Melanie Robertson
Denison,TX
Summary
I am a professional, friendly & dedicated individual who has
ambition to succeed in any given environment. I love to
learn and am always up for a challenge. I get along well with
others yet work efficiently on my own.
Overview
12
12
years of professional experience
Work History
Credentialing Consultant Freelance
Self
08.2022 - Current
- Coordinated credentialing processes to ensure compliance with regulatory standards and company policies.
- 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.
- Conducted primary source verification such as background checks and board certifications.
- Safeguarded confidential provider information by adhering to strict data privacy regulations, HIPPA and company policies.
- Received and evaluated applications to look for missing and inaccurate information.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
- Expedited the on-boarding process for new providers, ensuring timely completion of all required documentation and verifications.
- Enhanced credentialing processes by streamlining documentation and verification procedures.
- Demonstrated excellent problem-solving skills when confronted with complex issues or discrepancies during the credentialing process.
- Maintained a thorough understanding of accreditation standards, enabling accurate interpretation of guidelines for staff members when needed..
- Developed strong relationships with external organizations
- Prepared records for site visits and file audits.
- Improved turnaround time for credentialing applications by implementing an efficient online system.
- Reduced errors in credentialing files by conducting thorough reviews and consistently maintaining attention to detail.
- Supported transition to electronic credentialing systems, facilitating more efficient and paperless process.
- Managed credentialing files with strict adherence to confidentiality and privacy laws, ensuring secure handling of sensitive information.
- Reviewed and verified provider documentation for accuracy and completeness, minimizing errors in the credentialing system.
- Maintained comprehensive database of provider credentials, ensuring up-to-date information for auditing purposes.
- Collaborated with cross-functional teams to resolve discrepancies in provider files, improving accuracy and reliability.
- Led initiatives to enhance credentialing workflows, reducing processing time while maintaining quality standards.
Credentialing Specialist
Avesis/Guardian
04.2024 - 08.2024
- Organized the newly obtained Dental Enrollment Inbox & initiated a process of assignment of emails to members of credentialing team
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
- Ensured compliance with industry standards by regularly updating policies and procedures related to credentialing.
- Contributed to policy updates in response to changing healthcare regulations, ensuring ongoing compliance.
- Conducted thorough background checks and primary source verifications to uphold high standards of care.
- Addressed and resolved discrepancies in provider documentation, maintaining high level of data integrity.
- Liaised with healthcare providers to address and resolve any credentialing issues promptly, maintaining strong professional relationships.
- Coordinated credentialing processes to ensure compliance with regulatory standards and company policies.
- Analyzed trends in credentialing operations, identifying areas for improvement and implementing strategic solutions.
Credentialing Specialist - Dental Network Recruitment
Cigna Insurance Companies
05.2023 - 02.2024
- Primary Source Verification
- Identified discrepancies or red flags in provider applications & documents (Initial & Re-credentialing)
- Communicated missing items or incomplete documentation, Document Verification
- Ensured timely completion of credentialing process
- Identified areas for improvement in the credentialing processes/policies & recommended specific enhancements
- Demonstrated strong attention to detail during thorough review/investigation of provider applications/documents
- Maintained confidentiality/security of sensitive information t
- Demonstrated excellent organizational skills while managing multiple tasks
- Exhibited exceptional customer service skills
- Communicated with providers, offices & DSO's to ensure network, roster & plan accuracy.
- Conducted audits of credentialing files to maintain accuracy and adherence to company standards.
Marketing & Recruitment Manager
Texoma Regional Blood Center
10.2019 - 05.2022
- Maintaining events schedule to mitigate blood usage (6-10 mobile events weekly), create operating procedures & training material for phlebotomy staff regarding professionalism & customer service.
- Manage the following:
- Media communications: live news, printed, public alerts, and social media pages.
- Website alerts/digital signage messages.
- Community leadership & engagement events.
- Community outreach programs
- Educational and marketing materials
- Advocacy for blood donation Scholarship Program.
Credentialing Specialist
DentalOne Partners
06.2017 - 10.2019
- Company Overview: Plano, TX
- Efficiently navigated through all aspects of the credentialing process – from on-boarding to payer approval.
- Maintained & audited provider files
- Completed & submitted applications, forms & documents in a timely manner (initial, re-cred, terms, add locations, etc.)
- Assist providers in maintaining current licenses, certifications , malpractice policies & other credentials
- Completed credentialing & re-credentialing applications & necessary
- Addressed par/non par-related claims issues, TIN changes, DENOVO's, EFT enrollments, provider portal access
- Tracked submissions, pending items & completed all follow-up communication.
- Ensured continuous provider participation with all payers - communicated with PR Reps for proper backdating of effective dates for claims capture and processing
- Audited Rosters & Master Committee Lists
- Conducted NPDB queries
- Assisted providers with CAQH account setup/updates
- Updated credentialing databases and software to ensure accurate credentialing timelines
- Complied with all company policies & relevant regulations
- Collaborated with team to ensure compliance with NCQA auditing & reporting standards/requirements
- Collaborated with the Revenue Cycle Manager & VP, pinpointing risks, files issues & flagged providers
- Maintained confidentiality of provider records and data.
- Identified process improvements & assisted in the implementation of new process/application - moving the credentialing process tracking from Excel/Google Docs to a web-based software/application, that would accurately auto-fill the provider's information & signature into all payor specific applications & contracts then generate the various credentialing packets each payor.
Senior Credentialing Specialist & Dental Network Recruiter
Cigna Insurance Company
10.2013 - 06.2017
- Company Overview: Dental)-Denison, TX
- Communicated with providers, offices & DSO's to ensure network, roster & plan accuracy.
- Conduct calls/meetings to educate dentists/staff how the contracted rates affect network participation level; then ensure understanding that the level of network participation directly impacts weather a patient uses INN or ONN benefits & how that will affect the processing of claims
- Experienced in various departments/aspects of dental PPO/HMO network: client recruitment, fee schedule negotiation, provider services/relations, contract negotiation/implementation (Corporate/DSO, Group, Facility, & Provider), dispute resolution, claims capture/reprocessing
- Assisted providers/offices/DSO's through various credentialing processes (i.e.: initial, delegated & recertification)
Education
Associate of Science - Mathematics
Grayson College
Denison, TX05-2026
High school diploma -
Denison High School
Denison, TX05.1997
Skills
- NCQA Standards
- QA/QC
- Data entry/data management
- Process improvement
- Data analysis skills
- Communication skills
- Contract Negotiation
- Client/Provider Relations
- Attention to detail
- Problem-solving
- Public speaking
- Issue resolution
- MS office
- Time management
Timeline
Credentialing Specialist
Avesis/Guardian
04.2024 - 08.2024
Credentialing Specialist - Dental Network Recruitment
Cigna Insurance Companies
05.2023 - 02.2024
Credentialing Consultant Freelance
Self
08.2022 - Current
Marketing & Recruitment Manager
Texoma Regional Blood Center
10.2019 - 05.2022
Credentialing Specialist
DentalOne Partners
06.2017 - 10.2019
Senior Credentialing Specialist & Dental Network Recruiter
Cigna Insurance Company
10.2013 - 06.2017
Associate of Science - Mathematics
Grayson College
High school diploma -
Denison High School
Similar Profiles
Brittney ValleBrittney Valle
Mentor at SelfMentor at Self
Kimberly BaranekKimberly Baranek
House Claner at SelfHouse Claner at Self
Evan KingEvan King
Freelance Music Producer at SelfFreelance Music Producer at Self
Dedra ClayDedra Clay
Underwriting Service Assistant Team Resource at State FarmUnderwriting Service Assistant Team Resource at State Farm
Mary Jane FieroMary Jane Fiero
SR. Electronic Banking Specialist/Loans and Advances Clerk at Cendera Bank, N.A.SR. Electronic Banking Specialist/Loans and Advances Clerk at Cendera Bank, N.A.