María Valverde
Mesa,AZ
Summary
Dedicated and well-trained professional with more than 10 years of experience. Logical Provider Enrollment Specialist with exemplary critical thinking and decision making talents. An enthusiastic professional with more than 3 years' coordinating credentialing data for health practitioners. Ready to apply talent in financial eligibility processes with a new organization.
Overview
5
5
years of professional experience
1
1
year of post-secondary education
Work History
Provider Enrollment - Credentialing Specialist
AbsoluteCare
03.2023 - 05.2023
- Prepare and submit enrollment applications for assigned and new and existing providers until they are assigned with payers
- Respond to health plan provider inquiries and manage the Credentialing In Box
- Maintain and update provider profiles on CAQH, PECOS, AHCCCS and NPPES
- Follows up on the status of enrollment applications as well as maintaining all updated needed using Smart Sheets
- Using Smart Sheets, keeps detailed log of all pending and completed tasks
- Communicates with HR, compliance, and operations for onboarding new providers and facilities as well as provider transitions
- Review practitioner applications for completion and accuracy and ensure appropriate follow-up; monitor and report on the credentialing progress of each practitioner
- Maintain timely and accurate data entry and periodically revise practitioner data in the credentialing database.
Provider Enrollment - Credentialing Specialist
Southwest Network
08.2022 - 03.2023
- Prepare and submit provider enrollment of new and existing providers until they are enrolled with assigned payers
- Respond to health plan provider inquiries and manage the Credentialing In Box
- Maintain and update provider profiles on CAQH, PECOS, AHCCCS and NPPES
- Follows up on the status of enrollment applications as well as maintaining all updated needed using Smart Sheets
- Using Smart Sheets, keeps detailed log of all pending and completed tasks
- Track credentialing and enrollment applications
- Communicates with HR, compliance, and operations for onboarding new providers and facilities as well as provider transitions
- Review practitioner applications for completion and accuracy and ensure appropriate follow-up; monitor and report on the credentialing progress of each practitioner.
Provider Enrollment -Credentialing Specialist
Vaco Recruiting Services
04.2022 - 07.2022
- Prepare and submit initial credentialing and re-credentialing applications until they are assigned to all payers
- Maintain and update provider profiles on CAQH, PECOS and NPPES
- Track credentialing and enrollment applications daily
- Communicates with HR, compliance, and operations for onboarding new providers and facilities as well as provider transitions
- Review practitioner applications for completion and accuracy and ensure appropriate follow-up; monitor and report on the credentialing progress of each practitioner
- Ensure timely and accurate credentialing and re credentialing application submissions for each practitioner as it relates to each client health plan; monitor and report progress of each practitioner
- Enroll practitioners with all appropriate client health plans; monitor and report on progress of each practitioner
Provider Enrollment - Credentialing Specialist
Behavioral Health Services
02.2022 - 04.2022
- Prepare and submit initial enrollments; credentialing and re-credentialing
- Utilzed Modio plateform to process enrollments and submit to payers
- Respond to health plan provider inquiries
- Maintain and update provider profiles on CAQH, PECOS and NPPES
- Follows up on the status of enrollment applications as well as maintaining all updated needed using Smart Sheets
- Using Smart Sheets, keeps detailed log of all pending and completed tasks
- Update necessary departments on credentialing updates
- Review practitioner applications for completion and accuracy and ensure appropriate follow-up; monitor and report on the credentialing progress of each practitioner
Credentialing Specialist - Provider Enrollment
Bayless Integrated Healthcare
05.2021 - 01.2022
- Prepare and submit applications and reappointment paperwork for practitioners and facilities, checking for full completeness and accuracy
- Monitor expiring licensure, board, and professional certifications, along with all other time sensitive documents
- Ensure that all personnel and services adhere to facility and staff policies, department guidelines, regulations, and government laws
- Prepare and submit provider enrollment for assigned and new and existing providers
- Constantly collect and process significant amounts of verification and accreditation information, and thus must constantly maintain and update accurate databases for both practitioners and facilities
- Maintain NHSC information for employees
- Maintain close communication with all appropriate practitioners to ensure that records are up-to-date and consistent
- Communicates with HR, compliance, and operations for onboarding new providers and facilities as well as provider transitions
- Maintain and update provider profiles on CAQH, PECOS and NPPES
Credentialing Specialist
Valle Del Sol
01.2021 - 05.2021
- Responsible for credentialing, re-credentialing and maintaining high quality and accurate information for new and established healthcare providers in a timely manner
- This include primary source verification, data collection, data entry, and document review
- Coordinate with practitioners to complete practitioners’ applications/reapplications and attestations for credentialing
- Maintain NPI, CAQH, and Credential My Doc databases, including but not limited to processing change of addresses for each provider/practice location, name changes, professional liability insurance renewals, and occupational license renewals
- Maintain a current electronic insurance grid identifying the credentialing status of all providers for contracted payers and government agencies and communicates updates regularly to Management
- Utilize website as primary source for verification of credentialing and review state board of pharmacy, DEA and NPI
Quality Staffing of America/ CVS
01.2020 - 12.2020
- Credentialing Pharmacy contract
- Participate in credentialing and re-credentialing
- Complete pharmacy credentialing and re-credentialing applications and follow-up as needed
- Oversees credentialing database, report to ensure up-to-date information
- Assist with the compliance of federal, state and local licensing regulations to pharmacy credentials
- Utilize website as primary source for verification of credentialing and review state board of pharmacy, DEA and NPI
- Reach out and work directly with the pharmacy community, via phone, email, and fax
- Monitor high volume of incoming email activity, respond to emails accordingly in a timely manner
- Pharmacy communication and issue resolution via phone, email_fax.
Medicare Rep II
Insight Global / Centene
08.2019 - 09.2019
- Research Plan information and educate member
- Verify patient eligibility for Medicaid/Medicare Part A- D
- Perform benefit investigations
- Reference current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status matters
- Provide assistance to members and/or providers regarding website registration and navigation
Medical, Authorizations Specialist
RemX / McKesson Specialty
06.2018 - 08.2019
- Claims Review/Insurance verification, Contact payers to verify patient eligibility and product specific coverage information
- Review of ICD-10,
- Performs verification of benefits; contacts patients to inform them of their benefits and collects co-Insurance
- Serves as point of contact for sales and service representatives on such things as updates to orders, patient communication and account issues to address
- Utilize internal resources to identify and provide alternate funding sources for patients without insurance or adequate coverage through their insurer
- Insurance authorization and verifications
Education
Bachelor of Science - Business Management
2007
Human Resources Management
2007.01 - 2007.02
Diploma - Medical Office Specialist
01.2000 - 03.2001
Skills
- Coding, Liaison, Behavioral Health
- Provider Enrollment, Direct care staff Credentialing, Pharmacy Credentialing, and Facility Credentialing
- Ability to communicate clearly and in a concise manner; both verbal and written
- SOFTWARE
- Word, Excel, Outlook, GoogleSuites, CAQH, Smart Sheets, Modio, Monday, Intellisoft, AHCCCS, APEP, PECOS, Payor Portals HRIS System, PeopleSoft, lyrical, Oracle, SharePoint, Advance Claim, Passport OneSource, Sales Force
Timeline
Provider Enrollment - Credentialing Specialist - AbsoluteCare
03.2023 - 05.2023
Provider Enrollment - Credentialing Specialist - Southwest Network
08.2022 - 03.2023
Provider Enrollment -Credentialing Specialist - Vaco Recruiting Services
04.2022 - 07.2022
Provider Enrollment - Credentialing Specialist - Behavioral Health Services
02.2022 - 04.2022
Credentialing Specialist - Provider Enrollment - Bayless Integrated Healthcare
05.2021 - 01.2022
Credentialing Specialist - Valle Del Sol
01.2021 - 05.2021
- Quality Staffing of America/ CVS
01.2020 - 12.2020
Medicare Rep II - Insight Global / Centene
08.2019 - 09.2019
Medical, Authorizations Specialist - RemX / McKesson Specialty
06.2018 - 08.2019
University of Phoenix - , Human Resources Management
2007.01 - 2007.02
Career Centers of Texas - Diploma, Medical Office Specialist
01.2000 - 03.2001
University of Phoenix - Bachelor of Science, Business Management