Manager Office
Resume:
FAITH C. FISCHER
Houston, TX 77082
716-***-**** (m)
**********@***.***
PROFESSIONAL SUMMARY
Senior Lead Credentialing Specialist with 28 years of progressive healthcare experience. Detail oriented with strong work ethic, skills in credentialing, re-credentialing, regulatory and compliance auditing and time management. Received several employee recognition awards for high standard work performance. FUNCTIONAL EXPERIENCE
Credentialing • Training • Program Management • Regulatory Compliance for SDOH, CMS and NCQA Audits • CACTUS, CAQH & FACETS • MS Excel, MS Word and MS Access • Content Navigator • Outlook • Excellent verbal and written communication skills, interpersonal skills, and organizational skills • work remotely EXPERTISE
Credentialing and Privileging • Regulatory Compliance • Insurance Requirements • Various Audits
• Process Improvement • Multi-tasking
PROFESSIONAL EXPERIENCE
Provider Enrollment Regulatory Specialist
Blue Cross Blue Shield of WNY: 2012-2020
● Provide support to the Provider Enrollment Manager ensuring the regulatory guidelines are compliant for the DOH, CMS and NCQA, which includes the preparation of material for onsite audits and mock audits, annual review of CMS regulatory guidelines, NCQA elements and NYSDOH.
● Preforms various audits as required by the regulatory agencies to validate the Provider Network for accuracy and member’s access to care.
Senior Credentialing Specialist
Blue Cross Blue Shield of WNY: 2001-2012
● Lead Credentialer for the Credentialing Operation Unit with front-line staff questions
● Credentialed over 1000 new providers and re-credentialed over 3,000 providers annually.
● Ensured the credentialing staff was timely in meeting all production goals.
● Achieved the daily credentialing application quota (24 apps daily)
● Proficient in reviewing applications and primary source verification for timeliness and accuracy for all practitioners’ to ensure high quality provider panels
● Review applications for malpractice and negligence cases/concerns, NYS and national adverse sanctions review
● Prepare File review for levels I, II, II based on specific level criteria.
● Flagged providers for investigations relating to physician and provider National Practitioner Database reports, OIG (Office of Inspector General) and OMIG reports and OPMC (Office of Professional Medical conduct)
● Follow and maintain regulations outlined by NYS, NCQA and CMS
● Ensured the consistency of the credentialing policy & procedures.
● Maintain provider files by performing audits, research and generation of monthly reports
● Prepare schedules, agendas, and meeting minutes for committee review
● Provided the successful implementation of a tracking system for issues associated with activities necessary to maintain and document ongoing compliance with Federal and State regulatory and accrediting agencies.
● Participated in regulatory compliance and credentialing meetings EDUCATION
Erie Community College, South Orchard Park, NY Medical: Secretarial Science
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