Rocio Guillen
Lake Forest,CA
Summary
Proven Credentialing Specialist with a track record of enhancing provider enrollment processes and data management at CalOptima. Skilled in HIPAA compliance and fostering provider relations, I improved credentialing accuracy and efficiency. My expertise in decision-making and database maintenance led to a 30% faster onboarding, showcasing my commitment to organizational development and results. I have over 15 years of credentialing knowledge in NCQA URAC, Joint Commissions.
Overview
26
26
years of professional experience
Work History
Credentialing Specialist
CalOptima
2022.11 - 2024.08
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
- 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 verifications such as background checks and board certifications.
- Safeguarded confidential provider information by adhering to strict data privacy regulations and company policies.
- Facilitated communication between departments, resulting in improved collaboration during the credentialing process.
- Received and evaluated applications to look for missing and inaccurate information.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
- Demonstrated excellent problem-solving skills when confronted with complex issues or discrepancies during the credentialing process.
- Expedited the onboarding process for new providers, ensuring timely completion of all required documentation and verifications.
- Enhanced credentialing processes by streamlining documentation and verification procedures.
- Developed strong relationships with external organizations, leading to increased cooperation during verification processes.
- Achieved greater accuracy in database management by regularly updating provider records and tracking status changes.
- Maintained a thorough understanding of accreditation standards, enabling accurate interpretation of guidelines for staff members when needed.
- Provided exceptional customer service to both internal and external stakeholders, addressing inquiries promptly and professionally.
- Contributed positively to team dynamics by fostering a collaborative and supportive work environment.
- Improved turnaround time for credentialing applications by implementing an efficient online system.
- Stayed current on industry trends by attending relevant conferences, seminars, or workshops as required.
- Supported quality improvement initiatives by identifying potential areas of risk within the credentialing department and recommending proactive solutions.
Credentialing Specialist
Freelance
2020.10 - 2022.10
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
- 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 verifications such as background checks and board certifications.
- Safeguarded confidential provider information by adhering to strict data privacy regulations and company policies.
- Facilitated communication between departments, resulting in improved collaboration during the credentialing process.
- Received and evaluated applications to look for missing and inaccurate information.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
- Demonstrated excellent problem-solving skills when confronted with complex issues or discrepancies during the credentialing process.
- Expedited the onboarding process for new providers, ensuring timely completion of all required documentation and verifications.
- Enhanced credentialing processes by streamlining documentation and verification procedures.
- Developed strong relationships with external organizations, leading to increased cooperation during verification processes.
- Achieved greater accuracy in database management by regularly updating provider records and tracking status changes.
- Maintained a thorough understanding of accreditation standards, enabling accurate interpretation of guidelines for staff members when needed.
- Ensured compliance with industry standards by regularly updating policies and procedures related to credentialing.
- Provided exceptional customer service to both internal and external stakeholders, addressing inquiries promptly and professionally.
- Contributed positively to team dynamics by fostering a collaborative and supportive work environment.
- Assisted in training new employees on proper credentialing procedures, contributing to their rapid integration into the team environment.
- Prepared records for site visits and file audits.
- Improved turnaround time for credentialing applications by implementing an efficient online system.
- Stayed current on industry trends by attending relevant conferences, seminars, or workshops as required.
- Supported quality improvement initiatives by identifying potential areas of risk within the credentialing department and recommending proactive solutions.
- Reduced errors in credentialing files by conducting thorough reviews and consistently maintaining attention to detail.
- Optimized workflow efficiency within the department through regular process evaluations and implementation of best practices.
- Improved office efficiency by effectively managing internal communications and correspondence.
- Partnered with departmental managers to ascertain hiring needs and subsequently provide candidate recommendations.
- Collected and analyzed information to monitor compliance outcomes and identify and address trends of non-compliant behavior.
- Pre-screened resumes prior to sending to corporate hiring managers for consideration.
Credentialing Analyst
Verifpoint & Credential Services
2013.01 - 2022.10
- Cultivated strong working relationships with various regulatory agencies by attending conferences, participating in industry forums, and staying abreast of changes in legislation that could impact our clients'' businesses or operations.
- Maintained up-to-date knowledge of industry trends, best practices, and regulatory changes to ensure optimal efficiency within the credentialing department.
- Expedited the onboarding process for new providers by accurately verifying their education, training, experience, certifications, and licenses within strict timelines.
- Troubleshot issues with electronic applications, quickly identifying problems and implementing solutions to maintain workflow efficiency.
- Implemented regular training sessions to keep team members informed about relevant laws, policies, and procedures related to healthcare credentialing.
- Ensured compliance with state regulations and accreditation standards by conducting thorough audits of credentials files.
- Facilitated strong relationships between providers and facilities through effective communication and coordination during the credentialing process.
- Supported quality assurance initiatives by conducting ongoing reviews of internal procedures and making recommendations for improvements as needed.
- Enhanced department productivity with proper organization and timely completion of tasks.
- Streamlined the credentialing process by implementing efficient tracking systems and maintaining accurate records.
- Assisted in maintaining an updated database of credentialed providers, allowing for quick access to essential information when needed by senior management or other departments within the organization.
- Served as a key liaison between healthcare providers and insurance companies, ensuring ongoing accuracy of information exchange.
- Completed comprehensive background checks, ensuring all candidates met company standards for quality care provision.
- Collaborated with medical staff to gather necessary documentation for timely processing of provider applications.
- Developed user-friendly guides for healthcare professionals seeking credentialing assistance, streamlining their experience while ensuring compliance with internal protocols and external regulations.
- Successfully resolved complex issues regarding licensing discrepancies or other concerns involving provider qualifications.
- Received and evaluated applications to look for missing and inaccurate information.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
Credentialing Coordinator
MemorialCare Medical
2012.02 - 2012.12
- Served as a resource for departmental staff by maintaining a thorough understanding of current trends and best practices in the credentialing field.
- Maintained accurate files, records and credentialing documents in well-maintained databases using [Software].
- Assisted with special projects as needed, demonstrating adaptability and commitment to the success of the organization.
- Elevated client satisfaction rates through prompt resolution of any provider-related issues or concerns that arose during the credentialing process.
- Boosted productivity levels within the credentialing team by training new employees on proper procedures and best practices within the role.
- Worked closely with practitioners to help each obtain privileges at assigned healthcare facilities
- Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
- Tracked expiration dates on documents and communicated with appropriate staff to avoid late filing.
- Assisted in maintaining accreditation status by preparing necessary reports and materials for site visits and audits.
- Reduced errors in documentation by thoroughly auditing provider files for completeness and accuracy.
- Ensured smooth communication flow between departments by acting as a liaison between medical staff services and other administrative units.
- Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
Credentialing Specialist
Metlife
1999.02 - 2010.10
- 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.
- Conducted primary source verifications such as background checks and board certifications.
- Safeguarded confidential provider information by adhering to strict data privacy regulations and company policies.
- Facilitated communication between departments, resulting in improved collaboration during the credentialing process.
- Received and evaluated applications to look for missing and inaccurate information.
- Obtained NPI numbers for providers and facilities and updated existing profiles.
- Demonstrated excellent problem-solving skills when confronted with complex issues or discrepancies during the credentialing process.
- Expedited the onboarding process for new providers, ensuring timely completion of all required documentation and verifications.
- Enhanced credentialing processes by streamlining documentation and verification procedures.
- Developed strong relationships with external organizations, leading to increased cooperation during verification processes.
- Achieved greater accuracy in database management by regularly updating provider records and tracking status changes.
- Maintained a thorough understanding of accreditation standards, enabling accurate interpretation of guidelines for staff members when needed.
- Ensured compliance with industry standards by regularly updating policies and procedures related to credentialing.
Education
No Degree - Claims Coding And Quality Management
Medical And Technical Institute
San Ysidro, CA08.1999
Skills
- HIPAA Compliance
- Provider enrollment
- Background Checks
- Data Management
- Credentialing oversight
- Application coordination
- Provider Relations
- Insurance procedures
- Report Generation
- Document Review
- Data Acquisition
- Proofreading
- Facility support
- Database Maintenance
- Employee Onboarding
- Group Assistance
- Management collaboration
- Microsoft Office
- Documentation and Recordkeeping
- Information Protection
- Remote Conferencing and Communication
- Complaint Handling
- Decision-Making
- Training and mentoring
- Organizational Development
- Clerical Oversight
- Data Analysis
- New Hire Onboarding
Languages
Spanish
Full Professional
Timeline
Credentialing Specialist
CalOptima
2022.11 - 2024.08
Credentialing Specialist
Freelance
2020.10 - 2022.10
Credentialing Analyst
Verifpoint & Credential Services
2013.01 - 2022.10
Credentialing Coordinator
MemorialCare Medical
2012.02 - 2012.12
Credentialing Specialist
Metlife
1999.02 - 2010.10
No Degree - Claims Coding And Quality Management
Medical And Technical Institute
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