NASHEBA KEY-ALLRED
Credentialing Specialist
Raleigh,NC
Summary
- 10 years of progressive Medical Management experience working in corporate and healthcare office environments.
- Expertise in managing credentialing and enrollment processes.
- Solid knowledge of utilization management review guidelines and standards.
- Proven ability to work independently and efficiently with superior results.
Overview
16
16
years of professional experience
Work History
Contract Coordinator
Centene Corporation
Raleigh, NC
05.2022 - Current
- Negotiate rates with Non Par Providers and prepare Single Case Agreements in Icertis system for review and signature.
- Train new staff as required.
- Maintain spreadsheets and databases; collect, track, prepare, compile, and distribute statistical data.
- Assist in ensuring successful completion of the contracting process by supporting contract negotiators.
- Coordinate with multiple departments to ensure contracting process is completed timely and accurately and within required established standards and guidelines.
- Responsible for maintaining and organizing physical and electronic file systems.
- Ensured compliance with corporate contracting standards by providing support to other departments.
Contracts and Credentialing Specialist
Easter Seals UCP NC & VA, Inc
Raleigh, NC
04.2017 - 05.2022
- Managed contractual relationships and performances of in-network provider groups as primary point of contact.
- Completed new provider orientation for all applicable product lines to educate on policies and initiatives, resolve issues, and educate staff/providers.
- Establish consistent and strong relationships with provider groups utilizing an account management approach.
- Established and lead cross-functional communication with internal departments.
- Collaborated with internal cross-functional team to support provider performance and resolve barriers and challenges.
- Provided detailed explanation of fee-for-service reimbursement to providers and management.
- Worked closely with colleagues to efficiently resolve provider contractual inquiries.
- Managed provider data integrity by monitoring and overseeing activities such as credentialing providers, adding locations, updating demographics, and handling termination processes.
- Assisted with claims department and client authorizations.
- Executed special projects as requested.
Billing Specialist
Legacy Healthcare Services
Raleigh, NC
12.2015 - 04.2017
- Responsible for tracking and collecting A/R ensuring receivables did not remain outstanding beyond 90 days.
- Reviewed documentation of weekly task sheets/flow sheets for completeness as designated by the Director of Clinical Services and in accordance with the current authorization for services for each client.
- Accurately entered weekly billing documentation into data system.
- Proficiently entered payments into data system electronically and manually.
- Built and maintained a professional relationship with clients, billing counterparts and case managers.
- Used effective means of communication to research and resolve billing discrepancies in a timely manner and according to appropriate guidelines determined by individual program requirements.
- Communicated all issues or concerns relating to billing errors in a timely manner to the Administrator, Treasurer, and/or Assistant Administrator.
- Reviewed and tracked reports through data system to ensure yearly authorizations for services were updated upon renewals and reflect changes in authorized hours.
- Accurately reviewed client information to ensure authorized diagnosis codes were utilized on claims (insurance and Medicaid).
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Resolutions Coordinator
BCBSNC/Manpower
Chapel Hill, NC
12.2014 - 09.2015
- Coordinated and assigned dispositions of Level 1 Appeals, Provider courtesy reviews and Provider coding reviews.
- Determined appropriate response letters based on disposition.
- Assisted with internal and external communication related to grievances and appeals.
- Initiated the initial data entry into the appropriate tracking systems.
- Received and distributed all incoming and outgoing correspondence to the Appeals unit.
Credentialing Coordinator
Community Care Network of VA
Henrico, VA
05.2013 - 10.2014
- Acted as a liaison between the CVO and hospital clinical departments and other external customers.
- Processed applications for initial appointments and reappointments to the medical and/or allied health/health professional affiliates staffs for CVO customers.
- Maintained a computerized database of practitioner data for use in the CVO enrollment process.
- Analyzed information received to ensure that it was incompliance with the various regulatory standards that must be adhered to for credentialing for the entities and any delegated managed care contracts.
- Ensured workload deadlines were being met in a consistent manner.
- Scanned credentialing verification information into appropriate practitioner folders; maintains paperless system accurately and efficiently.
- Monitored the expirations of all practitioner licenses, certifications, DEA certification, National Practitioner Data Bank, and professional Malpractice / liability insurance.
- Developed and maintained a good working relationship with practitioners and support staff to obtain necessary and timely information to facilitate the provider enrollment/re-enrollment process.
- Worked collaboratively with fellow team members to create, evaluate and maintain department work flows, processes, policies and systems.
- Independently resolved problems, made decisions, and negotiated issues as needed.
Provider Enrollment Associate II
Pediatrix Medical Group/Aerotek
Glen Allen, VA
01.2013 - 05.2013
- Processed and gathered all necessary documents to ensure all physicians were enrolled in government programs and are participating in company approved managed care organizations.
- Entered and maintained individual provider records into the Council for Affordable Quality Healthcare (CAQH) online database.
- Organized and maintained a computerized database of practitioner data for use in the credentialing & provider enrollment process.
- Maintained credentialing reports and update d Provider Enrollment Goldmine database.
- Efficiently maintained detailed provider enrollment files in an electronic format, including electronically received documents and scanning of hard copy documents, and documented each stage of the enrollment and re enrollment process thoroughly.
- Developed and maintained relationships with individual contacts for government agencies as well as managed care organizations.
- Monitored and updated expired licenses, as requested.
- Responded promptly to all questions, received via phone or email, regarding any healthplan and/or group/pin.
Complex Customer Service Representative
NCI AdvanceMed Corporation
Henrico, VA
06.2012 - 11.2012
- Reviewed, evaluated, and, analyzed all relevant case documentation through the CMS system to successfully handled inquiries in a timely manner.
- Resolved claimant requests, questions and provided analysis of situations to determine best use of resources.
- Served as a liaison between the claimant and submitters in response to case inquiries.
- Directed unresolved issues to designated nursing staff for further investigation if necessary.
- Participated in educating and communicating the program requirements to submitters and claimants'.
- Responded to all written inquires (letter, fax, and email) in a professional manner.
- Recorded details of inquiries, comments and issues through data entry into the Workers' Compensation Case Control System (CMS) as required.
- Recorded details of actions taken and provided follow-up and resolutions based upon established protocols.
- Maintained a high level of knowledge and comply with all Medicare and Medicaid protocols, policies and procedures.
Billing Assistant
Health Diagnostic Laboratories
Richmond, VA
11.2011 - 05.2012
- Entered demographic and charge entry within LIS and billing platform.
- Appropriately assigned ICD-9, CPT and HCPS codes to outpatient medical records.
- Efficiently handled claims edits and correspondence.
- Promptly followed-up with referring practice regarding missing information for unpaid/unprocessed claims.
- Performed customer service/communication skills to interact professionally with patients, insurance representatives, outpatient clinic staff, billing office staff, and medical center management.
Lead Credentialing Specialist
Virginia Premier Health Plan Inc
Richmond, VA
11.2008 - 09.2011
- Entered and managed accurate data into the credentialing database(s) and preparing reports and other documents presented to the Medical Management Committee.
- Routinely updated providers on their credentialing status as requested and provided timely follow-up for requests of outstanding information.
- Performed background inquiries including criminal convictions, education credentials, professional licensure and federal debarment checks.
- Maintained and managed data accounts in database.
- Proactively collaborated with all departments to manage the timely satisfaction of client services obligations under all contract agreements.
- Made observations and recommendations for process improvement to the Compliance Director.
- Maintained a strong working knowledge of credentialing operations and procedures.
Credentialing Specialist II
McKesson Medical Surgical/KForce
Richmond, VA
06.2008 - 09.2008
- Processed credentialing and re-credentialing applications and enrollments of health care providers.
- Entered, updated, and maintained NPI and any other applicable provider numbers into the database.
- Reviewed applications and prepared verification letters maintained in a database.
- Contacted medical office staff, licensing agencies, and insurance carriers to complete credentialing and re-credentialing applications.
Skills
- Contracts, Policies
- Contract Negotiation
- Contract Management
- Proficient in Microsoft Access, Excel, Outlook, Powerpoint and Word
- Adobe
- Approach, PowerPoint
- One Note
- Auditing, Sharepoint
- Contract Administration
- CMS, Microsoft Word
- Communication skills, Network
- Oral, Organizational
- Problem solving skills
- Customer service, Quality
- Data entry, Research
- Database, Scanning
- HIPAA Compliance
- Documentation, Phone
- Email, Workbench
- Insurance
- Medical Management
- Significant knowledge of Auditing processes and procedures
- Proven ability to identify, analyze, and solve problems
Timeline
Contract Coordinator
Centene Corporation
05.2022 - Current
Contracts and Credentialing Specialist
Easter Seals UCP NC & VA, Inc
04.2017 - 05.2022
Billing Specialist
Legacy Healthcare Services
12.2015 - 04.2017
Resolutions Coordinator
BCBSNC/Manpower
12.2014 - 09.2015
Credentialing Coordinator
Community Care Network of VA
05.2013 - 10.2014
Provider Enrollment Associate II
Pediatrix Medical Group/Aerotek
01.2013 - 05.2013
Complex Customer Service Representative
NCI AdvanceMed Corporation
06.2012 - 11.2012
Billing Assistant
Health Diagnostic Laboratories
11.2011 - 05.2012
Lead Credentialing Specialist
Virginia Premier Health Plan Inc
11.2008 - 09.2011
Credentialing Specialist II
McKesson Medical Surgical/KForce
06.2008 - 09.2008
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