Front Desk Credentialing Manager

JANICE G COOPER

832-***-****/************@***.***

OBJECTIVE

To secure a position in a team-oriented environment where I can utilize my extensive experience in the workforce to provide a positive contribution to an organization in need of my skill set which includes administrative support, front desk receptionist and Human Resources.

EDUCATION

1973 – Graduated from Kashmere High School – Houston Texas

QUALIFICATIONS:

Extensive years of experience in healthcare Industry/Human Resources

Proven knowledge of, NCQA, TJC, specific state requirements, and CMS regulations related to credentialing

Eligible for CPCS and/or CMSC Certification

Excellent verbal and written communication skills; organizational skills; detail-oriented; team player

Proven ability to prioritize multiple projects/excellent organizational skills

Proven ability to provide administrative support and professional front desk reception skills

Computer skills in Word, Excel, Access, Outlook and Virtual Credentialer

Human Resources

HR ADVISOR/INTAKE COORDINATOR – LEAVES DEPARTMENT

Retrieve on-line Employee Request For Leave applications from database – create Leaves Folders

•Contact campuses/departments to request DC-E-2 confirming last day worked and return dates when employees go out on leave

•Communicate with physician offices to request or clarify data on medical certification documents

•Request missing documents for employee files (i.e., applications/med certs, etc.).

•Assist with pulling e-mails from the Leaves mailbox and maintaining Leaves tracking spreadsheet

•Send out Eligibility/Approval documents to employees, campuses/departments and Benefits Departments

•Track anticipated return dates and send out leave exhaustion letters to all employees as needed

•Provide support with LOA Salary Worksheets & Return From Leave Worksheets while reviewing payroll to ensure accuracy of paychecks to employees including leave balances before & after leave.

•Serve as liaison for other departments regarding leaves, absence balances, and pay inquiries.

•Provide employees with accurate information related to medical certification requirements, return-to-work, and leave guidelines

•Monitor all documentation to determine correctness of information, including coding information.

•Audit leave files and assume responsibility for correspondence relating to leaves of absence for all district employees.

• Advise and assist in all areas of Leaves and troubleshoot issues before escalating to next level.

•Serve as a resource and assist in resolving complex questions and issues.

•Participate in the development of department goals, objectives, and systems.

•Maintain compliance with all federal and state regulations.

•Provide ongoing assistance and guidance concerning continuous improvement of workflow processes.

•Perform other duties as assigned.

EXPERIENCE – UNIVERSAL AMERICAN – 10/2002 to 06/2013

CREDENTIALING MANAGER 07/2007 to 06/2013

Developed and implemented improved workflow processes and reporting packages

Directed staff activities including interviewing, hiring, training, and performance evaluation

Delegated the day-to-day operations to departmental staff, exercised accountability; ensured customer satisfaction, cost control/delivery of services, directed credentialing activities and peer review/quality assurance

Assisted Director in monitoring departmental budget and monthly finances while meeting budget goals

Promoted individual professional growth and development by meeting requirements for mandatory, continuing educations, skills competency, supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

Ensured staff met requirements for processing credentialing and re-credentialing applications and additional privilege requests of health care providers, review applications, prepare verification letters and maintains database. Reviewed applications and other data for accuracy and completeness

Ensured staff performed verification of reappointment applications by preparing requests for information letters, tracks responses and follow-up for needed information. Obtains licensure, certification and insurance certificates at time of reappointment.

Ensured staff entered accurate/up-to-date data for each applicant into the credentialing database (Virtual Credentialer) to include maintaining accurate demographic, appointment/reappointment

Monitored staff’s ability to collect and verify expirable documents including professional licenses, DEA, DPS, board certification and professional liability insurance according to the rules and policies.

Generated weekly reports to track expiration dates and ensure quality.

Ensured staff remained in compliance with the accrediting and regulatory agencies (i.e. TJC, CMS) in regards to credentialing while developing and maintaining a working knowledge of the statutes and laws.

Assisted in the managing of flow of information between the credentialing and provider relations staff. Maintained open communication with the Provider Relations team and other customers as identified.

Worked with staff to solve problems on a daily basis.

Ensured staff prepares agendas and related materials for all Credentialing meetings and maintained minutes of such meetings, assuring timely follow through on action items and policy changes.

Ensured staff prepared and disseminated correspondence related to credentialing actions.

Prepared timely responses to verification requests submitted by external entities.

Maintained knowledge of accrediting and credentialing requirements and associated practices.

Managed to ensure that production and outcomes of the department were in compliance with established credentialing and provider data benchmarks

Established successful cycle time, production standards and inventory control systems

Provided oversight and training to ensure compliance with all CMS, NCQA and all applicable state insurance department regulations governing the health plan products

Maintained renewal process with vendors and make recommendations for contractual changes as needed

Other duties as assigned by upper management.

SR CREDENTIALING COORDINATOR/TEAM LEAD – 07/2003 to 07/2007

Processed credentialing/re-credentialing files according to all accrediting and regulatory agencies (NCQA, CMS, TJC) for committee review.

Maintained confidentiality and security of provider files.

Responded to inquiries from other departments on credentialing status.

Consistently met requirements for processing credentialing and re-credentialing applications by reviewing applications for accuracy and completeness and preparing appropriate verification letters.

Performed verification of monthly reappointment applications by preparing/mailing requests for information letters, tracking responses and follow-up for needed information. including professional licenses, DEA, DPS, board certification and professional liability insurance according to established Credentialing policies and procedures.

Entered accurate/up-to-date data for each applicant into credentialing database (Virtual Credentiler) including demographic, appointment/reappointment dates.

Assisted in establishing process to generate weekly reports to track re-credentialing due dates, expiration dates; production standards and inventory control systems for all functional areas of the department.

Ensured the timely notification of provider changes in preparation for provider directories

Tracked and monitored non-responsive providers and professionally requested information from providers to complete provider files in timely manner.

Updated customer service and provider relations departments with provider response issues on a regular basis

Ensured files ready for committee review meet accuracy and completeness.

Ensured all outstanding issues are resolved prior to committee review.

Assisted manager/supervisor in auditing credentialing and re-credentialing files for committee presentation

Worked closely with Medical Director to review requested information from practitioners tabled/pended from previous meetings to ensure information received is acceptable.

Prepared list of provider credentialing/re-credentialing files for submission to Medical Director for “Clean File" or Credentialing Committee review and approval Prepared committee packets as outlined in the committee agenda

Coordinated/attended the credentialing committee meetings by setting up the time, date and place of meeting. Took minutes/tracked committee member participation as outlined in policy & procedures. Assisted manager with preparation for external audit of files/P&Ps.

Other credentialing related duties as assigned by the management team.

Measured employee competencies in job performance.

Provided communication to Managers and offices regarding established and changing HR statutes.

Ensured all required labor posting and notices are in place at all office locations

Identified legal requirements and government reporting regulations affecting human resources functions and ensured policies, procedures, and reporting are in compliance.

Recruited, interviewed, tested, and selected employees to fill vacant positions.

Kept records of benefit plan participation such as insurance/pension plan, personnel transactions such as hires, promotions, transfers, performance reviews, and terminations, and employee statistics for government reporting.

Advised management in appropriate resolution of employee relations issues.

Responded to inquiries regarding policies, procedures, and programs.

Administered performance review program to ensure effectiveness, compliance, and equity within organization.

Administered salary administration program to ensure compliance and equity within organization.

Administered benefits programs such as life, health, dental and disability insurances, pension plans, vacation, sick leave, leave of absence, and employee assistance.

Investigated accidents and prepared reports for insurance carrier.

Conducted wage surveys within labor market to determine competitive wage rate.

Prepared employee separation notices and related documentation, and conducts exit interviews to determine reasons behind separations.

Represented organization at personnel-related hearings/investigations (i.e., workers compensation hearings, etc.)

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