Madeline Velez
Summary
Focused and dedicated Managed Care professional with 0ver fifteen years of successful service and support to providers and customers in the Health care insurance industry. Use my attention to details and my skills to meet goals to provide excellent service to both providers and customers. Work independently while maintaining good relations with team members. Skilled in the Credentialing processes that support and service the provider network. Knowledge of the NCQA and URAC standards. Well rounded Customer service background. Excellent interpersonal skills.
Overview
17
17
years of professional experience
5
5
years of post-secondary education
Work History
Provider Contract Specialist
04.2016 - Current
- Responsible for coordinating the process for new and existing providers joining the Network
- Primary duties include preparing the information for timely and accurate submission to the Provider Data Management area
- Serve as the local Market expert supporting and managing the provider onboarding process
- Review provider information loaded to systems for accuracy, if errors load to corrections log
- Act as liaison between Credentialing team and Provider Network Managers
- Provide status of applications to Providers as well as internal Partners.
Credentialing Specialist
One Retail /HearingLife
08.2015 - 12.2016
- Responsible for the enrollment of clinics and Providers in insurance Networks
- Requested license and tax forms necessary for the enrollment process
- Updated Tracking databases on excel spreadsheets
- Applied for NPI on behalf of providers
- Obtained and updated CAQH for some providers
- Verified Audiologists' and Hearing instrument specialist information and completed applications
- Updated and maintained provider files on Excel spreadsheets
- Provided assistance in the creation of workflows and SOPs
- Responsible for scanning and saving applications and licenses on a share drive
- Completed other assigned functions required by manager.
Credentialing Specialist
Complexcare Solutions
07.2014 - 04.2015
- Pulled and scanned paper applications from the sharedrive
- Reviewed and processed Provider applications for the purpose of credentialing Nurse Practitioners, Nurses, Medical providers and Social Workers
- Contacted providers for additional documentation or clarification
- Pulled CAQH applications from database for providers
- Verified license on the various State Board of Nursing websites as well as ABMS
- Ran Sanction checks on government websites such as OMIG, OIG, Opt-Out, SAM
- Requested Broad certification letters
- Ran and collected NPDB
- Collected and updated CAQH for providers
- Prepared credentials file for presentation to the Credentialing Committee
- Participated in Peer review of files prior to sending them to committee meetings
- Participated in Department audits
- Updated and maintained provider files on database and Cactus system
- Responsible for the assembly of hard copy file after it was scanned and saved on a share drive.
Credentialing Re-credentialing Coordinator II
Horizon Blue Cross Blue Shield of New Jersey
05.2011 - 03.2013
- Processed applications for new providers, requested and followed-up with offices for missing information
- Maintained provider files on databases and updated checklist and created files
- Obtained current licenses, W9 and other tax forms necessary for applications or to update existing files
- Updated provider information to maintain database with accurate and timely information this included changes, additions and terminations
- Updated panels for Networks and advised counterparts of credentialed providers
- Contributed to the creation of new workflows and streamlining of existing ones
- Assisted Network Managers by quickly and effectively solving provider issues, including fee schedules and Directory updates
- Requested site visit and ADA survey from Network Managers as required by specific networks
- Responsible for re-credentialing of providers in the network every three years to maintain network
- Reviewed provider credentials such as license, DEA, CDS in accordance with the accreditation standards of NCQA/URAC for the purpose of credentialing and recredentialing providers for contracting into the network
- Documented actions of the Credentials Committee
- Acted as liaison to the network providers and operations by identifying issues, initiating a resolution and avoiding problems
- Maintained quality control and satisfaction of Network integrity by outreach to the providers, the establishment of a professional relationship and constantly seeking new ways to improve customer service
- Assisted manager in other requested functions.
Credentialing Provider Relations Specialist
Horizon Blue Cross Blue Shield of New Jersey
10.2006 - 05.2011
- Responsible for reviewing the new provider applications to process for credentialing into the network
- Followed up with provider offices for missing or incomplete information
- Processed all provider additions, changes and terms; ensuring information is complete and accurate and updating of files
- Credentialing of providers assuring required documentation and site visits are complete and accurate
- Inputted and updated provider databases to provide complete, accurate and timely information
- Identified and recommended opportunities to improve effectiveness and efficiency of workflows for the provider credentialing process
- Assisted in the recredentialing process including sitting in on the credentialing committee meetings to accept or decline provider participation into the network
- Inputted data for provider fee negotiations
- Worked on special projects such as mailings.
Education
Bachelors of Science - Business Administration
St. Peter's University
Jersey City, NJ 09.2000 - 05.2005
Skills
- Experienced in Network Management
- Experience in MS Word, Excel
- Ability to communicate clearly and effectively
- Ability to plan and organize work
- Knowledge of NCQA standards
- Ability to manage multiple tasks
- Special attention to detail
- Experience on Cactus credentialing software
- Effective team player
- Knowledge of CPT and ICD codes and claims processing
- Experience on Availity system, DPE
- Database Administration
- Problem Solving
Accomplishments
Fully met expectations for Credentialing and recredentialing providers. Qualified for bonuses by meeting or exceeding targeted goals by processing 95% of the applications within allotted time, for credentialing applications as set forth by company metrics. I was instrumental in implementing a team building program in our department. Trained on HIPPA compliance.
Languages
Spanish
Native or Bilingual
Timeline
Provider Contract Specialist
04.2016 - Current
Credentialing Specialist
One Retail /HearingLife
08.2015 - 12.2016
Credentialing Specialist
Complexcare Solutions
07.2014 - 04.2015
Credentialing Re-credentialing Coordinator II
Horizon Blue Cross Blue Shield of New Jersey
05.2011 - 03.2013
Credentialing Provider Relations Specialist
Horizon Blue Cross Blue Shield of New Jersey
10.2006 - 05.2011
Bachelors of Science - Business Administration
St. Peter's University
09.2000 - 05.2005
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