Senior Medical Staff Credentialing Leader
Resume:
Medical Services Professional with over ** years of experience encompassing Credentialing Specialist and Manager roles within Medical Staff Offices and managed care organizations. Expertise in provider enrollment functions and NCQA and TJC regulatory compliance. Skilled in training, developing, and directing credentialing teams to achieve and maintain NCQA and TJC accreditation.
Medical Services Professional Skills Summary
Initial and Reappointments
Meeting Management - create agendas, take minutes. Update providers on privileges decisions
Primary Source Verification in compliance with regulatory standards
Privileges and requirements review
Delegated Credentialing review; contracts and processes implementation
Bylaws, policies and procedures, and workflows development and amendments
Provider Enrollment application completion and submission to managed care including Medicare
Managed Provider Enrollment & Primary Source Credentialing Department – 15 employees
Provider orientation, in-service and education
Team-building, educating and training
Professional Experience
Trinity Health of Northeast, Hartford, Ct September 2021 to present
Medical Staff Office- Regional Sr Medical Staff Coordinator
Perform a wide range of duties within Medical Staff Offices of Medical Centers and Managed Care organizations in various roles including Credentialing Specialist, Credentialing Coordinator and Manager. Manage credentialing, privileging and regulatory compliance.
Process initial applications for appointment and reappointment. Handle primary source verification.
Review privileges for required education and experience. Ensure CME requirements are met.
Prepare for and participate in TJC or NCQA reviews and TJC accreditation renewals.
Plan weekly and monthly meetings. Manage challenging circumstances and resolve complex practitioner issues.
Coordinate with provider enrollment and participate in CVO facility activities.
Work closely with leadership and colleagues to ensure smooth business operations and departmental objectives are exceeded or met.
Assist MSO in creating work flows to enhance successes with daily credentialing and privileging activities
Train existing staff and newly hired staff with objectives to increase productivity and promote team spirit
Create procedures from the existing policies and by-laws
Edit by-laws for approval from Credentials, MSC and Board
Develop privilege proformas
Work in conjunction with CPI to ensure all application requirements are expeditiously met.
The Hardenbergh Group, Livonia, Michigan September 2011 – August 2021
Medical Services Professional Contractor – Nationwide
Perform a wide range of duties within Medical Staff Offices of Medical Centers and Managed Care organizations in various roles including Credentialing Specialist, Credentialing Coordinator and Manager. Manage credentialing, privileging and regulatory compliance.
Process initial applications for appointment and reappointment. Handle primary source verification.
Review privileges for required education and experience. Ensure CME requirements are met.
Prepare for and participate in TJC or NCQA reviews and TJC accreditation renewals.
Plan weekly and monthly meetings. Manage challenging circumstances and resolve complex practitioner issues.
Coordinate with provider enrollment and participate in CVO facility activities.
Work closely with leadership and colleagues to ensure smooth business operations and departmental objectives are exceeded or met.
Assist MSO in creating work flows to enhance successes with daily credentialing and privileging activities
Train existing staff and newly hired staff with objectives to increase productivity and promote team spirit
Create procedures from the existing policies and by-laws
Edit by-laws for approval from Credentials, MSC and Board
Develop privilege proformas
Work in conjunction with CVO to ensure all application requirements are expeditiously met.
Johnston Memorial Hospital, Mountain States Health Alliance Feb 2011 – August 2011
Medical Staff Coordinator
Responsible for credentialing and privileging providers who join Mountain States Health Alliance.
Meet Joint Commission Standards
Attended departmental meetings for Medical Staff inclusion
Diagnostic Radiology Network [TPA], Boca Raton, FL June 2002 – January 2008
Director of Network Operations - Worked Remotely
Business Operations and Human Resources:
Directed business operations of Call Center and Scheduling, Credentialing, Network Development, Customer Service, and Marketing departments.
Provided support, guidance, leadership, and motivation to achieve maximum performance.
Interviewed prospective new employees and recommended candidates for hire.
Supervised three credentialing employees and two schedulers.
Marketing and Business Development:
Identified prospective network participants using imaging websites and accrediting entities which increased network participating, generating accounts receivables and higher profit margins.
Developed preferred provider diagnostic imaging network, which lead to the successful roll out of national radiology payor contracts with major insurance carriers.
Network liaison for both payor and participating facilities.
Represented company at Workers’ Compensation Trade Shows. Coordinated “give always”, registration, and set up.
Project Manager / Credentialing Coordinator:
Maintained Credentialing Department in compliance with NCQA and URAC regulatory standards
Ensured contract meets application specifications, including all sites and participating physicians
Acted as liaison between facility providers and company.
Maintained policies and procedures for telephone case management follow-up to workers’ compensation clients.
Performed physician site visits to ensure compliance with managed care compliance standards
Liaison to Credentialing review committee. Managed credentialing activities including Delegated Entities, assist with NCQA accreditation processes.
Accomplishments
Prepared for and participated with NCQA and TJC reviews.
Additional Qualifications
Software / Technology Proficiency
Echo, MSOW, Visual Cactus, MD-Staff
Microsoft Office – Outlook, Word and Excel
Education
Cary Grove High School, Cary, IL
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