Paula Brown, CPCS
Summary
Results-driven Certified Credentialing Specialist with extensive experience in healthcare provider credentialing and project management. Demonstrates a strong ability to manage and transpose large datasets with high accuracy, while ensuring compliance with standards set by the Joint Commission, NCQA, URAC, DNV, DoD, FDA, and HIPAA. Highly organized and detail-oriented, dedicated to delivering exemplary work across multiple projects. Proven problem-solver with exceptional communication skills and a commitment to operational excellence in medical standards and compliance.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Credentialing Training Coordinator (Remote)
Planned Systems International
04.2023 - Current
- Support the Army National Guard Office of the Chief Surgeon (ANG-CSG) by completing credentialing and privileging files according to AR-40-68, Joint Commission, and local state standards.
- Scheduled virtual training sessions for staff members and external vendors.
- Facilitate individual learning through remote instructor-led classes.
- Supervised progress during training sessions.
- Measured performance outcomes post-training.
- Evaluated existing workflows to pinpoint improvement opportunities.
- Ensured that all necessary equipment was available prior to a session commencing.
- Provided ongoing support to internal trainees and external customers throughout the entire training process.
- Mentored and onboarded new staff members to establish top client satisfaction.
- Developed targeted courses to achieve company training objectives and enhance skills of new employees in leadership roles.
- Analyzed feedback from training participants to make improvements to future programs.
- Acted as a liaison between employees and management to communicate training needs and outcomes.
- Explained project goals and expectations required of trainees.
Credentialing Specialist (Remote)
Bon Secours Mercy Health
, VA
03.2020 - Current
- Use MD-Staff and Verity to maintain facility databases containing physician records, files, and credentialing documents.
- Collaborated with physicians to ensure the timely completion of hospital applications.
- Kept close tabs on documentation expiration dates, communicating with the correct personnel to submit files prior to expiration.
- Performed primary source verifications, such as criminal histories, licenses, and board certifications.
- Database management skills, including querying, reporting, and document generation.
- Submission of background checks, as required for credentialed practitioners to contracted vendors. Retrieval and review of the reports as part of the credentialing packet.
- Communicates effectively with outside agencies (i.e., State Board of Medicine, Drug Enforcement Agency, National Practitioner Data Bank, etc.). As well as other departments, hospitals, insurance companies, and managed care organizations, to obtain or share, as authorized, information regarding physicians' credentials or privileges.
- Addressed credentialing requests, overseeing compliance with governmental and organizational guidelines regarding tiered data access.
Credentialing Specialist (Remote)
Favor TechConsulting
Vienna, VA
11.2020 - 04.2023
- Support to the Army National Guard Office of the Chief Surgeon (ANG-CSG) by completing credentialing and privileging files according to AR-40-68, Joint Commission, and local state standards.
- Responsible for managing the verification process for all healthcare professionals (physicians, dentists, nurses, and allied health personnel).
- Complete Primary Source Verification (PSV) of credentials such as licenses, certifications, registrations, professional school education, postgraduate education, residency, specialty training, board certifications, work history, and current references, while ensuring that the organization and staff are in accordance with ARNG-CSG directives, industry trends, and standard credentialing procedures.
- Reviewed and processed credentialing applications to ensure accuracy, completeness, and compliance with all accreditation standards.
- Maintained detailed records of provider data in the credentialing database system.
- Researched discrepancies between submitted provider data and verified sources when necessary.
- Participated actively in special projects or initiatives pertaining to improvement of operational efficiency within the department.
- Addressed and resolved discrepancies in provider documentation during credentialing.
- Monitored expiration of licenses and certifications, notifying providers of renewal requirements.
Care Managment Associate
Aetna
Norfolk, VA
06.2019 - 03.2020
- Responsible for the initial review, assisting in the research, and resolution of claims payment issues.
- Auditor of the team task.
- Complete authorization, such as open, close, extend, decrease, or increase hours.
- Assist in the research and resolution of claims payment issues.
- Monitored multiple databases to keep track of all members' information.
- Write and prepare administrative and partial denial letters for personal care hours for the state.
- Participates in member care management rounds and meetings.
- Identifies the principal reason for admission, facility, and member product to correctly apply intervention assessment tools.
- Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services
- Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAC and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures
Quality Assurance Specialist
LifeNet Health
Virginia Beach, VA
10.2018 - 06.2019
- Performs review of documents, data entry filing, and retrieving of production records/information into systems. Compile prepare and copy appropriate donor related documents along with appropriate laboratory results.
- Accurately and effectively evaluate information for preliminary donor eligibility, including: relevant medical records, clinical course, hemodilution assessment, medical history and behavioral risk assessment information.
- Verify donor information received from recovery agencies, as well as medical examiners office, hospitals, labs, etc.... to determine suitability
- Perform paper record scanning to electronic format and verification of scanned document.
- Prepare and send copies of Quality Assurance documents and summary reports required by internal and external clients, as assigned and in a timely manner.
Credentials Analyst
Sentara (Optima)
Virginia Beach, VA
07.2017 - 08.2018
- Conducts data gathering, verification and analysis of practitioners CAQH applications.
- Manage credentials for medical staff and affiliate appointment and privileges through both the initial and reappointment application process.
- Responsible for maintaining all credentials records, and maintains data in system-wide database.
- Verified certifications held by medical providers, their professional liability certificate of insurance, as well as verify practitioners are free of sanctions utilizing databases such as NPDB.
Credentialing Specialist SME
Anthem, Inc.
Norfolk, VA
04.2012 - 06.2017
- Performed primary source verification of providers' credentials, education, and employment history according to departmental policy.
- Conduct electronic queries using databases for verification and sanction information for the credential file and contract application.
- SME participated in training an average of 15 new employees or more per year.
- Proficient with credentialing platforms such as CACTUS, Facets, ECHO, and Macess.
- Utilized CAQH to locate essential documents for the credentialing process.
- Validated primary source documents such as licenses, diplomas, certifications and other related credentials.
- Evaluated potential providers to confirm qualifications for joining the network.
Education
Associate of Applied Science - Computer Information Systems
Centura College (Tidewater Tech)
05.2005
Skills
- Proficient in Microsoft Outlook, Word, Excel, Powerpoint, Access, Data Entry (60 WPM)
- Detail oriented with strong analytical skills, ability to identify problems and develop solutions
- Proficient in Epic, CCQAS, PMT, Facets, QNXT, CACTUS, CAQH, MD Staff, Verity and ECHO
- Excellent communication skills, both written and verbal
- Flexible and adaptable in regards to learning and understanding new technologies
- Ability to effectively prioritize and execute tasks in a high pressure environment
- Excellent self-management, organizational, and analytical skills
- Medical records management, Physician Relations, confidentiality
- Policies implementation
- Proofreading
- Credentialing audits
Certification
- NAMSS Certified Provider Credentialing Specialist (CPCS), Issued - May 2022 - Expires Dec 2025
Active Clearance(s)
- NACI
Timeline
Credentialing Training Coordinator (Remote)
Planned Systems International
04.2023 - Current
Credentialing Specialist (Remote)
Favor TechConsulting
11.2020 - 04.2023
Credentialing Specialist (Remote)
Bon Secours Mercy Health
03.2020 - Current
Care Managment Associate
Aetna
06.2019 - 03.2020
Quality Assurance Specialist
LifeNet Health
10.2018 - 06.2019
Credentials Analyst
Sentara (Optima)
07.2017 - 08.2018
Credentialing Specialist SME
Anthem, Inc.
04.2012 - 06.2017
Associate of Applied Science - Computer Information Systems
Centura College (Tidewater Tech)
- NAMSS Certified Provider Credentialing Specialist (CPCS), Issued - May 2022 - Expires Dec 2025
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