Lorece LJ Montgomery
Lorece Jenkins Montgomery
5100 Olympia Court Suffolk, VA 23435 ------------
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Professional Summary
Medical Healthcare Insurance Professional / Credentialing Specialist
Proven record of enforcing department policies by primary source verification of physician state license, DEA license and physician certification. Skilled in healthcare administration, inventory management, managing multiple projects, following compliance according to NCQA standards and credentialing database management. Managed the credentialing and re-credentialing for multiple states and contiguous counties. Excellent in attention to detail, flexibility, time management, problem solving and strong communication skills
Work History ______________________________________________________________________
April 2017 � February 2019 Arkansas BlueCross BlueShield Little Rock, AR
Provider Network Specialist
� Efficiently administrate Provider Network Operations enrollment, credentialing, re-credentialing and contracting activities. In-depth investigation and analysis as well as internal and external communication regarding these areas.
� Responsible for maintaining operational knowledge of divisions and subsidiary operations and how they relate to overall enterprise objectives.
� Responsible for assignment of provider numbers, credentialing providers, and determining whether admission to networks is appropriate and handling provider billing inquiries.
� Progressive research and follow up of all provider applications and provider inquiries.
� Initiate and maintain good relations with providers and their staff, PHOs, hospitals, joint venture partners, and other areas.
� Effectively utilize knowledge of provider academic training programs, specialty and sub-specialty qualifications, board certification processes, medical mal-practice insurance, primary source verification processes, licensing boards, accreditation organizations, National Practitioner Data Bank and AR State Medical Board Centralized Credentials Verification Service.
� Obtain/maintain accurate and up-to-date records on the credentials, qualifications, demographics and reimbursement of thousands of providers in ProvWeb, Health Advantage Amisys, Blue Advantage Amisys, and mainframe systems for Arkansas and multiple states.
September 2009 � April 2017 Arkansas BlueCross BlueShield Little Rock, AR
Claims Specialist/Utilization Review Researcher
� Responsible for accurate and timely adjudication of medical claims which may include additional investigation or communication in order to obtain necessary information to complete the claim.
� Researched and reviewed procedure codes and diagnoses codes using URGL guidelines to determine if codes are approved, denied or if medical records are needed for review in order to finalize claims.
� Investigated and interpreted contract benefits, edit/audit resolutions for accurate adjudication.
� Interpreted developmental steps for processing and payment of ITS claims.
� Reviewed medical records and routed claims that require further review to Adjustment area, nurses, or other areas as needed.
� Referred to ICD9, CPT4, HCPS Procedure Codebook, and medical terminology handbook for further processing of claims.
� Identified processing problems and made recommendations for improvements.
� Consistently maintained quarterly QA standards above 97% during tenure and recognized as top performance achiever within the BANA department.
January 2006 � September 2009 BlueCross BlueShield of South Carolina Columbia, SC
Quality Review Analyst
� As team leader of five, voluntarily completed special projects, queried reports and delegated tasks among team members, resolved difficult assignments, assisted in interviewing process and trained new employees, etc.
� Assured communication of provider profiling and performance information with other BCBSSC provider service areas.
� Coordinated and facilitated credentialing activities with Quality Management and regional entities who participated in the auditing and credentialing process.
� Performed delegated provider credentialing audits/site visits at hospitals throughout the state and published the report of the findings after determining audit scores.
� Draft audit reports and audit findings with recommendations for improvement.
� Coordinated provider credentialing process which included documentation and management of credentialing information.
� Performed day-to-day contact with professional certifying agencies, State Licensing Boards, insurance companies, office managers, physicians, medical schools, ProvWeb and the National Practitioner Databank/Health Integrity.
� Entered, updated data, and ran queries using the credentialing database.
� Made oral presentations, created reports and written documentation that provided findings of primary source verification, medical record reviews and sanctions for quality improvement of participating providers to the Medical Director and credentialing committee.
Education_____________________________________________________________________
Lane College Jackson, TN
Bachelor of Arts in Interdisciplinary Studies (Elementary Education)
� Magna Cum Laude; GPA 3.8; Maintained Dean�s list all semesters of training
� Named in Who�s Who Among Students in American Universities & Colleges
Lorece Jenkins Montgomery
5100 Olympia Court Suffolk, VA 23435 ------------
------------
Professional Summary
Medical Healthcare Insurance Professional / Credentialing Specialist
Proven record of enforcing department policies by primary source verification of physician state license, DEA license and physician certification. Skilled in healthcare administration, inventory management, managing multiple projects, following compliance according to NCQA standards and credentialing database management. Managed the credentialing and re-credentialing for multiple states and contiguous counties. Excellent in attention to detail, flexibility, time management, problem solving and strong communication skills
Work History ______________________________________________________________________
April 2017 � February 2019 Arkansas BlueCross BlueShield Little Rock, AR
Provider Network Specialist
� Efficiently administrate Provider Network Operations enrollment, credentialing, re-credentialing and contracting activities. In-depth investigation and analysis as well as internal and external communication regarding these areas.
� Responsible for maintaining operational knowledge of divisions and subsidiary operations and how they relate to overall enterprise objectives.
� Responsible for assignment of provider numbers, credentialing providers, and determining whether admission to networks is appropriate and handling provider billing inquiries.
� Progressive research and follow up of all provider applications and provider inquiries.
� Initiate and maintain good relations with providers and their staff, PHOs, hospitals, joint venture partners, and other areas.
� Effectively utilize knowledge of provider academic training programs, specialty and sub-specialty qualifications, board certification processes, medical mal-practice insurance, primary source verification processes, licensing boards, accreditation organizations, National Practitioner Data Bank and AR State Medical Board Centralized Credentials Verification Service.
� Obtain/maintain accurate and up-to-date records on the credentials, qualifications, demographics and reimbursement of thousands of providers in ProvWeb, Health Advantage Amisys, Blue Advantage Amisys, and mainframe systems for Arkansas and multiple states.
September 2009 � April 2017 Arkansas BlueCross BlueShield Little Rock, AR
Claims Specialist/Utilization Review Researcher
� Responsible for accurate and timely adjudication of medical claims which may include additional investigation or communication in order to obtain necessary information to complete the claim.
� Researched and reviewed procedure codes and diagnoses codes using URGL guidelines to determine if codes are approved, denied or if medical records are needed for review in order to finalize claims.
� Investigated and interpreted contract benefits, edit/audit resolutions for accurate adjudication.
� Interpreted developmental steps for processing and payment of ITS claims.
� Reviewed medical records and routed claims that require further review to Adjustment area, nurses, or other areas as needed.
� Referred to ICD9, CPT4, HCPS Procedure Codebook, and medical terminology handbook for further processing of claims.
� Identified processing problems and made recommendations for improvements.
� Consistently maintained quarterly QA standards above 97% during tenure and recognized as top performance achiever within the BANA department.
January 2006 � September 2009 BlueCross BlueShield of South Carolina Columbia, SC
Quality Review Analyst
� As team leader of five, voluntarily completed special projects, queried reports and delegated tasks among team members, resolved difficult assignments, assisted in interviewing process and trained new employees, etc.
� Assured communication of provider profiling and performance information with other BCBSSC provider service areas.
� Coordinated and facilitated credentialing activities with Quality Management and regional entities who participated in the auditing and credentialing process.
� Performed delegated provider credentialing audits/site visits at hospitals throughout the state and published the report of the findings after determining audit scores.
� Draft audit reports and audit findings with recommendations for improvement.
� Coordinated provider credentialing process which included documentation and management of credentialing information.
� Performed day-to-day contact with professional certifying agencies, State Licensing Boards, insurance companies, office managers, physicians, medical schools, ProvWeb and the National Practitioner Databank/Health Integrity.
� Entered, updated data, and ran queries using the credentialing database.
� Made oral presentations, created reports and written documentation that provided findings of primary source verification, medical record reviews and sanctions for quality improvement of participating providers to the Medical Director and credentialing committee.
Education_____________________________________________________________________
Lane College Jackson, TN
Bachelor of Arts in Interdisciplinary Studies (Elementary Education)
� Magna Cum Laude; GPA 3.8; Maintained Dean�s list all semesters of training
� Named in Who�s Who Among Students in American Universities & Colleges