Sr. Manager, Credentialing & Licensure at Radia Inc. PS (2023-02 – Present)
Oversight of Credentialing, Licensure, and Payer Enrollment for over 350+ physicians & ACPs, 50+ facilities, 50 State Licensing Boards. Direct report to Chief Executive Officer (CEO); participant in Executive Leadership Team providing strategic oversight of all credentialing, recredentialing activities, provider enrollment, delegated contracting, licensing, and enterprise level planning of new credentialing software
- Direction of day-to-day activities of division
- Developing key performance indicators to ensure streamlined approach to credentialing and monitor staff performance
- Implemented policies and procedures which align with NCQA (National Committee for Quality Assurance) & TJC (The Joint Commission)
- Participate in Leadership Team on weekly committee meetings providing key deliverables to ensure organizational alignment
- Oversight of all practitioners in the Internal Credentialing process to ensure the practitioners are privileged by their targeted start dates
- Provide leadership to establish credentialing best practices and oversee the credentialing process to meet targeted go-live dates for new/existing facilities
- Developed processes for scaling operations
- Support the manager and supervisors with the supervision of the credentialling team members including hiring qualified candidates, work allocation, training, performance evaluation and management, and staffing ratios
- Provide analytical support and lead the process of collecting, analyzing, and reporting credentialing metrics
- Build relationships with partnered facilities
Director, Credentialing & Licensure at TeleSpecialists (2020-11 – 2023-01)
Oversight of Credentialing and Licensure for over 100+ physicians, 250+ facilities, 35+ State Licensing Boards. Direct report to Chief Administrative Officer(CAO) and Managing Partner; participant in Executive Leadership Team providing strategic oversight of all credentialing and licensure. Responsible for directing credentialing, recredentialing activities, provider enrollment, delegated contracting, licensing, Regulatory Compliance, Quality, and strategic planning of new credentialing software and creation of Credentialing Verification Office (CVO).
- Direction of day-to-day activities of division
- Developing key performance indicators to ensure streamlined approach to credentialing and monitor staff performance
- Lead organizations first NCQA accreditation and obtained 99.6%- and 3-year accreditation
- Supports credentialing regulatory activities, including auditing partners and reporting any risks in the network to regulators and leadership.
- Participate in Executive Leadership Team – strategic planning
- Oversight of all practitioners in the Internal Credentialing process
- Provide leadership to establish credentialing best practices and oversee the credentialing process to meet targeted go-live dates for new/existing facilities
- Developed processes for scaling operations
- Support the managers with the supervision of the credentialling team members including hiring qualified candidates, work allocation, training, performance evaluation and management, and staffing ratios
- Develop and implemented a quality program to ensure accuracy of information and timeliness of submissions.
- Provide analytical support and lead the process of collecting, analyzing, and reporting credentialing metrics
- Research government and state requirements for credentialing in new states and collaborate with other leaders to identify issues and opportunities that lead to achieving department and company goals.
- Build relationships with facilities
- Chair Credentials Committee
Manager, Provider Enrollment and Credentialing at Steward Health Care Network (2019-04 – 2020-05)
Responsible for managing credentialing and recredentialing activities, provider enrollment, project plans and compliance with regulatory accreditation.
- Managing, organizing, and coordinating all aspects of the Credentialing and Recredentialing activities for practitioners and organizational providers in accordance to credentialing standards and guidelines.
- Management of the Provider Enrollment and Credentialing Department
- Establishing, implementing and monitoring performance goals, metrics, and processes for the Provider Enrollment and Credentialing department.
- Prepare and maintain various reports, data, and summaries of credentialing activities.
- Create and manage provider credentialing processes to ensure that policies, workflows, desktop manuals are be followed in in compliance with State, Federal, and NCQA guidelines as well as contracted health plan directives.
- Identify opportunities for improvements in the process and develops strategies to implement appropriate changes/enhancements.
- Develop partnerships with relevant internal and external staff; independently troubleshooting issues as they arise.
- Accountability for delegated oversight, including performing pre-delegation and annual audits to ensure compliance with the delegated credentialing agreements and regulatory standards.
- Coordination and management of the health plan Credentialing Committee(s).
- Respond to general inquiries and assist in resolution of administrative and operational issues.
- Manage staff data entry to maintain database/computerized credentialing system.
- Administrating and maintaining quality control processes of all Credentialing activities.
- Maintain on-going participation in cross-training activities, ensuring appropriate staff training and coverage of incoming volume.
- Actively engage in addressing special projects as they arise, conducting preliminary research and follow-up, and tracking/monitoring to facilitate on-going reporting of project status.
Supervisor, Provider Audit, Regulatory Compliance and Credentialing at Blue Cross Blue Shield of Western New York & Blue Shield of Northeastern New York (2016-04 – 2019-04)
Responsible for managing credentialing and recredentialing activities, front end enrollment, project plans and compliance with regulatory accreditation.
- Management of credentialing, front end enrollment, and regulatory compliance staff.
- Monitor and report department activities.
- Develop and maintain policies and procedures for credentialing.
- Interviews, hire, train, supervises department staff.
- Provides ongoing education to staff.
- Identifies department needs relating to file update and automation.
- Manage and lead Corporate Credentials Committee.
- Upholds current and thorough understanding of credentialing standards and requirements to ensure the credentialing/recredentialing process is in alignment with NCQA, CMS, SDOH, and Healthcare Policy.
