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
11.2022 - 08.2024
- 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
10.2020 - 10.2022
- 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
01.2013 - 10.2022
- 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
02.2012 - 12.2012
- 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
02.1999 - 10.2010
- 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
11.2022 - 08.2024
Credentialing Specialist
Freelance
10.2020 - 10.2022
Credentialing Analyst
Verifpoint & Credential Services
01.2013 - 10.2022
Credentialing Coordinator
MemorialCare Medical
02.2012 - 12.2012
Credentialing Specialist
Metlife
02.1999 - 10.2010
No Degree - Claims Coding And Quality Management
Medical And Technical Institute
Similar Profiles
Kenia LechugaKenia Lechuga
TCS Personal Care Coordinator Sr. at CalOptimaTCS Personal Care Coordinator Sr. at CalOptima
Concepcion RodriguezConcepcion Rodriguez
Personal Care Attendant at CalOptimaPersonal Care Attendant at CalOptima
NIDIA ESTESNIDIA ESTES
PACE Day Center Supervisor at CalOptimaPACE Day Center Supervisor at CalOptima