Tomica Gordon
PA
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
22
22
years of professional experience
Work History
Credentialing Coordinator
Independence Blue Cross
Philadelphia, PA
06.2016 - Current
- Responsible For processing and completing the credentialing and recredentialing applications for all providers in accordance with NCQA, State and Federal requirements.
- Accurately enters all critical data elements of the provider applications in to the Credentialing Systems
- Boosted productivity levels within the credentialing team by training new employees on proper procedures and best practices within the role.
- Conducts primary source verification for all credentialing and recredentialing applications
- Served as a resource for departmental staff by maintaining a thorough understanding of current trends and best practices in the credentialing field.
- Reduced errors in documentation by thoroughly auditing provider files for completeness and accuracy.
Marketing Operations Specialist
INDEPENDENCE BLUE CROSS
Philadelphia, PA
01.2011 - 07.2016
- Responsible for auditing and processing new small Business Customers for IBC, Keystone, AHNJ and AHDE, according to the Underwriting Guidelines and within established timeframes.
- Responsible for identifying discrepancies in Account Installation System and paperwork received from Sales and other Departments
- Process benefit/Plan/ administrative changes, reinstatements and Cancellation.
- Communicates with Brokers and Account Executives verbally and in writing.
- Assist in providing training to team members and New Marketing Operations Specialists.
Medicare Member Appeals and Grievance Specialist
INDEPENDENCE BLUE CROSS
Philadelphia, PA
05.2007 - 01.2011
- Prepares and investigates Medicare Part C, Part D and QIO appeal cases for review by the Medical Director Committee according to Unit Policy, CMS guidelines, and within established timeframes.
- Prepares First Level Medicare grievances cases according to Unit Policy and CMS guidelines.
- Researches the history relevant to the grievance case, including the member's enrollment and eligibility status, benefit plan, and circumstances surrounding the denial of services or rejection of claims.
- Communicates with members, representatives, and providers, verbally and in writing according to the policies of the Medicare Member Appeals Unit.
- Ensures that all Plan and External Review Entity overturns are effectuated timely and remain in compliance with CMS regulations.
Provider Service Senior Representative
INDEPENDENCE BLUE CROSS
Philadelphia, PA
11.2004 - 05.2007
- Support Team Leader in all areas of daily performance, including audits of team productivity, and automated phone accountability.
- Supports Supervisor and Management as Team Leader when T/L is out of office, or away from her desk.
- Coaching, mentoring, and educational assistance of new hire Provider Service Representatives-complimentary to the training process in both the training class and on the floor.
- Works directly under Manager or Supervisor in resolution process for special projects related to problems that arise via provider phone calls or mail received.
Provider Service Representative
INDEPENDENCE BLUE CROSS
Philadelphia, PA
12.2002 - 11.2004
- Intermediary for Independence Blue Cross to physicians and facilities, utilizing available resources to educate, research, expedite, and document, based on benefit policies and claim submissions.
Education
High School Diploma -
Simon Gratz High School
Philadelphia, PA07.1997
Skills
- Microsoft Word
- Typing 54 WPM
- Written Communication
- Records Review
- Medical Terminology
- Effective Communication
- Critical Thinking
- Organizational Skills
- Self Motivation
- Professionalism
- Team Collaboration
References
Available upon request
Timeline
Credentialing Coordinator
Independence Blue Cross
06.2016 - Current
Marketing Operations Specialist
INDEPENDENCE BLUE CROSS
01.2011 - 07.2016
Medicare Member Appeals and Grievance Specialist
INDEPENDENCE BLUE CROSS
05.2007 - 01.2011
Provider Service Senior Representative
INDEPENDENCE BLUE CROSS
11.2004 - 05.2007
Provider Service Representative
INDEPENDENCE BLUE CROSS
12.2002 - 11.2004
High School Diploma -
Simon Gratz High School