EBONY BIAGAS
Woodland Hills
Summary
Health care maintenance operations specialist with expertise in resolving complex issues and ensuring compliance. Demonstrated ability to manage credentialing processes and implement improvements that enhance operational efficiency. Skilled in fostering relationships with providers and stakeholders to achieve successful outcomes. Proficient in risk management, policy development, and audit procedures, with a strong focus on critical thinking and problem-solving.
Overview
12
12
years of professional experience
Work History
Credentialing Coordinator
MedPOINT Management
03.2018 - Current
- Verifying the credentials of healthcare providers, including licenses, certifications, and education.
- Maintaining accurate and up-to-date files and databases of provider credentials.
- Ensuring compliance with relevant regulations and accreditation standards.
- Managing the credentialing process for new providers, including initial credentialing, and re-credentialing.
- Investigating and resolving any discrepancies or errors in credentialing information.
- Communicating effectively with healthcare providers and other stakeholders.
- Preparing and submitting reports on credentialing activities.
- Maintaining and updating credentialing databases and software systems.
- Monitoring expiring credentials and assisting with timely renewals.
Credentialing Coordinator
Blue Shield of California/Care1st
03.2017 - 03.2018
- Responsible for initial and re-credentialing of various PPO, Medicare, Medi-Cal, and Medicaid providers.
- Perform and report primary source verifications of provider credentials and maintain all medical licensing.
- Prepare and coordinate provider information to/from managed care quality committees.
- Schedule meetings and maintain credentialing database while tracking all direct provider contract data.
- Ongoing monitoring, tracking, and maintenance of provider and delegated group sanctions reporting's.
- Systems analyst and resource specialist for internal departments such as HEDIS and HCQA for daily issues related to provider credentialing activities.
Appeals & Grievance Coordinator
Blue Shield of California
04.2015 - 03.2017
- Process and handling of Medicare/CMS member and provider appeals and grievance requests regarding quality of care, claims, authorization denials and more.
- Navigate multiple platforms or applications to properly analyze, research, identify, or add pertinent and supporting information to each case.
- Facilitate with internal/external departments, such as customer care, medical groups, provider services, and claims, to obtain necessary case information, prior authorizations and more.
- Implemented process improvements and trained staff on workflows, procedures, job aids and more.
- Assigned case files to staff in addition to creating and managing distribution of files and production tracking logs.
- Analyze data and audited case files to each investigation and ensure remediation activities were implemented.
Member Services Coordinator
Blue Shield of California
07.2013 - 04.2015
- Assisted with Medicare/CMS member and provider calls and written requests regarding benefits, eligibility, enrollment, quality of care, claims and more.
- Analyze and resolve complex issues while meeting/exceeding performance metrics and goals in quality, auditing, and production.
- Perform inventory reduction (i.e. member/provider inquiries, adjust claims etc.).
- Facilitate authorizations, appointments, outreach to physicians and medical groups appropriately as needed.
- Developed and modified departmental policies and procedures to augment knowledge of Medicare medical and pharmacy products and benefits.
- Training and development for newly hired temporary and full-time employees on process, procedures and systems.
Education
Bachelor of Science - Psychology
Grand Canyon University - Online
06-2028
High School Diploma -
J.E. Young Academic Center
Fresno, CASkills
- Highly Motivated
- Team Leadership
- Analytical
- Time Management
- Issue Resolution
- Detail Oriented
- Interpersonal
- Resourceful
Timeline
Credentialing Coordinator
MedPOINT Management
03.2018 - Current
Credentialing Coordinator
Blue Shield of California/Care1st
03.2017 - 03.2018
Appeals & Grievance Coordinator
Blue Shield of California
04.2015 - 03.2017
Member Services Coordinator
Blue Shield of California
07.2013 - 04.2015
Bachelor of Science - Psychology
Grand Canyon University - Online
High School Diploma -
J.E. Young Academic Center
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