Summary
Overview
Work History
Education
Skills
Certification
Timeline
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Sunshine Martinez

Albuquerque,NM

Summary

Self-motivated and team-oriented professional with exceptional customer service skills. Over 20 years of experience in the healthcare industry with a strong background in provider enrollment, Medicaid and Medicare credentialing for physicians, physician licensing, and contracting providers with MCO's and government plans. Certified through the National Healthcare Association as a Certified Medical Billing and Coding specialist and as a Certified Medical Administrative Assistant since 2021. Versatile professional serving as the first point of contact for patients, ensuring their needs are met by verifying insurance, handling paperwork, and preparing records. Proficient in MS Office and EHR systems, with a comprehensive understanding of medical terminology. Dedicated to delivering personalized service for providers and ensuring quality patient care.

Overview

20
20
years of professional experience
3
3
Certification

Work History

Medical Secretary

ECECD- Families FIRST
10.2023 - Current
  • Enter client information into the client record on the electronic database as appropriate
  • Serve as back up for intakes which includes explaining the program, completing demographics, checking eligibility in Medicaid portal, obtaining consent signatures, and scheduling appointments with assigned Care Coordinator and other supports such as WIC
  • Attempt to contact clients and document those attempts as indicated on potential clients and inactive clients as well as check the Medicaid and Managed Care Organization status of clients
  • Schedule clients for Assessments
  • Notify care coordinator when inactive clients are eligible for billing
  • Establish contact with clients via phone, letter, and/or through partnership with WIC program when Region Coordinator provides list of clients to contact from Human Service Division and/or Managed Care Organization
  • Organize and maintain educational materials to ensure adequate supply of packets on hand
  • Performs other duties as assigned by direct supervisors and/or higher management to contribute to efficient office flow

Data Analyst

New Mexico Department of Health
01.2021 - 10.2023
  • Responds to the surge in notifiable conditions laboratory reports being sent to New Mexico and the surge in new cases throughout the COVID-19 pandemic
  • Address the hundreds of new lab results received electronically each day via fax
  • Any & all covid related hospitalized cases are sent to the COVID unit for further processing and data entry
  • Process/triage the reports, enter them in the database (NMEDSS), create investigations, enter lab reports in (NMEDDS) and perform Quality Assurance and data analysis
  • Participates in special project operations and other tasks as needed for Quality Assurance and data analysis by COVID NET

Medical Records Clerk

Renal Medicine Associates
08.2019 - 02.2020
  • Pulled medical records via electronic records system
  • Submitted and responded to medical records requests from patients or other Health care professionals
  • Respond to legal requests and other requests for medical records
  • Responded to data requests within a timely manner
  • Verify hospital charges
  • Download hospital reports and lab reports via online portals to submit with billing
  • Address any requests for additional information such as chart reports for procedures completed
  • Communicate with billing department regarding medical records request and denials received

Billing /Credentialing Supervisor

Albuquerque Health Services
02.2019 - 08.2019
  • Onboarding of new providers
  • Credentialing completed and applications submitted as needed for proper reimbursement
  • Responsible for training new employees with Clinic Web software and billing processes
  • Billing daily dosing per client rosters for all 4 locations as well as Physicians visits and mental health sessions
  • Credentialing and contracting new satellite locations in addition to all on board Therapists and Licensed Physicians via CAQH or through MCO portals
  • Set up MCO access for new employees
  • Appeals and corrected claims as needed
  • Client Liaison for all billing inquiries

Billing Specialist/ Collections

A&R Medical Supply
09.2017 - 01.2019
  • Billing and collecting DME orders
  • QA of DME orders prior to billing
  • Verifying insurance and obtaining authorizations as needed
  • Contact physicians for prescriptions and clinical notes
  • Assist patients with billing inquiries and payment arrangements
  • Ability to qualify patients according to CMS guidelines for all DME equipment
  • Demonstrate excellent customer service skills and ability to work under deadlines

Billing Specialist/ Provider Liaison

Zymeda Provider Solutions
12.2015 - 07.2017
  • Provider enrollment, credentialing and provider liaison
  • Coordinate and help facilitate providers through onboarding process
  • Obtain necessary Provider licenses and malpractice history if applicable
  • Verify patient insurance, co pays and deductibles
  • Access medical records via hospital database for appeals on denied or underpaid claims
  • Daily follow up with healthcare payers regarding claims and appeal status
  • Work monthly aging reports Aging reports (365 + accounts)
  • Demonstrate excellent customer service skills with payers and patients
  • Contact patient for additional insurance information pays and deductibles

Provider Enrollment Specialist

Pediatrix Medical Group, Inc
02.2013 - 11.2015
  • Company Overview: Temporary contract
  • Provider enrollment for all new onboarding physicians
  • Coordinating, processing, and tracking of all new and existing provider applications
  • Following up on and gathering credentialing and malpractice claims documentation to process provider applications
  • Obtain information from the provider or physicians necessary for provider enrollment with Medicaid and application MCOS’ such as BCBS, UHC and other health plans
  • Routine review and follow up on application status
  • Data entry, communicate professionally and effectively both written and verbally
  • Maintain an organized and accurate filing system, as well as an efficient and effective credentialing tracking system to ensure the credentialing is completed with a timely matter
  • Participates in assisting with special projects as assigned
  • Maintain individual productivity and performance standards
  • Communicates credentialing issues to supervisor or other management personnel
  • Temporary contract

Credentialing Specialist II/ Medical Collector

ASC Healthcare A1Imaging
10.2009 - 06.2011
  • Assist Network Manager with Network growth and development, physician recruitment and healthcare participation, also provided clerical support as needed
  • Responsible for obtaining, auditing and data entry of physician and ancillary applications
  • Collecting and maintaining of physicians CME'S and proper licensing in credentialing software
  • Assisted providers with obtaining physician licensing or renewals as needed for facilities throughout the United States
  • Completion of any credentialing and re-credentialing applications for both facility and physician participation in commercial and government plans
  • Follow up health plans regarding participation status
  • Primary source verification of new physicians, process new radiologist through AMA and other credentialing sources to verify credentials
  • Assisting providers with enrollment in Pecos system and obtaining National provider Identification numbers
  • Coordinating with new radiology groups for necessary credentialing documentation as needed
  • Maintain physician's spreadsheet with physician’s licenses
  • Maintain billing software, correcting /add referring & rendering provider numbers as needed
  • Assist with bucket review: Claims being withheld, pending information to send claims: such as provider number, W9, rendering physician, etc, submitted necessary appeals to adjudicate underpaid or non-paid claims

Credentialing Specialist I/ Provider Liaison

West Dermatology
07.2006 - 10.2009
  • Assist Network Manager with Network growth and development of the obtaining new contracts for providers with MCO’s
  • Oversee the Physician recruitment and healthcare participation process for all new providers
  • Provided clerical support as needed
  • Responsible for credentialing applications and MCO approvals for providers
  • Obtaining, auditing and data entry of physician and ancillary applications, CME's and proper licensing in credentialing software
  • Communicate with Wybtrak Software Company regarding updates; recognize any glitches or additional fields to modify within the software based on company needs
  • Administration and delivery of company wide spreadsheet containing contract status for physicians and payers
  • Completed Nationwide merger involving changing of tax identification numbers
  • Resolution of provider and patient grievances, analyze and problem solve various credentialing and billing issues

Medical Collector I

FPBO Billing Office of Loma Linda University
11.2004 - 12.2005
  • Commercial collector for Family practices, verified patient insurance, co pays and deductibles
  • Accessed medical records via hospital database for appeals on denied or underpaid claims
  • Daily follow up with healthcare payers regarding claims and appeal status
  • Worked monthly aging reports
  • Demonstrated excellent customer service skills with payers and patients
  • Contacted patient for additional insurance information, co pays and deductibles

Education

Certificate of completion - 1000 Core hours of CHW training

Department of Health
12.2024

CNM -

Health promotion and Community Health worker Fundamentals
12.2024

Medical Billing and Coding Specialist -

New Horizons computer learning centers
01.2021

Medical terminology -

Riverside Community College
01.2005

Intro to Human services -

Riverside Community College
01.2003

Skills

  • Provider credentialing and contract support
  • Community Health worker
  • Clinical support
  • Customer service
  • Patient scheduling
  • Strong organizational skills
  • Patient confidentiality adherence
  • Medical terminology expertise
  • Critical thinking
  • Telephone customer support
  • Medical records management
  • Professional telephone etiquette
  • Medicare/Medicaid
  • HIPAA compliance
  • Electronic recordkeeping
  • Insurance verification
  • EMR updating
  • Medical coding basics
  • Provider relations
  • ICD-10 coding
  • Electronic health records
  • Medical billing codes
  • Healthcare billing
  • UB-92 billing forms
  • Insurance authorization management
  • Current procedural terminology (CPT)
  • Data entry
  • Clerical support
  • Documentation and recordkeeping
  • Computer proficiency
  • Appointment setting
  • Collaboration and teamwork
  • Payment scheduling and collection
  • Insurance authorizations
  • EHR software
  • Appointment scheduling
  • Relationship building
  • Maintaining financial records
  • Patient billing
  • Medical billing
  • Claim forms
  • Epic systems
  • Problem-solving

Certification

  • Certified Medical Administrative Assistant (CMAA) - National Healthcare Association.
  • Certified Billing and Coding Specialist (CBCS) - National Healthcare Association.
  • Health Insurance Portability and Accountability Act Training Certificate-HIPAA Exams, Inc.or equivalent providers.

Timeline

Medical Secretary

ECECD- Families FIRST
10.2023 - Current

Data Analyst

New Mexico Department of Health
01.2021 - 10.2023

Medical Records Clerk

Renal Medicine Associates
08.2019 - 02.2020

Billing /Credentialing Supervisor

Albuquerque Health Services
02.2019 - 08.2019

Billing Specialist/ Collections

A&R Medical Supply
09.2017 - 01.2019

Billing Specialist/ Provider Liaison

Zymeda Provider Solutions
12.2015 - 07.2017

Provider Enrollment Specialist

Pediatrix Medical Group, Inc
02.2013 - 11.2015

Credentialing Specialist II/ Medical Collector

ASC Healthcare A1Imaging
10.2009 - 06.2011

Credentialing Specialist I/ Provider Liaison

West Dermatology
07.2006 - 10.2009

Medical Collector I

FPBO Billing Office of Loma Linda University
11.2004 - 12.2005

CNM -

Health promotion and Community Health worker Fundamentals

Medical Billing and Coding Specialist -

New Horizons computer learning centers

Medical terminology -

Riverside Community College

Intro to Human services -

Riverside Community College

Certificate of completion - 1000 Core hours of CHW training

Department of Health

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Sunshine Martinez