MD Staff
Marisol "Samara" Sandoval
Banning,CA
Summary
Certified Provider Credentialing Specialist adept at conducting provider credentialing, enrollment applications, and primary source verifications. Proficient in interpreting and ensuring compliance with accrediting and regulatory agencies. Detail-oriented and committed to delivering high-quality healthcare services. Excellent relationship-building, problem-solving, and communication skills.
Overview
13
13
years of professional experience
Work History
Credentialing & Provider Enrollment Specialist
Virginia Mason Franciscan Health
2024.01 - Current
- Complete and submit provider enrollment applications and delegated rosters for commercial and government health plans
- Maintain provider demographics in the enrollment system and update provider effective dates and files
- Monitor and update provider credentials such as licenses, professional liability insurance, and certifications to ensure they are up-to-date and compliant with regulatory agencies
- Provide routine follow-up and status confirmation of provider enrollment applications
- Communicate with providers, health plans, and billing departments to resolve provider's denied claims or enrollment issues.
- Build queries to generate provider rosters and prepare files for health plan audits, ensuring all necessary documents are up-to-date and compliant with regulatory requirements
- Conduct Ongoing Monitoring to ensure compliance, exclusions, and sanctions have not occurred concerning the providers
- Process reappointment and privileging applications for providers.
Credentialing Specialist
Forefront Telecare Inc
2021.05 - 2024.01
- Processed initial credentialing and re-credentialing applications for behavioral healthcare providers ensuring their CAQH profile is currently attested and added or updated provider locations to the CAQH portal
- Collected and verified data and documentation obtained during the credentialing process for the reviewing and approval bodies to have the information necessary to make decisions in compliance with accreditation standards and federal regulations
- Conducted primary source verifications of credentials to ensure good standings
- Monitored sanctions, licenses, and certifications to ensure they comply with accreditation standards
- Followed up with providers on missing or additional documentation required to process their credentialing applications
- Managed multiple priorities effectively, resulting in the on-time completion of credentialing tasks for numerous providers simultaneously
- Safeguarded confidential provider information by adhering to strict data privacy regulations and company policies.
Credentialing Administrator
Pacific Dental Services
2016.06 - 2021.04
- Processed credentialing and re-credentialing insurance applications for General Dentists and Specialists ensuring they possessed the appropriate professional licenses and credentials to participate in commercial and government health plans as required by the Insurance companies and regulatory agencies
- Maintain up-to-date delegated provider rosters and submitted them to the health plans
- Checked Deal Log bi-weekly for new offices' opening dates and obtained IRS confirmation from the Development Department
- Requested NPI Type 2 (Billing Entity NPI) for new facilities and processed TIN, PC, and ownership change insurance contracts and submitted them to the insurance plans
- Communicated with practitioners and insurance representatives to resolve provider enrollment issues and denied claims
- Monitored the ticketing system and resolved inquiries sent by the billing department regarding denied claims and provider enrollment status
- Updated provider records to ensure demographic information, credentials, and effective dates were up-to-date
Data Entry / QCS clerk
Aluminum Precision Products
2012.02 - 2016.02
- Entered alpha and numeric information for engineer planning and aircraft parts into the system
- Prepared paperwork and certification for shipping parts
- Prepared packing slips for shipping department and logistic carriers
- Tracked exceptions between the shipping log and invoice register
- Verified, updated and corrected source documents
- Submitted invoices by electronic data interchange
- Issued invoices to customers and provided sales summary to billing department
- Entered data into designated database forms
- Created spreadsheets and file backup documents
- Utilized strong multitasking skills to manage multiple priorities and tasks, ensuring timely completion of each assignment.
Education
GED -
Santa Ana College
Santa Ana, CA06.2000
Computer Applications & Office Occupations -
SER (Santa Ana College)
Certified Provider Credentialing Specialist -
NAMSS
03.2023
Certified Floral Designer -
Floral Design Institute
05.2024
Skills
- Detailed oriented
- Computer and data entry proficiency
- Excellent communication skills
- Deadline Management
- Relationship Building
- Strong Organization
- Able to concentrate on tasks, paying meticulous attention to detail regardless of distractions
Software
Salesforce
EchoOne
Cactus
Timeline
Credentialing & Provider Enrollment Specialist
Virginia Mason Franciscan Health
2024.01 - Current
Credentialing Specialist
Forefront Telecare Inc
2021.05 - 2024.01
Credentialing Administrator
Pacific Dental Services
2016.06 - 2021.04
Data Entry / QCS clerk
Aluminum Precision Products
2012.02 - 2016.02
GED -
Santa Ana College
Computer Applications & Office Occupations -
SER (Santa Ana College)
Certified Provider Credentialing Specialist -
NAMSS
Certified Floral Designer -
Floral Design Institute
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