ABIGAIL RIVERA C: 305.438.8652 | ms.abigailrivera@hotmail.com

Summary

Results-orientated Director of Credentialing with superb leadership and communication

skills. Easily cultivates trusting and productive relationships with physicians, executive

management and departmental staff. Dedicated and proactive with strong commitment to

creating high-quality standards.

Highlights

Team supervision Training Technologically proficient Continuous professional improvement

Hiring and recruitment Regulatory compliance Contract administration

Experience

Director of Credentialing

June 2014 to Current

Eden Health Plans – Miami, Florida

Oversee the day-to-day operations of the credentialing of providers for corporate and market managed health plans.

Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to plan specifications for multiple business units.

Oversee the provider setup processes ensuring accurately and timely setup for claims payment, member assignment and directory display.

Ensure compliance with CMS, AHCA and AAAHC credentialing requirements and participate in activities related to plan AAAHC accreditation.

Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives.

Identify process improvement opportunities to decrease cost, improve quality and increase efficiency within the department.

Oversee the development and review of policies and procedures, work processes, standard operating procedures and other tools ensuring standardization across the enterprise and compliance with AAAHC, AHCA and CMS standards and how to apply them.

Monitor Medicaid and Medicare sanctioning reports threw Office of Inspector General LEIE and SAM to ensure compliance with Health Care Financing Administration (HCFA) requirements regarding prohibition of excluded provider participation.

Facilitate Credentialing Committee activities and serve on Quality Improvement Committees when needed.

Assist system integration by providing input, testing and process improvement recommendations for changes and new design within core application system.

Assist non-corporate managed markets with credentialing issues such as inventory backlog during product or product expansions and improvement challenges.

Manager of Credentialing

March 2013 to May 2014

MCNA Dental Plans – Fort Lauderdale, Florida

Ensure compliance with AHCA, DHHS, CHIP, URAC and NCQA credentialing requirements and participate in activities related to plan URAC and NCQA accreditation .

Analyze situations accurately and adopt effective course of action. Make appropriate recommendations based on logical and justifiable reasoning.

Perform Primary and Secondary Source Verifications of Dental Practitioners via: Dental Board Certified websites, NPBD, DEA, OIG, DOH, PRN, TBDE, SAM, Medicare Opt Out, Provider Hospital privileges and Site Inspections.

Act as a resource to provide information and clarification to the Network Development, Provider Relations and Credentialing Department as well as the Practitioner applicants, and other interested parties concerning Credentialing processes, laws and regulations for Florida, Texas, Kentucky and Louisiana.

Manager of Credentialing

Nov 2010 to May 2013

Prestige Health Choice – Doral, Florida

Ensure compliance with AHCA and AAAHC, credentialing requirements and participate in activities related to plan AAAHC accreditation

Perform delegated credentialing oversight audits to ensure compliance with current accreditation standards of both State and Federal regulations. Efficiently track, report and communicate all audit information to delegates and required internal departments.

Perform Primary and Secondary Source Verifications of Practitioners and Ancillary/Facility providers via: AMA, AOIA, DO, DPM, NPBD, DEA, OIG, DOH, PRN, TBDE, SAM, National Sex Offender Search, Medicare Opt Out, Provider Hospital privileges and Site Inspections for Independent Diagnostic Testing Facilities (IDTF’s), Primary Care Physician Offices and Rehabilitation Therapy Services Facilities.

Assist the Quality Management, Compliance, Provider Relations and Configuration department on special projects and system programming to promote department efficiency. Maintain and review accurate records, files, Policies and Procedures.

Audit computer-generated certification and assignment reports to determine eligibility for Professional and Allied providers who do not hold valid credentials.

Act as a resource to provide information and clarification to the Network Development, Provider Relations and Credentialing Department as well as the Practitioner applicants, and other interested parties concerning Credentialing processes, laws and regulations for Florida.

Manager of Credentialing

June 2005 to Nov 2010

Freedom Health & Optimum Healthcare (Global TPA, LLC) – Tampa, Florida

Ensure compliance with CMS, AHCA and NCQA credentialing requirements and participate in activities related to plan NCQA accreditation

Prepare and attended all Credentialing Committee Meetings, insuring the proper levels for professionals, submitting the meeting minuets as well as presenting the providers with issues to the Committee for approval or further investigation and documentation.

Manage and direct Credential Specialists and Credential Support Clerks, and other staff as necessary. Attend to administrative and clerical details utilizing initiative, problem analysis techniques, good judgment and confidentiality. Ability to access and maintain Payroll information and communicate effectively.

Process letters of intent to return/improve and reasonable assurance certificated staff. Type correspondence and notices with minimum direction; prepare materials and reports as needed.

Maintain and update credentialing records while maintaining strict confidentiality of credential files and all job-related matters.

Perform Primary and Secondary Source Verifications of Practitioners and Ancillary/Facility providers via: AMA, AOIA, DO, DPM, NPBD, DEA, OIG, DOH, PRN, TBDE, SAM, National Sex Offender Search, Medicare Opt Out, Provider Hospital privileges and Site Inspections for Independent Diagnostic Testing Facilities (IDTF’s), Primary Care Physician Offices and Rehabilitation Therapy Services Facilities.

Advise Practitioner applicants on proper procedures of completing credential applications. Evaluate transcripts and credentials. Receive and process new and renewal credential applications for a variety of credentials, certificates, permits, and waivers.

Act as a resource to provide information and clarification to the Network Development, Provider Relations and Credentialing Department as well as the Practitioner applicants, and other interested parties concerning Credentialing processes, laws, and regulations for Florida, New York, Georgia, North and South Carolina.

Great at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools. Carry out complex oral and written directions; make decisions independently; communicate effectively. Meet clearly stated expectations and take responsibility for achieving results.

Problem solver with ability to encourage others in collaborative problem solving. Provide technical assistance regarding credentialing problems. Operate and troubleshoot a variety of office equipment including computers, printers, faxes, scanners and copiers.

Establish and maintain cooperative working relationships; and to prepare correspondence with minimum direction. Review department policies and provide recommendations regarding redesign to meet current compliance requirements.

Skills

Proficiency with computer systems, networks and software applications such as Microsoft Office (Outlook, Word, Excel & Power Point)

IKA, Internet Research, CAQH

Fluent in Spanish and English, written and spoken, flexible and receptive.

High-level computer skills. Understand, interpret, and apply.

Education

Criminal Justice Nov 2003 – Sept 2005 Keiser College – Miami, Florida

High School Diploma 1991 Bridgewater-Raritan High School East – Bridgewater, New Jersey

References

References available upon request