Randall Tom
Albuquerque,NM
Summary
Goal Driven, Results Oriented, Team Player and Multi-Tasker Experienced administrative professional with 1+ years in provider credentialing services. Works productively with facilities, provider groups and individual professionals. Knowledgeable about application requirements for government and private insurance plans. Experienced Credentialing Specialist adept at conducting application reviews and primary source verifications. Excellent relationship-building, problem-solving and communication skills. Experienced administrative professional with 1+ years in provider credentialing services. Works productively with facilities, provider groups and individual professionals. Knowledgeable about application requirements for government and private insurance plans. Experienced administrative professional with 1+ years in provider credentialing services. Works productively with facilities, provider groups and individual professionals. Knowledgeable about application requirements for government and private insurance plans. Achievements include completing more than 6 healthcare provider applications each month with no critical errors. Highly organized and detail-oriented with in-depth knowledge of insurance regulations. Responsive and engaging Human Resources Assistant skilled in supporting employees and managers with diverse HR needs. Expert with word processing, database and benefits administration software. Focused on keeping systems updated and facilitating positive employee relations. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Clinical Credentialing Assistant
USDHHS-Indian Health Service-Albuquerque Indian Health Center
10.2023 - Current
- Responsible for managing the verification process for healthcare professionals (physicians, dentists, midlevel practitioners [PAs and NPs], pharmacists and other allied health professionals)
- This includes reviewing applications for completion, verification of state licensure, collecting information from the National Practitioner Data Bank (NPDB.org), collection of information from State Licensing Boards, verification of Board Certification and Continuing Medical Education
- Job duties will include: 1
- Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility
- Conducts thorough background investigation, research and primary source verification of all components of the application file
- Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow-up
- Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified
- Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions
- Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise
- Assists with managed care delegated credentialing audits; conducts internal file audits
- Utilizes credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act
- Monitors the initial, reappointment and expiable process for all medical staff, Allied Health Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts
- Provides general information and directions in response to inquiries in person or by telephone, refers inquiries to appropriate personnel, deliver messages verbally and in writing to staff
- Maintains confidentiality and protects operations on all sensitive information
- Receives incoming correspondence, and based on subject matter, content and knowledge of the functions of the organizations, routes materials to appropriate person(s)
- Maintains CMO's records for all incoming and outgoing correspondence related to credentialing, licensing and CME activities
- Prepare agendas, coordinate and manage administration of department specific meetings and presentations, attend meetings and subsequently follow-up on significant and timely matters
- Interact with other departments to effectively and efficiently conduct special projects and assignments
- Prepares and plans for Board and Committee Meetings, including scheduling, preparing/distributing agenda and other materials, providing support during the meetings, drafting minutes and tracking attendance
- Composes business correspondence, monitors external and internal communications, and addresses communications in an expeditious manner, related to credentialing, licensing and Creativities including bringing critical issues to the immediate attention of the CMO
- Receives and screens incoming phone calls and mail for the CMO related to credentialing, licensing and CME activities
- This may include summarizing the content of incoming materials or specially gathered information
- Operates basic office equipment: copiers, calculators, computers, typewriter, and fax machine
- Performs administrative and clerical functions related to Joint Commission accreditation process, on behalf of the CMO
- Responsible for the coordination and file maintenance of the credentialing and privileging process for the CMO office
- Ensures that all Residents and Students submit required documentation for credentialing, as well as complying with all Indian Health Service requirements regarding fingerprinting, immunizations, and other occupational health requirements of Indian Health Service, prior to the start of their rotations at Albuquerque Indian Health Center
- Performs other duties as assigned
- Assists Care Coordination, Quality, Member and Provider Outreach staff related to clinical outcomes, quality improvement, health risk assessment engagement, claims training and/or retention efforts.
Voucher Examiner
USDHHS-Indian Health
05.2022 - 10.2023
- Review patient accounts to determine the status of the account, making standard adjustments
- Performs work consisting of examination for accuracy, adequacy of documentation or citation, compliance with regulations, and justification of claims and other requests for payments
- Review delinquent patient accounts records, following up with responsible parties via telephone and correspondence according to organization policy and procedures
- Maintains files system of patient accounts or follow-up with responsible parties on outstanding balances Examine accounts to resolve difficult reconciliations requiring an analysis of adjustments and corrective entries in the patient account system
- Review and examines various bill types, of patient care of third-party payers and performs third party collection process on all unpaid and partial payments outstanding financial screening on hospital and medical group account activity to identify residual balances, high-deductible plan participants and self-pay patients
- Maintains documents of all activity related/performed on patient accounts in patient financial folder Responsible for identifying patient accounts deemed non-collectable, Comprehension of the pre-billing/pre-adjudication of claim filing to successfully identify out of pocket expense to counsel patient and/or families regarding financial responsibilities
- Escalates chronic no pay or bad debt accounts to supervisor
- Prepare monthly, quarterly and annual reports utilizing the Accounts Receivable program
- Responsible for self-education by reading third party newsletters, periodicals and updates circulated by management
- Works closely with New Mexico and Arizona Medicaid Manage Care Organizations to identify and address Native American health disparity issues and cultural competency concerns related to care coordination, services and care delivery
- Promotes Native Americans' access to healthcare coverage and educating communities about the services provided by Medicare and Medicaid
- Define strategy for Indian Managed Care Entity (IMCE) in media and tribal partnerships to support the health plan's IMCE program, as well as support NA/AI strategic plan for growth and improve health outcomes by focusing on integration efforts for Managed Care Organizations in the States of Arizona and New Mexico
- Assists Care Coordination, Quality, Member and Provider Outreach staff related to clinical outcomes, quality improvement, health risk assessment engagement, claims training and/or retention efforts.
Medical Support Assistant
USDHHS-Indian Health
10.2014 - 05.2022
- Interviewing patients and/or family members to obtain pertinent and accurate patient registration information, i.e., demographic, alternative resource information and authorization to enable the Service Unit to bill for health care services including the Non-Beneficiary services; entering data into the patient database records management system (EHR/RPMS, this includes my typing speed of 45 wpm with a timed five-minute typing test
- Additionally, making certain the patient's EHR meaningful use requirements are met
- Also, ER/triage and Urgent Care updates as well as arm banding patients as required
- Assisting as needed in obtaining Advance Directive forms in addition to admitting, discharging and transferring (ADT) of patients
- Obtain and getting ICD 10 & CPT codes for patient admissions
- Obtaining photocopies of legal documents regarding adoption, power of attorney and name changes
- Checking in patients with appointments using the current service unit scheduling system with various clinics throughout the service unit
- Interview new patients and obtaining information to initiate a new health record, reactivating records that were previously sent to Federal Storage, communicating with Medical Records department to retrieve a retired or stored record
- Operating personal computer, in regards to word processing, data entry and data retrieval
- Assisting new patient in complete new or update forms, which include Medicare Secondary Payer, Assignment of Benefits, HIPPA/Privacy Act forms and Certificate of Indian Blood, in addition to the Affordable Care Act (ACA) exemption forms also printing Patient Wellness Handouts
- Further, should the patient not have any type of third-party insurance, referrals are made to the Patient Benefit Coordinators (PBC) on site
- Also, assisting with PBC duties on a daily basis, which includes follow up on patient cases with CASA, NM Income Support Division (ISD), Department of Veterans Affairs and Social Security Administration as patients request
- Refers patients without insurance coverage to the Patient Benefits Coordinator for navigation of options to manage healthcare costs, including using the Market Place for obtaining health insurance coverage
- Further, assisting with PBC duties when PBC staff aren't available and assisting patients with questions on their benefits and explaining the re-certification process along with submission of proper documents
- Assist patients with the process of applying for benefits and explaining the four managed care organizations (MCOs) that are utilized by the State of New Mexico
- Additionally, I am able to utilize the portals Yes NM to assist with checking, updating and helping patients renew and explain various assistance programs available to patients
- Knowledgeable with the patient flow system at Crownpoint Healthcare Facility, Pueblo Pintado Clinic and Thoreau Health Clinic, in addition to working face-to-face with patients on a daily basis
- Working in stressful situations and dealing with a variety of people who may be disgruntled and complain about processes and procedures all while remaining relaxed and explaining reasons for facility procedures
- Assisting as phone operator at Thoreau Health Clinic for patients when calling to schedule appointments, follow up on referrals or taking messages for providers
- Creating visits in the EHR/RPMS for ancillary clinics in addition to scheduling appointments for Saturday clinics
- Verifying eligibility with assistance NM Medicaid, AZ, AHCCCS, My Ability, Presbyterian Online, Availity portals
- In addition to educating and encouraging patients to apply with NM Centennial Care Managed Care Organizations (MCO's) such as Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan and Western Sky Community Plan of New Mexico
- Further, knowledgeable in verifying Medicare Part A, B, C and D in addition to verifying Veteran's Assistance and Private Insurance which includes workers compensation
- This includes triggering Medicare Part D requests via EHR/RPMS
- In addition, clerical duties as needed which include file and records management, providing daily logs and monthly reports, answering phone calls, faxing as needed
- Problem-solving skills and providing customer service as key components with Patient Registration
- Also, assisting with off-site flu clinics and working rotating shifts
- Working with providers and assisting all staff members with clinic calendar for which days providers will be at THC
- Delegated at times to assist and oversee Patient Registration duties as requested by Supervisor
- Lastly, assist Medical Records, as needed, with assisting patients with Request of Information (ROI) from outside facilities, Immunization Records for patients as requested and make charts for new patients, charts that have been sent to Archives or name change requests
- Scanning all documents that have come in along with going chartless and assisting with Quality Assurance for all documents to streamline the process of becoming electronic and cease utilizing charts
- Other areas that I work with include assisting billers to help correct claim errors, this assists with eligibility and documentation errors
- Assisting providers with developing and maintaining health programs that are culturally appropriate and align with community values, customs, and traditions of American Indian/Alaska Native population
- Works closely with New Mexico and Arizona Medicaid Manage Care Organizations to identify and address Native American health disparity issues and cultural competency concerns related to care coordination, services and care delivery
- Promotes Native Americans' access to healthcare coverage and educating communities about the services provided by Medicare and Medicaid
- Define strategy for Indian Managed Care Entity (IMCE) in media and tri
Education
MBA - Healthcare Administration
New Mexico Highlands University
Las Vegas, NM12.2025
Master of Arts - Liberal Arts And Sciences
University of New Mexico
Albuquerque, NM12.2022
Skills
- Dependable, Honest, Goal Driven, Results Oriented, Reliable, Team Player and a quick learner Proficient in Microsoft Office (Word, Excel, Power Point, Access and Outlook) Apple OS systems, in addition to website maintain and development Experience in Accounts Payable/Receivable, Time and Attendance with payroll experience Excellent verbal and written communication skills Accountability for all necessary job functions, including meeting deadlines, customer service oriented and being prompt Self-motivated, fast learner, willing to learn with the ability to pay attention to detail and accuracy Ability to work well under pressure Prompt and attention to detail as required Work history with all areas of the hospital-Administrative, Nursing, Clinical, Quality Management to address errors and patient complaints
- HIPAA Compliance
- Provider enrollment
- Employee Onboarding
- Application management
- Data Management
- Credentialing oversight
- Regulatory Compliance
- Data Acquisition
- Application coordination
- MD Staff expertise
- Critical Thinking
- Problem-Solving
- Accreditation information management
- Human Resources Operations
- Microsoft Office
- Office Organization
- Administrative Skills
- Maintaining files
- HR policies
- Interpersonal Communication
- Personnel Documentation Verification
- Generating Reports
- Compliance Reporting
- Human Resources Standards
- Minute Taking
- Transcribing Meetings and Messages
Certification
- BLS Certification, 04/01/26
- MD Staff Training - 6 months
Timeline
Clinical Credentialing Assistant
USDHHS-Indian Health Service-Albuquerque Indian Health Center
10.2023 - Current
Voucher Examiner
USDHHS-Indian Health
05.2022 - 10.2023
Medical Support Assistant
USDHHS-Indian Health
10.2014 - 05.2022
MBA - Healthcare Administration
New Mexico Highlands University
Master of Arts - Liberal Arts And Sciences
University of New Mexico
- BLS Certification, 04/01/26
- MD Staff Training - 6 months
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