Credentialing Quality Specialist - Harris Health - Houston, TX
(2021-03)
- Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with federal, state, local and University regulations, guidelines, policies, and standards.
- Conducts primary source verification, collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards and UNM Health System criteria.
- Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to CVO Credentialing Manager and entity Medical Staff Affairs for sound decision making in accordance with Medical Staff Bylaws, credentialing policies and procedures, federal, state, local and government/insurance agency regulations.
- Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
- Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures.
- Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
- Participates in the development and implementation of process improvements for the system-wide credentialing process; prepares reports and scoring required by regulatory and accrediting agencies, policies and standards.
- Communicates clearly with providers, their liaisons, entity Medical Staff Affairs. medical staff leadership and Administration, as needed to provide timely responses upon request on day-to-day credentialing and privileging issues as they arise.
- Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
- Performs miscellaneous job-related duties as assigned.
Credentialing Coordinator/Manage Care - Sagis, PLLC - Houston, TX
(2020-05 - 2021-03)
- Add physicians to network for Healthcare plans
- Start up of all licensures for different states for Physicians, completed all state applications
- Renewed Licensures for different states
- Assist with various projects as assigned by direct supervisor
Credentialing Coordinator/Manage Care - Nova Medical Center - Houston, TX
(2018-09 - 2020-03)
- Processes credentialing/re-credentialing files according to Nova Medical Centers' standards for committee review adhering to NCQA/state regulatory requirements.
- Maintains communication between affected departments on status of credentialed providers in Smartsheets.
- Updates and maintains the Physician Supervision Schedule and ensures the timely notification of provider changes to medical staff and other inter-department stakeholders
- Ensures timely and professional communication with providers, documents interactions and follow ups as required to ensure timely file completion
- Ensures monthly monitoring and reporting of files to ensure compliance, i.e. licenses, DEA, malpractice, OIG, SAMS, NPDB.
- Tracks and monitors non-responsive providers.
- Maintains confidentiality and security of provider files.
- Fields, logs and tracks injured employee complaints and reports them to committee for review.
- Ensures treatment quality reviews on mid-level providers performed by supervising physicians are completed, logged and tracked for compliance.
- Assists in preparing and updating credentialing policies and procedures for review by committee.
- Prepares provider initial and re-credentialed provider files for internal and external audits under the guidance and direction of supervisor.
- Assists in preparing Quarterly committee meeting agenda and reports as well as minutes following meetings.
- Attends committee meetings as assigned by the SVP, Network & Payor Strategy
Medical Staff Coordinator Manager - Nexus Health Systems - Houston, TX
(2015-10 - 2018-08)
- Credentialing all providers in the practice including Medicare, Medicaid and Managed Care applications
- Responsible for applying Hospital privilege for all providers in the practice and working closely with the hospital's credentialing department
- Meets with providers to gather, review and provide guidance on completion of credentialing packets. Also, coordinates the accurate input of physician information into CAQH and Medicare, Medicaid and hospital database
- Responsible for processing of accurate complementation of Texas Standardized Credentialing Application in MS Word files for each physician
- Oversees input of physician documents into database and proper maintenance of Medicare and Medicaid documents
- Continuously verify the status of CVs, provider licenses, DEA, DPS certificates and specialty certificates
- Continuously track the renewal of provider licenses, DEA, DPS, ACLS certificates
- Maintain record keeping on providers' CME and follow up to ensure CME have been completed
- Complete various provider applications, and track the status of applications once submitted
- Maintain provider files for credentialing purposes
- Contact appropriate organizations upon hiring of new providers
- Update the appropriate departments on the status of providers credentialing on Managed Care/ Insurances
- organizing meetings and managing databases.
Medical Staff Coordinator - Kindred Healthcare - Houston, TX
(2009-10 - 2015-10)
- Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
- Conducts thorough background investigation, research and primary source verification of all components of the application files.
- Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
- Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified.
- Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
- Responds to inquiries from other healthcare organizations, interfaces with internal customers on day-to-day credentialing and privileging issues as they arise.
- Utilizes the MDStaff credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
- Monitors the initial, reappointment and expirables process for all medical staff, Allied Health Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance, as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
