations governing healthcare practitioners'' licensure and certification requirements.
- Analyzing quality of care complaints and other non-compliance quality issues
- Gathering and organizing quality data
- Served as a resource for departmental staff by maintaining a thorough understanding of current trends and best practices in the credentialing field.
Business Analyst
Ntelicor
05.2019 - 04.2022
- Improved business processes by analyzing current practices and recommending optimization strategies.
- Reduced operational costs through thorough data analysis and implementing cost-effective solutions.
- Enhanced company-wide decision-making by developing comprehensive reports on key performance indicators.
- Streamlined project management with effective communication and collaboration across cross-functional teams.
- Ensured compliance with industry regulations by conducting thorough risk assessments and implementing necessary controls.
- Collaborated closely with stakeholders to identify opportunities for process improvements and drive continuous innovation in the organization.
- Evaluated potential investments by performing financial analyses to assess profitability and viability within the company''s long-term strategy.
- Performed gap analysis to identify areas of improvement.
- Applied honed problem-solving skills to analyze and resolve issues impacting business operations and goal achievement.
- Generated business intelligence reports to inform strategic decision-making.
- Collaborated with teams in product line transition to streamline manufacturing footprint.
- Drafted reports on company financial metrics to assess successes and account for deficiencies.
Credentialing Coordinator
Palmetto GBA
02.2018 - 05.2019
- Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
- Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
- Enhanced the organization''s reputation through meticulous maintenance of accurate, up-to-date records on all affiliated providers.
- Collaborated with department heads to develop a comprehensive credentialing policy, ensuring compliance with industry standards.
- Reduced errors in documentation by thoroughly auditing provider files for completeness and accuracy.
- Kept informed regarding pending industry changes, trends or best practices.
- Conducted periodic compliance audits and reviews to identify areas of improvement.
- Performing provider credentialing activities including primary source verification, records review, and credentialing file preparation
- Performing provider outreach to support timely credentialing and recredentialing
- Monitoring provider licensure and sanctions via standard reporting databases
- Compiling required data and reporting in support of delegated credentialing agreements and external partnerships
- Assisting with accreditation survey and audit preparation
- Analyzing data and make recommendations for improvement to the credentialing and QI programs
- With guidance from the Credentialing Manager:
- Creating training materials, policies, and operating manuals
- Updating the quality assurance policies and procedures when workflow changes are made
- Analyzing quality of care complaints and other non-compliance quality issues
- Gathering and organizing quality data
Systems Analyst
Cahaba GBA
07.2011 - 02.2018
- Enhanced system efficiency by identifying and resolving complex technical issues.
- Streamlined processes for improved productivity through thorough systems analysis and optimization.
- Collaborated with cross-functional teams to develop innovative solutions for business challenges.
- Implemented strategic IT initiatives, contributing to overall company growth and success.
- Provided expert technical support, reducing system downtime and minimizing disruptions to daily operations.
- Designed user-friendly interfaces for various software applications, increasing ease of use and functionality.
- Managed multiple projects simultaneously, consistently meeting deadlines and budget constraints.
- Led a team of developers in the successful completion of large-scale projects, fostering a positive work environment.
- Trained new hires on company-specific software tools, ensuring seamless integration into the team''s workflow.
- Spearheaded efforts to adopt emerging technologies within the organization, keeping pace with industry advancements.
- Established effective relationships with key stakeholders across departments to facilitate collaboration on critical projects.
- Performed system analysis, documentation, testing, implementation, and user support for platform transitions.
Education
Associate of Applied Science - Healthcare Reimbursement
Virginia College - Birmingham
Birmingham, AL01.2002
Skills
- Background Investigations
- Proficiency in IDX, SAS, UAT
- Professional Networking
- Practitioner Application Monitoring
- Test Scripts UAT Business Process
- Medicaid CPT Java Data Entry Claims Issues CMS COB ICD-10 CPT Appeals Process Claims Adjustments
- Claims Analyst with 8 years of experience in effectively communicating policy provisions to policyholders and responding to inquiries from insured customers, claimants, and attorneys Skilled in reviewing and updating claim les, executing outstanding items, and expediting le closure Adept at consulting with insurance companies, adhering to process procedures, and exceeding performance ratings Proficient in creating medical records requests, updating claim-related policies, and working on provider claims research projects
Timeline
Credentialing Coordinator
Molina Healthcare
04.2022 - 04.2023
Business Analyst
Ntelicor
05.2019 - 04.2022
Credentialing Coordinator
Palmetto GBA
02.2018 - 05.2019
Systems Analyst
Cahaba GBA
07.2011 - 02.2018
Associate of Applied Science - Healthcare Reimbursement
Virginia College - Birmingham
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