Quality Assurance Medical
Resume:
Lily Chow
West Covina, CA 91790
************@*****.***
QUALIFICATIONS:
18+ years experience in healthcare
Familiarity with NCQA, CMS, DHS, and DMHC requirements
Experience in build the credentialing department from ground-up
Strong communication skills
Have auditing experience (delegated medical groups or hospitals)
Have Hedis, healthplans, and NCQA audits experience
Proven initiative in reorganizing and completing assignments on time and with a high level of accuracy
Dependable and stable
Able to work independently or as a team member
EDUCATION:
Bachelor of Art (Cal Poly Pomona University)
SKILLS:
Excel, Microsoft Word, Power Point, MSL, AS400, Access, Wybtrak, Virtual Credentialer
EMPLOYMENT HISTORY:
11/09 to 1/11 Arcadian Management Services/Arcadian Health Plan
Credentialing Manager
• Developed and implemented policies and procedures
• Administrative support to medical director & credentialing committee meeting
• Support services to external department
• Responsible for credentialing verification (license, DEA, NPDB-HIPDB, federation, insurance, medicare opt-out, OIG, hospital, Medi-Cal suspended report, medical board sanction report), collecting, reviewing, tracking data, requesting credentialing from physicians, government, private agencies
• Credentialing and recredentialing process (appointment and reappointment application process)
• Works with Quality Management department on quality assurances issues
• Performs projects as assigned by the Sr. management
• Developed verification forms and letters
• Developed check list to assist the credentialing staff to improve the quality of work
• Redesigned department workflow to increase productivity
• Generated monthly reports to track productivity of staff
• Developed quality improvement audit tool for Credentialing Department
• Responsible for credentialing audits (Heal plans, Hedis, CMS…)
• Prepared agenda and minutes for credentialing committee meeting
• Provided employee training and performance appraisals
• Conduct delegation assessment for delegated IPAs/medical groups review and ongoing monitor of quality assurance issues
• Report to both credentialing and quality committees of any sanctions or quality issues
• Compiled reports to track credentialing activities, written letters for the department, and created filter and reports
• Responsible for all compliance issues for the department
Contact: Kathy Keen/QI Director 909-***-****
11/08 to 11/09 West Dermatology & Surgery Medical Group
Credentialing Specialist II
• Responsible for applying state licenses for physicians who is preparing to practice in the states that he/she doesn’t have a medical license.
• Renew medical licenses for physicians for all states that they have licenses.
• Responsible for applying all states new and renew DEA and pharmacy registration.
• Responsible for CLIA renewal and survey documents.
• Responsible for applying hospital privileges and reappointment.
• Responsible for maintaining all credentialing up to date on ongoing basis
• Responsible for membership, society association applications, fee, and dues for all contracted physicians within the medical group.
• Responsible for new and renew medical malpractice applications for all physicians within the medical group.
• Responsible for new and renewal of Fictitious Name Permit for the group.
• Responsible for license verification, NPDB, FSMB, AMA, work history, education and training verification, DEA, and insurance verification.
Contact: Donna ODonnell 909-***-**** Ext. 101
10/98 to 4/2008 CareMore Management/CareMore Health Plan
Director of Credentialing Department
• Developed and implemented policies and procedures
• Summarized cases from verification sources
• Administrative support to medical director & credentialing committee meeting
• Monitoring of daily credentialing expiration dates and recredentialing cycle
• Support services to external department, preparing agenda , and minutes
• Data requests from varies agencies
• Responsible for collecting, reviewing, tracking data, requesting credentialing from physicians, government, private agencies (credentialing verification/credentialing and recredentialing)
• Reviewed documents and ensure data entry is complete & accurate
• Wrote policies and procedures for quality improvement functions for credentialing department and worked with Quality Management department on quality assurances issues
• Performs projects as assigned by the Sr. management
• Developed verification forms and letters
• Developed check list to assist the credentialing staff to improve the quality of work
• Redesigned department workflow to increase productivity
• Generated monthly reports to track productivity of staff
• Developed quality improvement audit tool for Credentialing Department
• Responsible for credentialing audits (Heal plans, Hedis, CMS…)
• Prepared credentialing files for credentialing committee meeting
• Credentialing Verification
• Prepared agenda and minutes for credentialing committee meeting
• Provided employee training and performance appraisals
• Responsible for department budget
• Conduct delegation assessment for delegated IPAs/medical groups review and ongoing monitor of quality assurance issues
• Report to both credentialing and quality committees of any sanctions or quality issues
• Compiled reports to track credentialing activities, written letters for the department, and created filter and RTF files
• Responsible for all compliance issues for the department
Contact: Leeba Lessin/President 562-***-****
John Keipp, M.D./UM Medical Director 562-***-****
Jose Garcia/HR Director 562-***-****
6/94 to 6/98 FPA Medical Management, formerly AHI Healthcare Systems, Inc. (Company closed)
Lead Credentialing Specialist
• Prepared credentialing files for credentialing committee meeting
• Generated monthly reports to track productivity of staff
• Responsible for credentialing audits (Heal plans, NCQA…)
• Provided employee training and performance appraisals
• Report to both credentialing and quality committees of any sanctions or quality issues
• Supervised more than ten credentialing coordinators
• Assisted the credentialing director with special projects
• Identified and solves problem for credentialing coordinators
• Responsible for primary source verifications
• Maintained all credentials to be current at all time
• Credentialing Verifications
• Credentialing and recredentialing process
9/92 to 6/94 Allied Physician of California IPA
Provider Relations Coordinator, Member Services, Physician Contract Coordinator, Credentialing Specialist
6/92 to 4/93 Felix Yip, M.D., Urology
Position: Administrative Assistant
Duty includes front office assistant, scheduled surgery, back office assistant, entered claims
REFERENCES:
Excellent references available upon request
Contact this candidate