Veronica Crampton
QA Analyst
Milwaukee,WI
Work Preference
Summary
Experienced customer service representative with a strong background in quality management and provider enrollment. Skilled in analyzing customer interactions and providing feedback to enhance service quality and satisfaction. Proven ability to thrive in fast-paced environments and adapt to changes, consistently achieving high performance ratings. Eager to leverage expertise in customer service to contribute to a dynamic team. Personable and dedicated customer service representative with extensive experience in industry. Communicative customer service professional motivated to maintain customer satisfaction and contribute to company success. History managing large amounts of inbound calls and sustaining satisfactory relationships with customers. Offers skill with CRM systems paired with outstanding active listening and multitasking abilities.
Overview
11
11
years of professional experience
Work History
Quality Management Reviewer/Customer Service Representative
Anthem Life & Disability Operations at The Standard Insurance Company
06.2023 - Current
- Receive guidance and mentoring from more experienced process experts on products and implementation processes.
- Research operations workflow problems and system irregularities.
- Assists with the development and testing of process improvement solutions for new system, new accounts, and other operational improvements.
- Assists with the development and leading of project plans and communication implementation project status to members, brokers, and groups on a recorded phone system.
- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty Anthem policies, procedures, and regulatory requirements, while meeting production goals.
- Create enrollment records in the applicable system(s).
- Performing QA on Anthem Life & Disability plans, customer service calls, and emails. Auditing and scoring medical, dental, and eye plans that have been converted to a new payment and billing system. Performing QA on Anthem Life & Disability plan amendments and updates.
- Testing of new systems being implemented in January 2025.
- Answered inbound calls in the call center on the Caine phone system for member services and claims
- Evaluated and analyzed claims for accuracy and compliance with company policies.
- Collaborated with cross-functional teams to enhance operational processes and improve workflow efficiency.
Provider Enrollment Analyst/QA Analyst
FIRST Coast Service Options
10.2022 - 01.2024
- Review procedures and protocols for various state applications.
- Credentialing provider enrollment applications for Medicare participation.
- Obtain missing or additional information via telephone or in writing.
- Research and validate information as needed to complete the enrollment application.
- Determine if both state and federal regulatory requirements are met.
- Review supporting documentation for adequacy, and make a final recommendation on the application.
- Create enrollment records in applicable system(s).
- Making any updates in the system as necessary.
- Establishing Electronic Funds Transfer (EFT) of their Medicare payments.
- Research and respond to application-specific or general provider enrollment inquiries.
- Performs other duties as the supervisor may, from time to time, deem necessary.
- Working in a production environment while achieving quality requirements.
- Navigating the enrollment systems, FISS, STAR, and related software, and loading PECOS, MCS, and APEX of Part B physician and non-physician provider types, and certain other suppliers, CMS 855I-Physicians and Non-Physician Practitioners, CMS 855O Ordering and Referring Physicians and Non-Physician Practitioners, CMS 855R-Reassignment of Medicare Benefits, CMS 588-Electronic Funds Transfer (EFT) Agreement, and the CMS 460-Medicare Participating Physician or Supplier.
- Testing of the new CMS system being implemented in June 2023.payments.
- Research and respond to application specific or general provider enrollment inquiries.
- Performs other duties as the supervisor may, from time to time, deem necessary.
- Working in a production environment while achieving quality requirements.
- Navigating the enrollment systems, FISS, STAR and related software, and load PECOS, MCS and APEX of Part B physician and non- physician provider types and Certain Other Suppliers, CMS 855I-Physicians and Non-Physician Practitioners, CMS 855O Ordering and Referring Physicians and Non Physician Practitioners, CMS 855R- Reassignment of Medicare Benefits, CMS 588-Electronic Funds Transfer (EFT) Agreement and the CMS 460-Medicare Participating Physician or Supplier.
- Testing of new CMS system being implemented 6/2023.
Credentialing Specialist III / Data Reporting Analyst
Molina Healthcare
10.2021 - 07.2022
- Verifying potential and existing Provider's licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider's hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed against providers.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
- Coordinated assigned aspects of enterprise-wide credentialing and primary source verification process for practitioners and health delivery organizations.
- According to Molina policy and procedure. Where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability.
- Maintained a high level of confidentiality for provider information.
- Processing Credentialing Applications.
- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.
- Communicates with health care providers to clarify questions and request any missing information.
- Updates credentialing software systems with required information.
- Re credentialing/Termination.
- Requests credentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.
- Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.
- Completes data corrections in the credentialing database necessary for processing of re credentialing applications.
- Reviews claims payment systems to determine provider status, as necessary.
- Ongoing Monitoring/Watch Follow-up.
- Completes follow-up for provider files on 'watch status, as necessary, following department guidelines and production goals.
- Reviews and processes assigned federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.
- Reviews and processes monthly Medicare Opt-Out reports to determine if any provider has opted out of Medicare.
- Reviews and processes assigned NPDB Continuous Query reports and takes appropriate action when new reports are found. Verifying potential and existing Provider's licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider's hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed against providers.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
- Coordinated assigned aspects of enterprise-wide credentialing and primary source verification process for practitioners and health delivery organizations.
- According to Molina policy and procedure. Where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability.
- Maintained a high level of confidentiality for provider information.
- Processing Credentialing Applications.
- Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.
- Communicates with health care providers to clarify questions and request any missing information.
- Updates credentialing software systems with required information.
- Re credentialing/Termination.
- Requests credentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.
- Collaborates with internal and external contacts to ensure timely processing or termination of re-credentialing applicants.
- Completes data corrections in the credentialing database necessary for processing of re credentialing applications.
- Reviews claims payment systems to determine provider status, as necessary.
- Ongoing Monitoring/Watch Follow-up.
- Completes follow-up for provider files on 'watch status, as necessary, following department guidelines and production goals.
- Reviews and processes assigned federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.
- Reviews and processes monthly Medicare Opt-Out reports to determine if any provider has opted out of Medicare.
- Reviews and processes assigned NPDB Continuous Query reports and takes appropriate action when new reports are found. Verifying potential and existing Provider’s licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider’s hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information. Verification of W-9 for any TIN and/or Name change for provider to ensure correct and timely reimbursements.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed against providers.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for the credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
- Coordinated assigned aspects of enterprise-wide credentialing and primary source verification process for practitioners and health delivery organizations.
- According to Molina policy and procedure. Where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability.
- Maintained a high level of confidentiality for provider information.
- Processing Credentialing Applications.
Credentialing Specialist II
Saviance Technologies (Molina Healthcare)
12.2020 - 09.2021
- Verifying potential and existing Provider's licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider's hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
- Streamlined credentialing processes to enhance efficiency and reduce turnaround times.
- Collaborated with cross-functional teams to resolve credentialing issues effectively.
Field Compensation & Sales Reporting Processor
Adecco USA (Northwestern Mutual Life Insurance Company)
08.2019 - 12.2020
- Verifying potential and existing Provider's licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider's hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
Credentialing /Vendor Onboarding Team Lead/Customer Service Representative
Milwaukee Center for Independence (Alife)
11.2016 - 05.2019
- Verifying potential and existing Provider's licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider's hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
- Manage all aspects of all daily authorization letter processing for service providers.
- Creative and innovative thinking to help build efficacy.
- Have full understanding of state statute 1915(c) Home and Community Based Service Waiver and all FEA and DHS requirements to ensure compliance.
- Have full understanding of state statute 1915(c) Home and Community Based Service Waiver and all CMS requirements to ensure compliance.
- Provide backup assistance to other departments and promote being a team player.
- Provide courteous and professional service in any inquiries with coworkers, managers, vendors, participants, ICA, and DHS.
- Provide excellent customer service to all in Responsible for all aspects of credentialing and re-credentialing, certification and licensing for Adult Family Homes (AFH), vendor providers, to include but not limited to verification of application/documents, mailing of requests for consideration, initial applications, approval, denial, termination letters, and accurately loading provider information in FMS and WISITS systems.
- Practice and promote safety in the workplace.
- QA and Auditing of provider files to internal and external customers.
- Effectively manage escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow through to closure.
- Managed escalated provider claims and assisted claims team and management in resolving vendor payment issues.
- Work with vendors to resolve and restore suspended services due to no authorization or non-payment of claim.
- Take the initiative and provide feedback for process improvements.
- Research/Lookup missing Federal Employment Identification Number (FEIN).
- Verify National Provider Identifier (NPI).
- Maintaining W-9 updates and conducting year end 1099 processes.
- Scanning documents into SharePoint site.
- Worked with the Payer Contracting team and Claims Department to ensure timely reimbursements.
- Provided customer service support/back up as needed.
Provider Enrollment and Credentialing Specialist
Dataquest LLC
09.2014 - 11.2016
- Verifying potential and existing Provider's licensure, liability insurance, CDS and DEA certificate.
- Verifying and updating provider's hospital privileges, Board certification and other criteria as required.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed.
- Meeting required turnaround times and accuracy rate.
- Reviewing and submitting files for credentialing committee as necessary.
- Assisting with other duties and special projects as assigned.
- Processing provider and approval letters after reappointment has been completed.
- Maintaining credentialing information by reviewing, entering, and following up on missing information.
- Reviewing National Practitioners Data Bank for adverse charges pending or filed against the provider.
- Tracking contract applications status.
- Assuring all files have a Welcome, Denial or Term Letter as appropriate.
- Meeting required turnaround times and accuracy rate.
- Maintaining fee schedules by creating, reviewing, and auditing provider fees.
- Keeping up to date provider enrollment process and records and track provider participation level.
- Facilitating provider related research based on suspended claims, PO returns and other feedback opportunities.
- Participating in the credentialing committee as necessary.
- Managing relationships and activity with Third Party Vendors to ensure timely completion of credentials verification and insurance enrollment.
- Developed, tracked and submitted signed Collaborative/Protocol Agreements.
- Maintaining working knowledge of various state requirements for provider practice; obtain and process appropriate paperwork as needed.
- Gather, review and track credentials verification paperwork; identify and appropriately escalate relevant issues related to malpractice history, Sanctions Exclusions, or otherwise.
- Independently completing submitting and tracking licensing and state-specific credentialing forms and correspondence to facilitate the timely licensure and credentialing of providers.
- Regularly reporting status and results of enrollment/reactivation activity both internally and externally.
- Facilitating completion of forms to enroll Quad Med providers in Medicare, Medicaid and other insurances as needed.
- Coordinating and leading Quad Med Credentialing Committee.
- Assisting in the development of provider employee and independent contractor agreements, as well as professional services agreements.
- Other duties as assigned.
Education
Diploma - Medical Billing and Coding
Sandford Brown College
West Allis WI08.2012
Skills
- Data entry and quality auditing
- Provider credentialing
- Medicare(PECOS) and Medicaid enrollment
- SAP and Oracle software
- Microsoft Office Suite
- Medical billing and coding
- Employee management
- Electronic medical records systems
- Help desk support
- Employee onboarding processes
- Quality assurance practices
- Process improvement strategies
- Data analysis techniques
- Customer service/Call center excellence
- Attention to detail
- Regulatory compliance knowledge
- Effective communication skills
- Problem-solving abilities
- Team collaboration skills
- Time management expertise
- Editing and review capabilities
- CRM software proficiency
- Organizational skills mastery
- Deadline achievement strategies
- Decision-making proficiency
- EDI file transfer management
- Claims resolution expertise
- Provider revalidation processes
- Sales Force
- CAQH Database
Timeline
Quality Management Reviewer/Customer Service Representative
Anthem Life & Disability Operations at The Standard Insurance Company
06.2023 - Current
Provider Enrollment Analyst/QA Analyst
FIRST Coast Service Options
10.2022 - 01.2024
Credentialing Specialist III / Data Reporting Analyst
Molina Healthcare
10.2021 - 07.2022
Credentialing Specialist II
Saviance Technologies (Molina Healthcare)
12.2020 - 09.2021
Field Compensation & Sales Reporting Processor
Adecco USA (Northwestern Mutual Life Insurance Company)
08.2019 - 12.2020
Credentialing /Vendor Onboarding Team Lead/Customer Service Representative
Milwaukee Center for Independence (Alife)
11.2016 - 05.2019
Provider Enrollment and Credentialing Specialist
Dataquest LLC
09.2014 - 11.2016
Diploma - Medical Billing and Coding
Sandford Brown College