Tammy Pratt
Belton,TX
Summary
Meticulous managed care contracting and credentialing professional, with excellent analytical and problem-solving skills, great attention to detail, proficient at multitasking and working under pressure to meet deadlines.
Employment Gaps:
- 7/2019 - 8/2020 - I assisted in caring for two family members who were terminally ill.
- 12/2022 - 1/2024 - I cared for my mother who became seriously ill. Willing to relocate to: Houston, TX - San Antonio, TX Authorized to work in the US for any employer
Overview
14
14
years of professional experience
Work History
Credentialing and Privileging Coordinator
CommUnityCare Health Centers
10.2024 - Current
- Manage the credentialing process for healthcare professionals, ensuring compliance with industry standards and regulations
- Review and verify documentation submitted by healthcare providers to ensure accuracy and completeness
- Maintain up-to-date knowledge of credentialing requirements and changes in regulations to ensure adherence to best practices
- Collaborate with internal departments such as HR, Compliance, and Legal to gather necessary information for credentialing purposes
- Identify discrepancies or red flags in provider applications or documents through thorough review and investigation
- Conduct background checks on healthcare providers using various databases and resources
- Perform primary source verification of education, training, licensure, certifications, work history, malpractice claims history, and other relevant credentials
- Communicate effectively with healthcare providers regarding missing or incomplete documentation required for credentialing
- Ensure compliance with industry standards/regulations throughout the entire credentialing process
- Maintain accurate records/documentation according to organizational policies/procedures
- Ensure timely completion of all aspects of the credentialing process within established deadlines
Managed Care / Credentialing Specialist
Tarrytown Expocare LLC
01.2024 - 04.2024
- Prepare initial applications and renewals of payer contracts before the signing of contracts to analyze all clauses, stipulations, regulatory obligations, and practical business risks.
- Maintain current knowledge of city, state, and federal regulations to ensure that company compliance is in accordance and implement corrective action plans as necessary.
- Manage pharmacy contracting process for TTE owned pharmacies to select and assist revenue management department with performance on administrative requirements and obligation.
- Review pharmacy contract setup to maintain compliance with contracted agreements.
- Support daily credentialing, re-credentialing, and contracting operations.
- Identify and Implement changes to ensure compliance with all company policies and procedures as well as regulatory requirements.
- Monitor, track, and report pharmacy compliance with guiding government regulations and internal policies and procedures.
- Research and problem solve to resolve claim issues and concerns.
- Respond to and track requests, inquiries, and communications with provider pharmacies.
- Collaborate with cross-functional teams on pharmacy payment-related matters.
- Develop, review, and distribute pharmacy communications to meet internal and payer requests.
- Investigate specific issues related to regulatory requirements through literature or internet resources.
- Proactively research, analyze, and interpret data to produce substantiated recommendations and to work effectively in a high-pressure, high demand claims support environment.
- Utilize critical thinking and organizational skills to ensure all work is performed with the highest level of quality, accuracy and delivered timely.
Provider Contracts Manager
Molina Healthcare
01.2022 - 12.2022
- Initiate, negotiate, generate, and track provider Letters of Agreement, contracts and amendments from initial draft to full execution utilizing approved standardized contract templates/amendments.
- Support network development throughout state to include researching, recruiting, and negotiating with providers.
- Participate in the evaluation of provider network and implementation of strategic plans to meet network adequacy standards.
- Clearly and professionally communicate contract terms, payment structures, and reimbursement rates to physicians, hospitals, and ancillary providers.
- Assist in analysis and coordination of amendments, reimbursement, and language changes.
- Coordinate preparation and distribution of documents to complete the contracting process in a timely and thorough manner according to standardized processes.
Credentialing Specialist / Interim Office Administrator
Counselors of Texas (Side by Side Counseling)
08.2020 - 11.2021
- Obtain, maintain and negotiate insurance payer contracts and credentialing for all clinic providers.
- Maintain therapists schedules; check in and schedule clients; answer phones and emails, sort and distribute mail.
- Bill insurance and clients for services; work claims denials.
Onboarding Coordinator
Catalyst Consulting
04.2019 - 07.2019
- Enter new provider demographics into database; collect and verify credentialing documents.
- Create monthly reports of updated delegated provider information and send to insurance payers.
- Work on contracting projects as assigned.
Contracting / Credentialing Representative II
RC Billing, Inc
08.2018 - 03.2019
- Collect and verify credentialing documents from providers.
- Complete and update CAQH profiles.
- Complete and submit Medicare credentialing applications using PECOS, Multi-State Medicaid Applications, as well as multiple Commercial insurance payer applications.
- Complete and submit applications for hospital privileges.
- Request, review and analyze Government, Managed Care and Commercial payer contracts; Negotiate payer contracts and rates in a timely manner to insure appropriate contract language such as timely filing, clean claims, length of term, rates, etc.
- Complete payer fee analyses to insure correct reimbursement.
- Track and thoroughly document contract status and follow-up processes.
- Maintain and submit client fee schedule change annually or otherwise.
- Demonstrate thorough understanding and knowledge of Government and Commercial payer credentialing processes/requirements.
Contract Specialist
Scott & White Health Plan (now Baylor Scott & White Health Plan)
02.2012 - 12.2017
- Maintain and assist in building Provider Network.
- Create new contracts and amendments and distribute to providers in a timely manner; track, process and execute contracts and amendments.
- Enter contract information into contract database.
- Interact regularly with Finance and Legal Departments to implement new fee schedules and legislative updates to all provider contracts.
- Collect and organize credentialing documents: verify insurance, medical licenses, and certificates; and submit to committee for review.
Education
Associate of Applied Science - Business
Olean Business Institute
Olean05.1992
Skills
- Attention to Detail
- Building / Maintaining Relationships
- Customer Service
- Data Entry / Analysis
- Multitasking and organization
- Managing Expirables (Licenses, Certifications, etc)
- Medical Credentialing Application Review / Verifications
- Medical Credentialing Software (Cactus, Modio)
- Record Maintenance
- PECOS, TMHP, CAQH, NPPES
Timeline
Credentialing and Privileging Coordinator
CommUnityCare Health Centers
10.2024 - Current
Managed Care / Credentialing Specialist
Tarrytown Expocare LLC
01.2024 - 04.2024
Provider Contracts Manager
Molina Healthcare
01.2022 - 12.2022
Credentialing Specialist / Interim Office Administrator
Counselors of Texas (Side by Side Counseling)
08.2020 - 11.2021
Onboarding Coordinator
Catalyst Consulting
04.2019 - 07.2019
Contracting / Credentialing Representative II
RC Billing, Inc
08.2018 - 03.2019
Contract Specialist
Scott & White Health Plan (now Baylor Scott & White Health Plan)
02.2012 - 12.2017
Associate of Applied Science - Business
Olean Business Institute
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