Customer Service Data Entry
Resume:
Denise Tos-Ton
626-***-**** Cell
adzmhv@r.postjobfree.com
SUMMARY
Conscientious leader with a strong background in the Healthcare Industry. Manage Licensing, DEA, Malpractice Insurance, CLIA, CAQH, Complete and submit credentialing
/recredentialing applications, verify NPI for all providers and home health agencies at all levels, federal, state and city. Expertise focuses on IPA, Manage Care, Ancillary ( Pharmacy, Home health & SNF) and Non Profit Organizations.
Knowledgeable in Federal and State guidelines, DMHC, NCQA and HealthPlans and Non-Profit Organizations..
Skills
Highly experienced with excellent judgment and professionalism. Well organized with the ability to multitask.
● Ability to communicate with individuals at various levels
● Strong attention to details
● Ability to maintain attendance
● Team Oriented
● Analytical Thinker
Software Skills
NPDB,NPI, CAQH, LICENSE BOARDS, PAVE, AVAILITY, PECOS,CACTUS, MORRISY, CRYSTAL REPORTS, EZCAP
Work Experience:
IMAS
June 2019 - March 2021
(Remote)
Process initial clinician applications from multiple states accessing caqh application. In detail all PSV verification as well as HDO's for multiple. States. Texas,Nevada, Arizona, New Mexico, California and Utah.
SERCO – City of Inglewood - 0ct 2019 to Present
Traffic Controller / Parking Enforcement
● Ensure the safety of streets and pedestrians
● Customer Service
● Ability to act in unforeseen situations
● Direct large crowds with good judgment
● Attention to surrounding areas of traffic and vehicles St. John’s Health Center (Temporary Assignment) January 2019 – April 2019 Medical Staff Coordinator:
● Responsible for Initial Credentialing – MD, OD, PA’s and NP’s
● All Primary Sources Verification as well as Liability Insurance Verification, Claims History, References, Proctoring and CME’s
● Responsible for completing initial and reappointment of applications
● Onboarding credential applications for all hospitals and SNFs
● Extensive follow-up
● Orientation
● Pre-employment Screening
Queens Care October 2018– January 2019
Credentialing/HR Coordinator:
• Responsible for Credentialing Initial LIPS
• Reappointments LIPS, OCHA
• Request License Expirations (TCH, MA, Pharmacy Interns, MFT, LCSW, RN, Psy)
• Quality Management Meeting Packets and email confirmation
• Pre-Employee Physicals and Screening
• Background Verification
• Employment Application Process
• Credentialing Meeting Setup
• Credentialing Minutes
• Delegated Provider database profile updates that was sent back to health plan
• Purge all termed files with excel spreadsheet, box and setup for storage
• PECOS Enrollment
• PAVE Enrollment
Care 1st Health Plan (Contract Position) June 2017 – September 2018 Credentialing Delegation Auditor:
• Audit contracted Medical Groups and IPA Groups
• ICE data entry scores on audit template
•Monitored Credential Expirations
• Policy and Procedures updates
• Contracts Reviews
Greater Covina Medical Group April 2005 – June 2017 Credentialing Specialist:
• Responsible for entire Credentialing Department
• Key person with effective communication to Management
• Process application to ensure accurate information in database
• 100% Health Plan Audit Score every year
• Implemented tracking log for Health Plans
• Train Provider office staff on CPPA completion
• Vendor/Provider claims,3rd party verification
• Monitor PCP enrollment and dis enrollment
• Process COB eligibility;claims
• Appointment and reappointment providers (600)
• Managed Hospital list tracking log for 805
• Credentialing meetings/minutes monthly
• Liaison for Board Meeting Minutes
• Board website monitoring according to ICE and Health Plans agreement EDUCATION
Gardena High School - Diploma
Undergraduate College Courses Completed (60 UNITS) West Los Angeles College Credentialing (CPCS) Prep Course Certificate 2016; ongoing continues education - 2020, 2021 and 2022
NAMSS Online Continuing Education Certificates
Guard Card Certification and License
2PROTECT TRAINING INSTITUTE
Cert # 237907
Cert # 236193
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