Lauren Bergmann
Milwaukee,WI
Summary
Productive Credential Specialist with excellent skills in customer service, office management and administrative support. Remains professional and tactful in all situations with focus on increasing satisfaction and retention. Versed in credentialing and contracting healthcare facilities and providers, conducting application reviews and primary source verifications.
Overview
12
12
years of professional experience
Work History
Contracting Specialist
Chorus Community Health Plan
03.2023 - Current
- Perform intake on providers and facilities looking to become part of our network
- Process provider applications, initiate contracts, send providers to be processed by either credentialing or approved at VP level.
- Negotiate rates and participation based on company policy and the Wisconsin Medicaid fee schedules
- Recruit providers and facilities into joining our insurance plan
- Worked on expansion in the state of Wisconsin by contracting with providers in different counties to provide access for members
- Run sanctions on perspective providers and verify Medicaid certification before enrolling providers
- Work with claims, provider data management, and credentialing to ensure new providers are up and running on date of new contract
- Provide any welcome material or training for new providers
- Term and contracts that are not following policy or who are leaving on their own and notify current patients of their options.
- Re-negotiate fee schedule when needed or add or terminate different lines of business upon request
Credentialing Specialist
Chorus Community Health Plan
01.2019 - Current
- Credentialed physicians, completed organizational applications, and prepared and presented committed meetings.
- Performed recredentialing or providers and organizations every 3 years.
- Used CAQH extensively for provider credentialing to ensure profiles were maintained and kept up to date.
- Enrolled physicians and facilities in both Medicaid and Marketplace lines of business.
- Performed delegation agreement paperwork and audits yearly.
- Monitored OIG and NPDB continuously for any reports listed for active physicians.
- Kept up to date on any facility accreditations including CMS and the Joint Commission to insure level of care met company policy.
- Ran sanctions on providers and facilities including state licensing board, NPDB, Streamline verify, WDSPS, OIG, Death Master File, and self disclosure paperwork.
- Communicated missing information, denials or approvals to the provider offices of facilities.
Prior Authorization Specialist
Molina Healthcare
03.2015 - 12.2022
- Processed all incoming authorization requests for Medicaid, Marketplace, and Medicaid lines of business
- Worked on phone queue to answer provider questions such as member eligibility, authorization status and requirements, and benefit limitations.
- Set up peer to peer calls
- Sent out both approval and denial letters based on lines of business
- Worked on state newborn report weekly
- Created workflows, lead meetings, and assisted with system upgrades
Prior Authorization Lead
Chorus Community Health Plan
06.2016 - 03.2019
- Trained all new staff on authorization process, created workflows, and generated new ideas for the job
- Processed incoming Medicaid and Marketplace authorization requests via our authorization portal or fax (experience includes inpatient, outpatient, mental health, DME, home health, skilled nursing, and pharmacy).
- Auto approved any OB admission per federal guidelines
- Determined whether authorization was required, if service was a covered benefit, and provided status to providers via phone
- Verified eligibility and benefit limitations. Notified providers if members were close to maxing out a particular benefit
- Worked with out of network providers by initiating authorizations, encouraging them to become in network providers, and handling single case agreements
Prior Authorization Lead
Wheaton Franciscan Healthcare
01.2012 - 03.2015
- Lead team of 10 and assisted in training and coaching of new and existing staff
- Responsible for working with all payors in provider notification of inpatient admissions
- Researched outpatient authorization requirements for plans using insurance tools, phone calls, and portals
- Obtained outpatient authorizations when required and communicated outcomes with the doctors when received
- Responsible for cancelling any appointments with patient if authorization was not in place the day before services
- Was soley responsible in the authorizations of a neurology group to authorize their specialty medications and an orthopedic office to authorize their radiology services
Education
Bachelor of Science - Social Work
Northern Arizona University
Flagstaff, AZ06.2026
High School Diploma -
Alexnader Hamilton
Milwaukee, Wisconsin06.2006
Skills
- Medical Coding
- Prior authorizations from both provider and payor side
- Provider contracting
- Compliance and Auditing
- Medicaid, Medicare, Marketplace, and Commercial insurance
- Training
- Excellent customer service skills
- Administrative Support
- Physician and Facility Credentialing
- Project Management
Timeline
Contracting Specialist
Chorus Community Health Plan
03.2023 - Current
Credentialing Specialist
Chorus Community Health Plan
01.2019 - Current
Prior Authorization Lead
Chorus Community Health Plan
06.2016 - 03.2019
Prior Authorization Specialist
Molina Healthcare
03.2015 - 12.2022
Prior Authorization Lead
Wheaton Franciscan Healthcare
01.2012 - 03.2015
Bachelor of Science - Social Work
Northern Arizona University
High School Diploma -
Alexnader Hamilton
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