Michele D. Chatham

Jamaica, NY ****

347-***-****

ad4lxj@r.postjobfree.com

SKILLS

● Microsoft, Word, Excel, Outlook, Access, PowerPoint

● Web evaluation software Webespirit

● Visual Cactus, Intellicred, Pegasys

● Telecommunication Systems

● ERAS

● Eagle, Nextgen, People soft and Stix, IDX, eCw

WORK HISTORY

Essen Medical Associates, LLC. April 2022 – August 2023

Credentialing Manager, Delegation- Remote

Oversee the day-to-day operations of the credentialing department (direct and delegation).

Submitted each monthly roster by its predetermined date, with accurate and complete data.

Coordinated with Network Representatives through monthly scheduled meetings to ensure timely receipt of monthly participation.

Analyzed returned rosters for discrepancies and gaps in participation.

Reviewed all open projects and provided estimated timelines for completion.

Prepared meeting minutes, Appointment letters and DOP letters. Provided updates to the roster submission guidelines based on Payor.

Implemented the covering location submission guideline for payors. Reviewed the delegation team’s file for accuracy and completeness.

Assisted the Credentialing Supervisor with preparing for quarterly audits delegation audits. Assisted with the preparation of files for the monthly Credentialing Committee Meetings.

Collaborate with the billing team to ensure claims are paid timely.

Notified the Compliance Director of all quality complaints and issues with providers. Maintained the roster secure data base.

Responsible for the submission of all delegation rosters to payors on a monthly timely basis.

Project Renewal, Inc.

Credentialing Manager - Hybrid July 2019 – July 2022

Works closely with each provider to complete third party billing/MCO Credentialing.

Maintains and updates the Credentialing Tracking Summary to ensure that enrollment is maintained in an efficient and effective manner.

Meets with new Licensed Practitioner to initiate and maintain active credentialing.

Meets with Billing Manager weekly to ensure continuous workflow for submitting claims and minimizing payment denials.

Collects all supporting documents from Credentialing prior to on-boarding.

Conducts monthly conference calls (Meetings) to identify any credentialing or billing issues and remedies a solution.

Monitors all expiration dates for supporting documents, informing practitioners of expiration date(s).

Bedford Stuyvesant Family Health Center, Brooklyn NY

Credentialing Supervisor - Hybrid Jan. 2017 – Sept. 2019

Responsible for all aspects of the credentialing, re-credentialing, and privileging processes for all medical providers who provide patient care at Bedford Stuyvesant Family Health Center (BSFHC).

Ensures that all providers are appointed and in network, with all major health plans, commercial and government based.

Routinely maintain and provides up to date data for each provider in credentialing.

Participate in all revenue strategy meetings to monitor any and all issues that may arise due to credentialing.

Maimonides Medical Center Brooklyn, NY

Credentialing Specialist (Temporary) March 2016 - May 2016

Maintained department compliance with all regulatory and accrediting bodies.

Participated in the development and implementation of credentialing processes and procedures.

Initial credentialing of physicians and allied health professionals.

Maintained an accurate practitioner database.

Performed primary source verifications for initial and re-appointments.

Prepared files for Credentialing Committee Readiness.

Centers Plan for Healthy Living Staten Island, NY

Credentialing Manager October 2014 - December 2015

Responsible for the day-to-day functions of the Credentialing Department’s operational processes as well as managed the activities of the Delegated and Non-Delegated Providers, Vendors in accordance with the established Credentialing policies and procedures

Actively participated in Internal and External Audit as required by New York State, Federal and Regulatory Agencies such as NCQA.

Managed the development of the Internal Database for Ongoing Sanction Monitoring and reporting. Managed and improved Prepared all statistical report for Director, Network Development.

Prepared monthly and quarterly sanction reports for Chief of Compliance.

Responsible for designing the process for the Credentialing Sub Committee. Implemented the New Credentialing Software system (Intelli Cred).

Responsible for collecting, Preparing and analyzing data for Credentialing in connection with Quality Improvement Regulations and Annual HEDIS Roadmap audits.

Collected and Prepared annual measures of Board-Certified physicians on systems used by the Credentialing Department.

Reported which data elements are captured by the Credentialing system or in comparison to delegated vendors which are responsible for 5% or more of our data.

Responsibilities included analyzing the sum of PCP that were on boarded, and credentialed annually for HEDIS reporting.

Reported Quality of Practitioner Credentialing by analyzing the number of credentialing audits conducted in a year for delegation.

Reported on the process of integrating credentialing data from vendors and how often it was performed.

Reported on the accuracy of credentialing data, received from vendors or external entities annually for HEDIS.

Brookdale Hospital

Payer Relations Manager (Temporary) October 2013-August 2014

Ensured all providers are in Network with current insurance companies, managed data for all providers in the system ensuring its accuracy updating demographics when needed.

Responsible for completed credentialing while maintaining copies of current states licenses, DEA certificates, and malpractice.

Conducted all primary source verifications for physicians at on boarding and of re-credentialing.

Conducted monthly and quarterly sanctions for compliance there by alerting Senior Management of any undisclosed negative findings.

Maintained knowledge of all health plan and regulatory agencies for credentialing purposes.

Ran monthly expired reports to ensure timely license renewals. Maintained CAQH log and updated CAQH profiles for providers.

Participated in monthly conference calls with payor’s, to give assurance of an efficient and effective credentialing process. Processed Medicare and Medicaid applications and re-validations. Managed all credentialing functions for delegation (prepared and maintained roster.

All enrollments provided through the downloading of application via the cactus database. Updated all data relating to the network participation of providers with various Networks (i.e. Blue Cross Blue Shield, Cigna, Aetna Healthfirst, Affinity GHI, Health plus, Metro Plus) all provider ID’s license issued and expiration dates, and any modifications in the provider demographics.

Performed customized queries for administration to identify any provider with enrollment and network participation pending OIG checks were submitted via cactus and retrieved into an excel spreadsheet then transferred via electronic mail to the Chief of compliance, identifying any matches.

Columbia Doctors New York, NY

Enrollment Manager September 2012-March 2013

Managed the functions of the Enrollment Staff and Senior Enrollment Staff in the collection, review, processing and compilation of credentialing documents and other functions as related to credentialing status of the physician network

Monitored the performance of Enrollment staff in volume, timeliness and accurate processing of enrollment requests, provider updates and terminations

Identified enrollment issues and escalated them to the appropriate parties as needed.

Followed up continuously until issue were resolved. Documented steps taken using appropriate tools available and communicated successful resolution of problems

Responded to inquiries from physicians, department administrators, managed care contacts and staff regarding managed care enrollment / credentialing

Established and maintains regular conference calls with managed care contacts and department credentialing staff to discuss open issues and methods for process improvement.

Demonstrated leadership by establishing and maintaining positive relationships with key representatives at contracted payors, University departments, large physician practices, and centers to facilitate resolution of problems for the practices and to anticipate and resolve issues related to new plan policies, procedures and enrollment.

Maintained superior knowledge of NCQA and JCAHO standard; as well as an understanding of alternative credentialing processes, such as CAQH and Delegated Credentialing.

Updated Credentialing Policy and Procedures to reflect new processes in place.

EDUCATION:

ST. FRANCIS COLLEGE BROOKLYN, NY

AOS, Accounting

BERKELEY COLLEGE, NEW YORK, NY

BBA, Business Administration Management

MBA, Operation Management Candidate

NAMSS: CPCS Candidate

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