NICOLE L. COLEMAN
TAMARAC
Summary
Dynamic Provider Network Management Specialist with extensive experience at Zing Health, excelling in data management and quality assurance. Proven track record in provider enrollment and credentialing, leading teams to enhance operational efficiency. Strong communicator adept at resolving complex issues, ensuring compliance, and fostering collaboration across departments.
Overview
18
18
years of professional experience
Work History
PROVIDER NETWORK MANAGEMENT SPECIALIST
Zing Health
12.2022 - Current
- Verify provider credentials and licensing using various websites such as CAQH, NPI registry, and DOH
- Enrolled providers and practitioners into provider data management system; updated membership status to approved or pending.
- Update provider and practitioners with claims payment and directory information
- Performed quality service checks on systemic data, ensuring accuracy of claims processing and provider directory information.
- Research, review, and make updates within the provider data management system
- Utilized VLook Tool for efficient data management
- Conducted research to identify and resolve issues within provider data.
SENIOR PROVIDER ENROLLMENT SPECIALIST
Community Health Systems
04.2021 - Current
- Reviewed and assessed new provider credentialing and re-credentialing files to ensure compliance and accuracy.
- Enters practitioner information into enrollment databases such as PECOS and/or various enrollment portals and ensures that the information in the databases is current and accurate.
- Validate PSVs using validation databases such as NPDB, State DOH, Various Board Cert web sites, Diversion Control Agency, etc.
- Obtain required documents such as diploma, state license, dea/cds, ED/Training, NPI registry, malpractice history, work history, gap history, cpr/bls, etc
- Prepares initial and/or re-enrollment application packets, on behalf of the practitioner, for those payers who require a paper enrollment application.
- Ensures the enrollment packets are appropriately signed, complete and accurate, and submitted to the payer with necessary attachments.
- Coordinates re-enrollment dates and sends out application packets for all practitioners who require re-enrollment.
- Monitors the pending credentialing claim report and takes any necessary action (which may include sending additional enrollment applications to the payer) to allow claims to be submitted for payment.
- Facilitated communication with payers, clinics, billing offices, and practitioners to clarify enrollment statuses and resolve issues.
- Receives information regarding new practitioners from clinics, onboarding, Medical Staff Office, and billing offices, which includes all mail, email and faxes received from Payers.
- Completes AO signature tasks in a timely manner.
- Enters payer Provider Identification Numbers (PINs) and the effective date into the credentialing system once they are received.
- Will communicate with Managed Care on an ongoing basis as to the status of payer contracts and other various enrollment issues.
- Regularly reviews and edits provider CAQH records and verifies that all pertinent elements are captured in the databases and that they match what is captured in the Credentialing database.
- Submit file for committee approval
- Conducted training sessions for new staff across various regions to promote adherence to company practices and enhance onboarding.
- Assigned specific tasks to staff members based on skills and workload to optimize team performance.
- Participates in implementation meetings for the purpose of obtaining payer enrollment requirements for new business start-up.
PROVIDER ENROLLMENT SPECIALIST II
ENVISION PHYSICIAN SERVICES / SHERIDAN HEALTHCARE
06.2017 - 04.2021
- Complete, with accuracy and thoroughness, all new hires for credentialing and re-credentialing applications (Medicare, Medicaid, BCBS, Tricare, Manage Care, CAQH) within timeframe (MULTI-STATE) (MULTI-LOB)
- Assisted in credentialing process to ensure timely provider enrollment and compliance.
- Ensure the credentialing database is updated and current
- Perform primary source verification using Credentialing Checklist and other verifications as defined by management and/or health plans
- Update provider record in credentialing system and CAQH application with data obtained through primary source verification
- Acted as the single point-of-contact for all ongoing contractual and service issues for providers.
- Created trend analyses and summaries to support informed decision-making for credentialing initiatives.
- Ensure government and managed care payers are notified and applications are completed.
- Notify government agencies of resignations, terminations, and/ or leave of absence.
- Verify provider numbers for hospital & office - based.
- Comply with Credentialing/Provider Enrollment Policy and Procedures and Departmental guidelines and Standard Operating Procedures
- Delegated tasks to staff members to enhance workflow efficiency.
- Identify and troubleshoot problem cases to Leadership/Director for intervention in a timely manner
- Staff Training/Coaching and Account Support
- Led special projects to develop and implement new processes, enhancing operational efficiency within the credentialing team.
- Report any real or suspected violation of the corporate compliance program, company policies and procedures, harassment or other prohibited activities in accordance with the reporting policies of the company
PROVIDER ENROLLMENT SPECIALIST I
ENVISION PHYSICIAN SERVICES / SHERIDAN HEALTHCARE
08.2016 - 06.2017
- Completed all new hires for credentialing and re-credentialing applications (Medicare, Medicaid, BCBS, Tricare) accurately and on time across multiple states.
- Registered new individuals with government plans
- Ensure government and managed care payers are notified and applications are completed.
- Obtain all credentialing documents from the appropriate parties
- Maintained updated and current credentialing database to support efficient processing.
- Notified government agencies of resignations, terminations, and leave of absence to ensure compliance.
- Verify provider numbers for hospital & office-based.
- Reads and abides by the company's code of conduct, ethics statements, employee handbook(s), policies and procedures and other corporate mandates, including participation in mandatory training programs
- Reports any real or suspected violation of the corporate compliance program, company policies and procedures, harassment or other prohibited activities in accordance with the reporting policies of the company
PAYMENT POSTER I
SHERIDAN HEALTHCARE
06.2015 - 08.2016
- Post payments and ensure allowances, adjustments and write-offs are posted correctly.
- Review insurance Explanation of Benefits and post payments to billing system.
- Investigated unidentified cash and resolved misdirected payments to enhance reconciliation processes.
- Prepared documentation and recommendations for timely refunds, ensuring accuracy and compliance.
- May perform check payment reconciliations and complete deposit reports.
- Recorded denial notices in the billing system to track claims status.
- Receive payment requests from the Collections Dept. and complete in a timely manner
- Mentor less experienced staff and may assist Billing Manager with training new employees
- Performed departmental tasks to support team operations and maintain workflow efficiency.
PROVIDER DATA MANAGEMENT ANALYST
AEROTEK STAFFING (CENTENE HEALTHCARE-TEMP ASSIGNMENT)
09.2014 - 05.2015
- Verify provider credentials and licensing using various websites such as CAQH, NPI registry, Sunbiz and DOH
- Enrolled providers and practitioners into provider data management system, ensuring accurate and up-to-date information
- Researched and reviewed provider requests to update information in provider data management system, enhancing data accuracy
- Updating provider and practitioners membership status to approved or pending status
- Update provider and practitioners with claims payment and directory information
- Performed quality service checks on systemic data, ensuring integrity of claims processing and provider directory information
- Investigated issues to identify solutions
SENIOR COLLECTIONS SPECIALIST
PEDIATRIC ASSOCIATES
04.2012 - 06.2014
- Oversaw management of rejected claims, facilitating appeals and denials resolution.
- Assessed Zirmed front-end rejections across Medicaid payers to enhance accuracy.
- Follow-up on unprocessed Medicaid claims for services rendered by provider.
- Newborn ACHA update sent to Medicaid to activate newborn Medicaid patients.
- Executed charge posting in medical billing to ensure accurate revenue capture.
- Utilized ICD 9 and CPT Codes for Charge Posting.
- Followed up on all other payers.
SENIOR COLLECTIONS SPECIALIST
CFS STAFFING (PEDIATRIX/MEDNAX-TEMP ASSIGNMENT)
02.2011 - 03.2012
- Followed up on unprocessed insurance claims for private and Medicaid insurance to ensure timely resolution.
- Contacted insurance companies to resolve rejected claims, facilitating smoother reimbursement processes.
- Oversaw medical billing processes in fast-paced office, ensuring accuracy and compliance with regulations.
PROCUREMENT SUPERVISOR
TOTALE MEDICAL
01.2010 - 01.2011
- Led team of 18 staff members to maintain operational efficiency.
- Procured medical documents for State of Florida to facilitate processing of home health medical supplies.
- Supervised procurement processes for medical supplies and equipment.
- Negotiated contracts with suppliers to secure favorable terms.
- Managed inventory levels to ensure adequate supply availability.
DOCUMENT MANAGEMENT SUPERVISOR
NATIONS HEALTH
01.2008 - 01.2010
- Supervised team of 23 to 32 staff members, enhancing operational efficiency through effective management.
- Oversaw procurement of medical documents for State of Florida, ensuring compliance for processing home health medical supplies.
- Supervised daily operations and ensured compliance with health regulations.
- Trained and mentored team members to enhance performance and efficiency.
- Managed schedules and coordinated staffing for optimal coverage.
Education
BACHELOR OF SCIENCE - BUSINESS ADMINISTRATION
AMERICAN INTERCONTINENTAL UNIVERSITY
03-2026
VOCATIONAL DEGREE - MEDICAL ASSISTING CERTIFICATION
CONCORDE CAREER COLLEGE
Skills
- Enrollment credentialing
- Credentialing processes
- Regulatory compliance
- Data quality management
- Data management
- Quality assurance
- Team leadership and collaboration
- Effective communication skills
Tools And Technology
Various Medical Billing and Credentialing Software Programs including: SalesForce, HRP, MD Staff/MD App, Veristream/CredStream, CARE, EmWorks, EVIPS, MSOW, Portico, Amisys, Sunbiz, CAQH Proview, NPDB, OIG, NPPES/NPI Registry, PECOS, AHCA Web Portal, Florida Healthcare Licensing, DEA website, Florida DOH, Various State DOH, Various State Board Certification, Diversion Control Agency, XPM, Medical Manager and Medisolutions, Google Suites, Windows Office, Outlook, Medicaid/Commercial Insurance Web Portal, Zirmed/Trimed, Emdeon, Medicare DDE, AS400, Facets
Summary Qualifications
- 32 years of Healthcare Experience/25 years in Leadership
- Credentialing/Provider Enrollment Supervision
- Provider Enrollment Level II (Team Lead/Sr. Level)
- Employee Training and Active Coaching
- Credentialing Coordinator (Full Primary Source Verifications)
- Provider Relations Specialist
- Provider Data Management Contract Analyst/Specialist
- Senior Level Medical Collector
- Senior Level Payment Poster
- Supervision of all Billing and Collections Functions
- Management of Personnel Resources
- Management of Financial Resources
- Quality Control Analysis
- Revenue Cycle Management Leadership
Timeline
PROVIDER NETWORK MANAGEMENT SPECIALIST
Zing Health
12.2022 - Current
SENIOR PROVIDER ENROLLMENT SPECIALIST
Community Health Systems
04.2021 - Current
PROVIDER ENROLLMENT SPECIALIST II
ENVISION PHYSICIAN SERVICES / SHERIDAN HEALTHCARE
06.2017 - 04.2021
PROVIDER ENROLLMENT SPECIALIST I
ENVISION PHYSICIAN SERVICES / SHERIDAN HEALTHCARE
08.2016 - 06.2017
PAYMENT POSTER I
SHERIDAN HEALTHCARE
06.2015 - 08.2016
PROVIDER DATA MANAGEMENT ANALYST
AEROTEK STAFFING (CENTENE HEALTHCARE-TEMP ASSIGNMENT)
09.2014 - 05.2015
SENIOR COLLECTIONS SPECIALIST
PEDIATRIC ASSOCIATES
04.2012 - 06.2014
SENIOR COLLECTIONS SPECIALIST
CFS STAFFING (PEDIATRIX/MEDNAX-TEMP ASSIGNMENT)
02.2011 - 03.2012
PROCUREMENT SUPERVISOR
TOTALE MEDICAL
01.2010 - 01.2011
DOCUMENT MANAGEMENT SUPERVISOR
NATIONS HEALTH
01.2008 - 01.2010
BACHELOR OF SCIENCE - BUSINESS ADMINISTRATION
AMERICAN INTERCONTINENTAL UNIVERSITY
VOCATIONAL DEGREE - MEDICAL ASSISTING CERTIFICATION
CONCORDE CAREER COLLEGE