Precious' Bouie Resume

Precious' Bouie Resume

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  Precious Bouie –Hughes 1781 N.W. 166th Street, Opa Locka, Fl 33054 (954) 639-3144 [email protected] Proven – Dependable and Adaptable Quality management & Credentialing Coordinator with a passion for problem solving,leadership,conflictmanagement and team building. Quality management & CredentialingCoordinator with over 20 years of experience seeking an organization where I may display my extensive background and skills in healthcare. WORK EXPERIENCE HS1/ HN1 Medical Management Jan 2005 – Dec 2014 Credentialing Coordinator / Quality Management Coordinator  Assisted in updatingrecords based on its application status or credentialingdocuments .  Responsiblefor monitoringand verifyingexpired credentialingdocuments and doing a follow-up procedure with the network providers.  Made recommendations to the Credentialing Directors on non-complianceconcerns.  Performed under minimal supervision with accountability for specific goals/objectives.Works with the credentialingmanager to develop performance improvement targets for quality,service,and efficiency.  Responsiblefor submittingand updating credentialingdocuments as regulatingto regulatory agency requirements.  Data entry on GDS software i.e. credentialingapplications,reports,company policy procedures .  Investigated and completed Quality Inquiry Referrals (QIR’s).  Coordinated and prepared files for the credentialingcommittee, Quality Utilization Committee, and Care Access Health Plan Executive meetings.  Adheres to HIPAA laws and procedures, department policies and client/patientconfidentiality.  My notable efforts and dedication resulted in two (2) promotions duringmy employment.  Developed trackingand trending processes for quality improvement.  Supported on-siteaudits. Provider Relations Representative /HN1  Perform initial contract recruitment for Networkfor Multiple Companies , Primary Care Physician, Hospital, Diagnostic Center.  Prepared and presented completed computer generated reports for contracting outcomes on monthly Networkgaps/ required specialties. Meeting with Senior Management/ Executive Representatives for projects goal, task or developments.  Responsible to visiting all contracted PCP and Specialist site, maintaining good relations and conducting site audits , delivery financial updates and meeting with management to review any delay of services.  Continual education on regulatory updates as well as internal news or business changes to all primary care physicians and specialty provider and identifying any member provider issues. Problem resolution.  Retrieving any and all credentialing required documents to ensure provider enrollment into network In timely matter  Obtaining contractual Approval for Network participation if contract was requiring additional negotiations of additional services or finances .  Evaluating and resolving any and all critical issues related to assign area of responsibility.
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   Effectively andtimely response to all emails from management, internal and external Providers.  Maintain current provider file to reflect everyvisit and compliance or complaint issues if any.  Coordinate with all internal departments any grievance / complaints or outstanding credentialing concerns  Worked closed with Medical Director in regards to contracting or credentialing concerns. Orwith issues that may or may not have an adverse outcome to any project.  Internal tracking and monitoring module that housed all incoming and outgoing utilization delays for issuing authorization due to provider network gaps.  Work with Executive administration with Special Projects or Development of Network out of state to ensure success full business outcomes  Full compliment Networkthat met all required covered areas . To assure the forgoing and implementation of new POS  The new business at hand.  Always available to assist the team and any department to make sure the success of all projects. Miami-Dade State Attorney May 2000 to March 2002 CaseAnalystII  Conducted legal research and gathered relevant information for preparation for the paternity case.  Prepared written reports that the attorney used to determine how the caseshould behandled.  I was responsiblefor trackingpaternity casedefendants by investigatingtheir whereabouts through community involvement and confidential personal record databasesystems and servingthem court order documents.  I developed a reputation of consistently collectinglarge lump-sums of child-supportpayments. United States Postal Service May 1999 to Feb. 2000 Mail Carrier  Sorted incomingand outgoing mail accordingto type and destination.  Checked mail to ensure correct postage and that packages and letters are in proper condition for mailing.  I was often asked to assistother mail carrierswith their routes once I completed my own.
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  Precious Bouie –Hughes 1781 N.W. 166th Street, Opa Locka, Fl 33054 (954) 639-3144 [email protected] Care Florida / Foundation Health Oct 1994 to Sept. 1998 CredentialingManager / Quality AssuranceManager  Reported directly to CEO/ Medical Director/ Quality AssuranceVP.  Monitored and track responses from primary sources and followthrough with plan of action.  Perform and established accounts for NPD/  Interviewed and trained all credentialing staff  Developed data based module to house credentialing,reportingand trackingof provider information.  Prepared reports for providers’plan participation approval meetings.  Implemented the credentialingdepartment , develop policy and procedure to meet NCQA  Prepared the department for meeting  Developed corrective action plans and work requirements for staff.  Implementing on-going studies to meet healthcareplan’s objectiverequired standards.  Implemented a new credentialingprocess to includere-credentialing.  Developed all of the company’s re-credentialingprograms and implemented a databaseto hold and track providers’information.  Managed daily department operations and staff with diligenceand efficiency.  Maintained reportingand query accounts.  I created a standard operation procedure for my department that help organized the re-credentialing process. Foundation Health –  Quality Assurance Specialist  Ensured Compliance with the Foundation Health appeals and grievance unity.  Review all appeals and grievance for timely filing and response . Timelines for follow up and reports and closure  Meet with Senior Management and maintained data bank for tracking and outcomes, closure.  Created reportsand develop system that reported the out of timelines and compliance regarding the process.  Work closely with Utilization Director and Medical Director to assure all compliance and regulation standards and  Bench marks were maintained and completed.  Review and worked with Customer Service Management team to developed processes to stream line events and reoccurrence’s of complaint to identify errorsor potential patterns of causes to high grievances and complaints
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  Humana Health CarePlans / IMC Jan. 1986 to Oct. 1994 IMC Hollywood Medical Center Night Shift / Receptionist – Intakeapt visits/ setappoints Promotion to : Referral Coordinator- processing/ completing physiciansreferral for members to see specialistor hospital admissions. Work closely with Medial Director for Stat referrals or directHospitals admission request. Promotion to: Corporate Humana SNF Coordinator: Provided support to plans for placement of members in nursing home facility screened members for eligibility of placement in contracted Tri-county nursinghomes. Responsible for obtaining a bed and non contracted facility if one was not available with in our network. Responsible for maintaining a concurrent log show membersskilled days available and non skilled days available Responsible to making sure member did not exceed the benefit approval time give for appropriate placement and stay. Credentialing Coordinator  AssistCredentialingManager with completing and preparingagenda and minutes filefor Credentialing Committee Meeting.  Prepared the providers’files for presentation to the credentialingcommittee for approval.  Maintained information relatingto processingcredential requirements in order for providers to keep an activestatus.  Remained updated on current credentialingstandards and guidelines as well as company policy and procedures.  I screened members for eligibility of placement in contracted Tri-county nursinghomes.  I developed and maintained well-established relationships with contracted nursinghome facilities and network with potential providers.
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  Precious Bouie –Hughes 1781 N.W. 166th Street, Opa Locka, Fl 33054 (954) 639-3144 [email protected] EDUCATION Medical Transcribing, Southern Tech Vocational September 1987 Barry University earned 36 credits enrolled in Bachelor’s Program Liberal Studies B.A. Degree, The Gate of Bethel College June 2015 Light University , Certificateof Completion Couples Recovery 2.0 Light University,Certificateof Completions Christian Counseling2. SKILLS Very Motivated, Always available to learn new functions . Willing to assist in other projects and areas. Professional with my peers and Senior Management. Mindful to always participate and present a pleasant work environment. Computer Literate, positive thinker, very good communication and listening skills. Multi – task and very self – sufficient . Team player and work well with others. Work independently and follows direction and instruction . Multi task and able to complete task on time . Current working knowledge of License, DEA, Insurance NPI, Backgrounds Check, ABMS , NPDB/ HIPDB, Aperture Profile., Unival and CAQH, Universal Application. Microsoft word - PowerPoint – Excel – Various healthcare databases and modules – types 40 wpm