EXPERIENCE
GLP THEOREM VENTURES CORPORATION
MEDICAL CREDENTIALIST/DATA ANALYST (AUDIT PROCESS LEAD)
JANUARY 2023-PRESENT
RANDY B. RIVERA
CREDENTIALINGSPECIALIST/DATA
ANALYST
PROFILE
Experienced Healthcare Analyst with
expertise in the areas of analytical and
interpersonal skills. Expert in the
business process of credentialing and
verification life cycle.
Lead a team of Auditors responsible for the Healthcare
Provider’s file accuracy prior to submission to the client.
Proficient with Federal, state & certifying agencies regulatory
and accreditation standards (e.g. JCAHO, NCQA, URAC, etc.).
Collaborate in cross-functional teams to evaluate system
performance and main trackers for system developments.
Work closely with Quality Assurance Lead to drive for higher
quality.
Coordinate and delegate operation discrepancies, and audit files
regularly.
Assist the Account/Project Manager in properly resolving client
issues and conflicts.
Work closely with other Process Leads to ensure operation
process flow and maximize efficiency.
Multitask multiple procedures and operations, and maintain
daily updates.
GLP THEOREM VENTURES CORPORATION
EMAIL:-PHONE:
-
ADDRESS:
Cabaluyan 1st Mangatarem,
Pangasinan
KEY SKILLS
Effective Trainer
Flexibility
MEDICAL CREDENTIALIST/DATA ANALYST (APP-INTAKE TEAM LEAD)
JANUARY 2008-PRESENT
Lead the “Application Intake” credentialing team, managing all
data acquisition and analysis, provider outreach, and application
review.
Assign workloads and delegate responsibilities to team
members.
Follow up with the team on assigned tasks to ensure project
deadlines are met.
Trained and mentored new analysts/encoders.
Responsible for all aspects of provider credentialing and recredentialing.
Credentialing Standards: Maintains consistency in database
entry to ensure accurate and consistent processes.
Increased efficiency by utilizing and revamping reporting
systems to successful monitor provider applications.
Researched and executed procedures for the Application Intake
team reducing duplicated work.
Collaborated with database, verifications, and audit team
members to ensure applications were correctly set up,
interpreted, and returned.
Responded by implementing process improvements to increase
the return rate of complete provider application; return rate
increased by 35%.
Became familiar with accreditation standards (e.g., JCAHO,
NCQA, URAC, etc.), as well as developing proficiency in verifying
licensure, professional liability, and Board Certification reports.
Ability to handle protected health information in a manner
consistent with the Health Insurance Portability and
Accountability (HIPAA).
Reviewed and analyzed complex provider records.
EDUCATION
COMPUTER EDUCATION
SAINT PAUL COLLEGE OF TECHNOLOGY
APRIL 2005
CERTIFICATIONS
UNDERSTANDING HIPAA COMPLIANCE COURSE – JANUARY 2021
PERSONAL INFORMATION
Date of Birth
:
March 10, 1986
Place of Birth
:
Novaliches, Quezon City
Status
:
Single
Age
:
37
Weight
:
69 kgs.
Height
:
176 cm.
