Lori Pletcher
Osceola,IN
Summary
Accomplished Credentialing Specialist with a proven track record at Essentia Health, enhancing credentialing processes and provider relations through meticulous data management and effective communication. Expert in HIPAA compliance and Credentialing Software, including Modio and Credential My Doc, significantly improved turnaround times and streamlined provider enrollment. Demonstrates strong problem-solving abilities and a commitment to accuracy and efficiency.
Overview
30
30
years of professional experience
Work History
Credentialing Specialist
Essentia Health
02.2024 - Current
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
- Managed multiple priorities effectively, resulting in the on-time completion of credentialing tasks for numerous providers simultaneously.
- Conducted audits of provider files, ensuring all necessary documents were up-to-date and compliant with regulatory requirements.
- Enrolled providers and Medicaid, Medicare, and private insurance plans.
- Enroll facilities with Medicare and Medicaid and private insurance plans.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
- Demonstrated excellent problem-solving skills when confronted with complex issues or discrepancies during the credentialing process.
Credentialing Coordinator
Third Street Community Clinic
09.2022 - 06.2024
- Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
- Upheld strict confidentiality standards, safeguarding sensitive provider information from unauthorized access or disclosure.
- Assisted with managed care auditing processes and performed internal file audits.
- Boosted productivity levels within the credentialing team by training new employees on proper procedures and best practices within the role.
- Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
- Strengthened relationships with external agencies by responding promptly to verification requests and inquiries regarding providers'' credentials.
- Expedited the onboarding process for new medical staff by efficiently managing initial appointments and reappointments.
- Assisted in maintaining accreditation status by preparing necessary reports and materials for site visits and audits.
- Tracked expiration dates on documents and communicated with appropriate staff to avoid late filing.
- Contributed to risk management initiatives by monitoring expiring licenses, certifications, and insurances, notifying providers of renewal requirements in a timely manner.
- Conducted primary source verifications such as background checks and board certifications.
- Enrolled providers and Medicaid, Medicare, and private insurance plans.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
Credentialing Coordinator
Naveris
01.2020 - 09.2022
- Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
- Upheld strict confidentiality standards, safeguarding sensitive provider information from unauthorized access or disclosure.
- Assisted with managed care auditing processes and performed internal file audits.
- Boosted productivity levels within the credentialing team by training new employees on proper procedures and best practices within the role.
- Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
- Negotiated reimbursement rates with insurance companies for a Unspecified Procedure Code
- Applied for a new procedure code
- Implemented and trained a new lab and reimbursement software
- Increased efficiency in data management by implementing a user-friendly database system for storing provider information.
- Collaborated with department heads to develop a comprehensive credentialing policy, ensuring compliance with industry standards.
- Fostered a positive work environment through active participation in team meetings, collaborating on strategies to improve departmental performance.
Credentialing Coordinator
Workit Health
10.2020 - 11.2021
- Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
- Upheld strict confidentiality standards, safeguarding sensitive provider information from unauthorized access or disclosure.
- Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
- Fostered a positive work environment through active participation in team meetings, collaborating on strategies to improve departmental performance.
- Maintained accurate files, records and credentialing documents in well-maintained databases using [Software].
- Expedited the onboarding process for new medical staff by efficiently managing initial appointments and reappointments.
- Communicated effectively with various parties each day using polished interpersonal and active listening skills.
Insurance Billing Specialist
Michiana Neurologic Medicine
04.2017 - 01.2020
- Minimized errors in claims submissions through regular cross-checking of CPT and ICD codes against medical documentation.
- Assisted colleagues during peak workload periods, demonstrating strong teamwork and commitment to overall departmental success.
- Collaborated with medical staff to obtain necessary documentation, enabling timely submission of accurate claims.
- Streamlined billing processes for improved efficiency through the implementation of electronic payment systems.
- Ensured strict adherence to HIPAA guidelines while handling sensitive patient information during the billing process.
- Increased revenue collection by diligently pursuing outstanding claims and negotiating with insurance companies.
- Assisted patients in understanding their coverage benefits, providing clear explanations and addressing any concerns or questions.
- Reduced processing time with thorough pre-authorization requests, ensuring prompt approvals for patient procedures.
- Stayed up-to-date with industry developments and changes in insurance policies to ensure ongoing compliance and adaptability in billing practices.
- Maintained strong working relationships with insurance providers, fostering open communication channels for claim resolution.
- Improved cash flow by promptly posting payments and reconciling accounts on a daily basis.
- Provided exceptional customer service to patients when discussing billing matters, demonstrating empathy and professionalism at all times.
- Optimized revenue recovery efforts by efficiently identifying underpayments and resolving discrepancies with payers.
- Conducted periodic audits to ensure compliance with industry regulations and maintain the integrity of billing operations.
- Optimized patient satisfaction by setting up transparent billing inquiry system, addressing concerns promptly.
- Reduced errors in billing statements with thorough audits, ensuring compliance with insurance regulations.
- Fostered stronger relationships with insurance providers, establishing regular communication to clarify billing procedures and requirements.
- Generated monthly billing and posting reports for management review.
Senior Medical Billing Software Specialist
Harmony HIT
01.2008 - 03.2017
- Improved software performance by identifying and resolving complex technical issues.
- Reduced software defects by implementing thorough testing procedures and quality assurance practices.
- Facilitated knowledge sharing sessions with colleagues to promote continuous improvement across the team.
- Integrated third-party APIs to expand software capabilities and offer additional value to users.
- Incorporated user feedback into software enhancements, leading to increased satisfaction rates among clients.
- Developed comprehensive documentation, simplifying troubleshooting and maintenance tasks for the team.
- Coordinated deployments of new software, feature updates and fixes.
- Corrected, modified and upgraded software to improve performance.
Medical Billing Specialist
McKinley Medical Group
12.2005 - 01.2008
- Communicated with insurance providers to resolve denied claims and resubmitted.
- Posted and adjusted payments from insurance companies.
- Communicated effectively and extensively with other departments to resolve claims issues.
- Located errors and promptly refiled rejected claims.
- Assisted patients with understanding their medical bills and provided clarification on complex insurance issues, promoting a positive customer experience.
- Identified and resolved patient billing and payment issues.
- Examined patients' insurance coverage, deductibles, insurance carrier payments and remaining balances not covered under policies when applicable.
- Ensured timely submission of claims to various insurance carriers, resulting in prompt payment for services rendered.
- Maintained strong working relationships with healthcare providers, fostering clear communication regarding billing-related matters.
- Managed patient accounts effectively, resolving discrepancies and addressing outstanding balances in a timely manner.
- Enhanced revenue collection through diligent follow-up on unpaid claims and denials with insurance companies.
- Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
- Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
- Collected payments and applied to patient accounts.
- Precisely completed appropriate claims paperwork, documentation and system entry.
- Precisely evaluated and verified benefits and eligibility.
- Provided exceptional customer service to both patients and insurance representatives, resolving inquiries quickly and professionally.
Senior Software Analyst
Medical Manager Midwest/Emdeon
01.1995 - 12.2005
- Collaborated with cross-functional teams to ensure seamless integration of new features into existing systems.
- Reduced system downtime by proactively monitoring application performance and addressing potential issues before escalation.
- Implemented automated testing frameworks, significantly reducing manual testing efforts and improving overall product quality.
- Mentored junior developers, fostering a supportive learning environment that accelerated skill development and career growth.
- Improved end-user experience through the design and implementation of intuitive user interfaces tailored to client needs.
- Enhanced software performance by identifying and resolving complex issues through thorough analysis.
- Delivered high-quality documentation for both technical and non-technical audiences, facilitating better understanding of application functionalities across teams.
- Assisted with pre-sales efforts by creating detailed technical proposals highlighting key benefits of the company''s software solutions.
- Fostered strong relationships with clients through clear communication and timely resolution of support requests, ultimately leading to high levels of customer satisfaction and repeat business.
- Developed robust software solutions for clients, resulting in increased efficiency and satisfaction rates.
- Participated in strategic planning sessions, providing valuable input on technology trends and their potential impact on company objectives.
- Managed multiple concurrent projects from initial conception through successful delivery, consistently meeting deadlines while maintaining a high standard of work quality.
- Led the migration of legacy systems to modern platforms, ensuring minimal disruption to business operations during the transition period.
- Troubleshot incidents reported by end-users to schedule system changes and identify permanent solutions.
- Collaborated with upper management to drive strategy and implement new processes.
Education
No Degree -
Ball State University
Muncie, INHigh School Diploma -
Penn High School
Mishawaka, IN06.1990
Skills
- HIPAA Compliance
- Provider enrollment
- Background Checks
- Data Management
- Credentialing oversight
- Application coordination
- Provider Relations
- Insurance procedures
- Report Generation
- Application management
- Document Review
- Facility support
Timeline
Credentialing Specialist
Essentia Health
02.2024 - Current
Credentialing Coordinator
Third Street Community Clinic
09.2022 - 06.2024
Credentialing Coordinator
Workit Health
10.2020 - 11.2021
Credentialing Coordinator
Naveris
01.2020 - 09.2022
Insurance Billing Specialist
Michiana Neurologic Medicine
04.2017 - 01.2020
Senior Medical Billing Software Specialist
Harmony HIT
01.2008 - 03.2017
Medical Billing Specialist
McKinley Medical Group
12.2005 - 01.2008
Senior Software Analyst
Medical Manager Midwest/Emdeon
01.1995 - 12.2005
No Degree -
Ball State University
High School Diploma -
Penn High School
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