Project Management Credentialing Specialist
Resume:
Cathy King
Jacksonville, FL *****
*********@*****.***
Professional Summary:
• Detail-oriented and experienced Delegation Credentialing Specialist with a strong background in healthcare, specializing in credentialing, regulatory compliance, and audit management
• Proven expertise in maintaining compliance with state and federal credentialing regulations, managing audits, and overseeing delegated functions to ensure adherence to healthcare policies
• Skilled in coordinating and executing delegated contract agreements, annual reviews, and documentation collection, including Disclosure of Ownership forms and W9.
• Adept at leading regulatory audits (NCQA, HEDIS, CMS), ensuring timely execution of assessments, and facilitating accreditation and regulatory review for healthcare products.
• Strong ability to monitor and evaluate delegation processes to drive continuous improvement and operational efficiency.
• Experienced in representing company initiatives and acting as the primary liaison with key stakeholders and vendors
• Possesses a Master of Business Administration in Project Management and Six Sigma Certification.
• Proficient in Microsoft Office and other relevant software. Skills:
• Excellent organizational skills
• Effective problem solver
• Excellent analytic and investigative mind-set
• Leadership skills
• Initiative-taking
• Excellent time management skills
• Project Management skills
• Ability to identify data trends and patterns
• Monitoring and research skills
• Compliance Risk & Management
• Strong Microsoft Office skills
• Data collection
• Excellent interpersonal skills
• Six Sigma Certification -Yellow Belt Six Sigma
Training
• Level 1 Scrum project
• Employment & Labor Law
• Conflict Management
• Continuous Improvement
• Financial Analysis
• Accounting
• Quality Assurance
• Training & Development
• Supervising Experience
• Customer Service
• Root Cause Analysis
• Business Analysis
• Organizational Skills
• Communication Skills
• SharePoint
• Sales
• Retail Sales
• Data analysis skills
• Compliance management
• Pivot tables
• NCQA standards
• Medical records
• Documentation review
Education:
• Master of Business Administration in Project Management Strayer University - Washington, DC
• Bachelor's Degree in Business Administration
Edward Waters College - Jacksonville, FL
• Bachelor's Degree in Accounting
Edward Waters College - Jacksonville, FL
Certifications and Licenses:
• Six Sigma Yellow Belt
• Certified Provider Credentialing Specialist
Professional Experience:
Reason of Gap: Seeking new opportunities did some Seasonal Project HEDIS abstractor
Robert Half – United Healthcare - Optum
January 2024 to March 2024 (Contract)
Reason for Leaving: Contract Ended
• Examine patient records to determine if the criteria for specific HEDIS 2024 (BPD, TRC) measure are met. Credentialing Specialist
Genesis10 - United Healthcare – Northern Light Health February 2024 to September 2024 (Contract)
Reason for Leaving: Contract Ended
• Reviewed and verified documentation submitted by healthcare providers to ensure accuracy and completeness
• Performed primary source verification of education, training, licensure, certifications, work history, malpractice claims history, and other relevant credentials
• Identified discrepancies or red flags in provider applications or documents through thorough review and investigation
• Ensured timely completion of all aspects of the credentialing process within established deadlines
• Performed primary source verification on education/training/licensure/certifications/work history/malpractice claims
Delegation Credentialing Specialist III
Florida Blue-Jacksonville, FL
October 2020 to February 2024 (Direct Hire)
Reason for Leaving: Company downsizing
• Served as the Credentialing Accreditation and Regulatory compliance subject-matter expert for the National Committee for Quality Assurance (NCQA), Center for
• Medicare Services (CMS), and Agency for Healthcare Administration (AHCA).
• Maintain Compliance with State and Federal Credentialing Regulations (National Committee Quality (NCQA), Center for Medicare Services (CMS).
• Credentialing subject matter expert for regarding accreditation and regulatory audits (NCQA, HEDIS, CMS, AHCA and Internal Audit).
• Managed and reconcile monthly delegated rosters to ensure accuracy and compliance.
• Collected and verify the annual required documents, including Disclosure of Ownership forms and W9, to maintain up-to- date records.
• Coordinated the repapering process for all delegated entities, ensuring timely execution of new Delegation Contract Agreements.
• Coordinated the Annual review of policies and procedures and job aids to ensure they are updated with the new accreditation and regulation changes. This includes delivering supporting evidence demonstrating implementation to delegates vendors or third parties when requested.
• Subject matter expertise new company initiative Sanitas, Florida Blue Medicare, Inc., and Truli for Health.
• Coordinates and oversee all delegated functions to ensure compliance (pre-assessment, annual assessment, and reverse audits) timely, ensuring that all audits are consistently administered in compliance with Federal, State, and contractual healthcare requirements including the Company policies and procedures.
• Collect and prepare documentation for submission of Credentialing HEDIS MY Roadmap - section 3 Measurement.
• Monitor and evaluate the effectiveness of all solutions, policies, practices, and processes regarding delegation to ensure continuous improvement.
• Coordinate all delegated functions (pre-assessment, annual assessment, and reverse audits) timely, ensuring that all audits are consistently administered in compliance with Federal, State, and contractual healthcare requirements including the Company policies and procedures. This includes the submission of final reports written or verbal to the appropriate committees.
• Ensure that delegate audits are completed within the required timeframe in accordance with National Committee Quality (NCQA) standards.
• Facilitate regulatory review Florida Blue Medicare, Inc., and Truli for Health products credentialing functions and responsibilities.
• Represent company initiatives as subject-matter expert and Primary liaison.
• Regulatory audits (National Committee Quality (NCQA), Center Medicare Services (CMS) and HEDIS)
• Vendor billing reconciliation for Florida Blue Medicare, Inc., and Trulia for Health
• Credentialing Committee Medical Director and other representatives for Florida Blue Medicare, Inc. and Trulia for Health.
Employee Compliance- Broker Remediation Consultant Deutsche Bank via Capital staffing, Jacksonville, FL February 2019 to October 2020 (Contract)
Reason for Leaving: Contract Ended
• Perform reviews of unreconciled trade transactions
• Analyze brokerage documents and trade pre-clearance transactional activity
• Maintain and monitor brokerage account disclosures within the firm’s timeframe
• Identify potential compliance violations of the firm and FINRA policy
• Managed follow-up escalated internal and external partners
• Conduct weekly updates of metrics and productivity Supply Order Sales
Medtronic -Jacksonville, FL
December 2018 to January 2019
• As part of the supply order sales team, we provide customers services and order processing support for customers using medical devices and insulin therapy products.
• Accurately documenting customer requests and processing orders and promoting products that will benefit customers.
• Check order status, update insurance information and obtain authorization for devices.
• Ordering supplies, reordering devices, order processing, billing, and returns. Accreditation and Regulatory Specialist III
Florida Blue-Jacksonville, FL
Jan 2012 to December 2018
• Served as the National Committee for Quality Assurance (NCQA), Center for Medicare
• Services (CMS), and
• Agency for Healthcare Administration (AHCA) and Accreditation Association of
• Ambulatory Health Care (AAAHC) credentialing, compliance subject-matter expert/consultant.
• Known as subject-matter expert and liaison on policies, contract issues and provisions, communications, workflow, and quality improvements initiatives.
• Generated business reports to senior management concerning current, pending, and future activity.
• Subject matter expert on accreditation and regulatory reviews National Committee for Quality Assurance (NCQA), Center for Medicare Services (CMS), AHCA for Credentialing and Provider Network Management.
• Conduct compliance gap analysis, implementation planning, and project management to ensure compliance with requirements.
• HEDIS liaison to facilitate the abstraction and collection of documentation, policies, and procedures, to support the yearly audit.
• Collect and prep credentialing documentation for triannual audit with National Committee for Quality Assurance
(NCQA) consultant.
• Lead AHCA compliance project group including annual submission of documentation for review.
• Completed monthly, quarterly, and annual compliance checklists that track compliance with accounts Code of Ethics to meet client servicing requirements.
• Investigated sanctions, complaints, and member/provider files and correspond with practitioners to assist with the credentialing and recredentialing decision.
Quality Compliance Analyst
December 2008 to January 2012
• Credentialing compliance auditor and trainer on credentialing and recredentialing processes.
• Credentialing compliance subject-matter expert (SME) of credentialing and primary source verification process.
• Served as point person to update high volume databases, ensuring information was current for audits.
• Developed multiple Excel spreadsheets utilized by managers to evaluate team members.
• Perform detailed trend analysis to determine root cause of problems and identify opportunities for quality improvement. Evaluate and monitor errors identified during the audit process through trend analysis and report to the manager.
• Conduct Quality Audits per internal process, National Committee for Quality Assurance (NCQA)accreditation standards and CMS, AHCA, JCAHO and AAAHC regulatory requirements and state statutory.
• Oversight of the credentialing committee peer review committee process to include collaborate with Medical Director and Peer Physicians during credentialing meetings; review of monthly credentialing committee minutes and suggest improvements to the audit process and credentialing guidelines.
• Assessed root cause of error occurrence and initiates training to rectify recurrence of error.
• Collaborated with a cross functional department to assure seamless communication.
• Trained new team members and cross trained within the department to share knowledge.
• Blue Cross Blue Shield Association audit
Credentialing Coordinator, Claims Examiner Medicare, and Claims Adjustment - Account Receivable September 1988 to December 2008
• Organizing, maintaining, and verifying all aspects of the credentialing process for healthcare practitioners. Comply with all legal and regulatory policies and procedures.
Contact this candidate