Credentialing Coordinator resume examples

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Skillful Credentialing Coordinator resume

San Le
Professional Summary
Highly analytical healthcare administrator combining more than 6 years of work in credentialing (Hospital & MCO) with proficiency in standards, procedures, policies, and operations with process improvement capabilities. Adaptable and accustomed to the integration of new database and software systems, and restructuring of work in an increasingly complex regulatory environment. A detail oriented and energetic/professional team player who is capable of working on own initiative along with the ability to produce accurate results under pressure. *Analytical & problem solving skills, detail oriented, communication/interpersonal skills, organization/time management skills *Data management, reporting, analyzation of data quality *Quality/Process improvement competency *Developing extensive reports for review and compliance *Ability to effectively meet challenges and deadlines *Extensive computer knowledge at a high proficiency level: MSOW, ECHO, CACTUS, STAR, CRIMSON, Salesforce, Facets, Evernote, Smartsheet, Sharepoint, CAQH Proview, Microsoft Office-All Application, Adobe Pro
Skill Highlights
Professional Experience
Supervisor / Visiting Nurses Services of NY, CHOICE Health Plans - New York, NY 08/2016 - Current
  • Knowledge of Joint Commission/NCQA credentialing/CMS regulatory standards/credentialing statutes and.
  • regulations for hospitals, MCO, delegated credentialing entities, and CVOs Develop and implement policies and procedures for the credentialing department and ensuring the health plan meets NCQA and state regulatory guidelines/standards and CMS directory requirements Improve efficiency of the credentialing team by implementing procedures and processes that increases productivity by getting providers in network.
  • Create new provider forms to be utilized across the department (i.e.: Provider Update Form, ADA Accessibility Form, Access and Availability form, Provider applications, credentialing checklist and requirements).
  • Supervise and coordinates activities related to credentialing and re-credentialing of network providers, while ensuring adherence to the Health Plan, regulatory, industry and delegation standards.
  • Team lead on credentialing audits (MLTC, Medicare, Select Health) and delegated credentialing audits.
  • Lead multiple projects (Social Adult Day Care Annual Audit, HIV PCP data clean up, provider directory and data clean up.
Senior Manager / New York Network Management, IPA - Brooklyn, NY 11/2015 - Current
  • Develop policies and procedures for the credentialing of independent medical and allied health practitioners for NYNM; ensures that credentialing policies meet NCQA and state regulatory guidelines/standards.
  • Develop and maintain systems for ensuring compliance with laws, rules, regulations and accreditation requirements; maintain oversight of NYNM database.
  • Standardize forms used throughout the System for the credentialing of licensed, independent medical and allied health practitioners.
  • Provide initial and ongoing training of credentialing to all credentialing staff to assure consistent implementation.
  • Audit records at pre- determined intervals to ensure that the process is being followed and credentials are current, with no lapses.
  • Develop and maintain reporting systems to provide timely information to administration regarding compliance status with guidelines, rules/regulations and internal policies and procedures (works through staff so that a systematic process for monitoring and reporting is timely and appropriate).
  • Work with NYNM management to ensure the readiness of the organization for accreditation surveys and other compliance inspections.
Credentialing Supervisor / 03/2013 - 11/2015
Credentialing Coordinator / NYU Lutheran - Brooklyn, NY 07/2012 - 03/2013
  • Supervise the application process for new medical/dental staff applicants and reappointment process; including primary source verification of credentials, evaluation of information collected for adequacy and completion, and the pursuit of additional information.
  • Closely monitor the information collected to assure it meets Joint Commission, DOH, and other regulatory requirements; ensure the quality assurance standards are upheld and conducts continuous audits as a means of oversight.
  • Supervise the credentialing coordinators on all activities to ensure that quality standards are met.
  • Identify steps individual employees can take to promote growth, development, and workplace wellbeing as part of competency assessment, performance planning, and appraisal process.
  • Coordinate maintenance of credential files and update ECHO database as necessary; generate profile and/or reports from Echo, assemble all verified information, and prepare credential files for presentation at the Credentials Committee meetings.
  • Work with the Professional Practice Evaluation Coordinator to assure that all Initial, Focused, and Ongoing Professional Practice Evaluations are processed.
  • In conjunction with director, manages the hospital's additional insured list.
  • Expedite problem solving and provides service support to physicians and other professional contacts.
  • Assist in setting up office systems for credentialing related matters.
Credentials Analyst / NY Presbyterian Hospital - New York, Columbia, NY 12/2010 - 07/2012
  • Process all initial and reappointment applications for Medical/Allied Health Professional Staff appointments and clinical privileges to meet policies and procedures, Medical Staff Bylaws, and JCAHO standard.
  • Process applications for temporary or one-case privileges, according to policy and procedure.
  • Prepare/update files for audits/surveyors and maintain/input electronic data.
  • Collect and maintain files in relation to credentialing, including applications, current licenses, DEA license, malpractice insurance, board certifications, and other pertinent forms.
  • Assemble, prepare, and submit credentialing information and applications to manager, medical director for Credentialing Committee/Medical Board/Board of Trustees review.
Education and Training
State University of New York - Buffalo Amherst, NY 2009 B.A: Social Science-Health & Human Services Social Science-Health & Human Services Cum Laude
Skills
ADA, CMS, database, DOH, forms, insurance, Team lead, director, meetings, Access, office, works, network, policies, Develop policies, problem solving, processes, quality, quality assurance, maintain files, update files, reporting, surveys
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Job-winning Credentialing Coordinator resume

LEON J MELBOURNE
Professional Summary

Experienced RN and Risk Manager with strong clinical and people skills. Knowledge of the consenting process, reporting requirements for adverse events, standard of care, and hospital work-flow operations.

Licenses

Registered Nurse RN

License Health Risk Manager (LHRM)

Skill Highlights
  • Skilled cardiac care nurse
  • Committed to compliance reporting
  • Personable
  • Process improvement strategies
  • MIDAS reports expert
  • Medical clinical procedures comprehension
  • Team player with positive attitude
  • Relationship building
  • Troubleshooting and problem solving
  • Flexible
  • Maintains strict confidentiality
  • Extensive anatomy/physiology knowledge
  • HIPAA compliance
Professional Experience
06/2009 to Current
Risk Manager Miami Children's Hospital Miami, FL

Manage MIDAS incident reporting system including continuous process improvement.

Develop and provide Risk Management orientation to new employees.

Investigate and report to DOH all allegations of sexual misconduct.

Support claim management including responding to requests for productions.

Conducted over 35 Root Cause Analysis (RCA) using the 5 Why 7 Way technique. Selected as lead for assuring the success of the RCA process.

Conduct chart reviews to determine potential exposures to the organization and assure standard of care is maintained.

Practice Enterprise Risk Management.

Complete potential compensatory reports for malpractice and general liability insurance carriers.

Spearheaded a multi-disciplinary team focused on issues related to electronic medical records and patient safety.

Assure organizational compliance in the process for obtaining consents by supporting employees in determining appropriate parties to consent for treatment in minors or incapacitated individuals.

05/2008 to 06/2009
Pediatric Emergency Room RN Homestead Hospital Miami, FL

Provided care to patients presenting to the ER including assessing, administering medications and treatments, monitoring responses to treatment and assuring patients admission/discharge.

01/2006 to 06/2009
Per Diem Staff RN II Miami Children's Hospital Miami, FL

Served as rotating RN to all areas of the hospital in the capacity of RN as needed.

01/2001 to 06/2009
CPR Instructor Miami Children's Hospital Miami, FL

Basic Life Support (BLS) & Pediatric Advanced Life Support (PALS) Instructor, American Heart Association.

06/2004 to 01/2006
Cardiac Intensive Care Unit RN II Miami Children's Hospital Miami, FL

Provided care to critically ill patient population: duties included assessment, data collection, diagnosing, implementing the appropriate plan of care in collaboration with the interdisciplinary team.

07/2003 to 06/2004
Risk Management Specialist Miami Children's Hospital Miami, FL

Responsibilities included coding of incident reports, investigating incidents, developing timeline reports and supporting the director as needed.

01/2001 to 07/2003
Pediatric Intensive Care Unit RN I Miami Children's Hospital Miami, FL

Provided care to critically ill patient population: duties included assessment, data collection, diagnosing, implementing the appropriate plan of care in collaboration with the interdisciplinary team.

01/1999 to 01/2001
Nursing Care Assistant Miami Children's Hospital Miami, FL

Responsibilities included taking vital signs, charting vital signs and basic patient care, phlebotomy, monitoring IV pumps and patient intake and output, assisting physicians with minor procedures, cost control and special equipment set-up.

01/1998 to 01/1999
Nursing Care Technician Baptist Health Systems Miami, FL

Responsibilities included obtaining and charting vital signs, patient input/output, IV monitoring, glucose monitoring, and basic patient care.

01/1996 to 01/1997
Credentialing Coordinator United Healthcare Miami, FL

Gathered credentials from potential providers who desired to be accepted by the health care company.

Education and Training
1998
Associate of Science: Nursing Miami Dade College Miami, FL
1994
Bachelor of Science Degree: Psychology Allied Sciences Howard University Washington, District of Columbia, United States
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Experienced Credentialing Coordinator resume

Cossetty P. Denbow
Professional Summary
Results oriented individual with diversified experience in the managed care field, financial field and retail field. Strengths include knowledge of delegation audits related to a major insurance carrier, requirements for the Agency for Health Care Administration and the National Commission for Quality Assurance, claims processing, data entry, credentialing, and auditing.
Skills
PC knowledge, Mac knowledge, QuickBooks Pro, QuickBooks POS, Microsoft RMS, Microsoft Office, Microsoft Access, Microsoft Publisher, SweetQ, AMISYS, Bloomberg and Quotron
References
References Will be furnished upon request
Work History
Credentialing Specialist II, 02/2015 to Current
Parallon Workforce Solutions Sunrise, FL
  • Responsible for supporting the development and implementation of the Credentialing Processing Center policies and procedures.
  • Responsible for credentialing new and established health care providers.
  • Responsible for the maintenance of information to include primary source verification, follow up, data collection, data entry, and document review.
Manager of Credentialing, 10/2014 to 12/2015
Eden Health Plans Inc Doral, FL
  • Responsible for performing the credentialing and re-credentialing functions in accordance with the Plan's policies and procedures to ensure compliance with all regulatory agencies requirements.
  • Interfacing with physicians and office staff and other interdepartmental staff to effectuate completion of files.
  • Responsible for credentialing all providers in network.
  • Responsible for the administration of The Data Bank, AMA, AOIA, CAQH, and all other websites required for primary source verification.
  • Responsible for coordinating Delegation audits with the Chief Compliance Officer.
  • Responsible for the maintenance and accuracy of the Network database.
  • Responsible for the coordination and preparation of the Credentialing Committee Meetings.
  • Worked closely with the CEO, CCO, and VP of Network Management to ensure compliance with the Agency for Healthcare Administration, Office of Insurance Regulators, and the Centers for Medicare and Medicaid Services.
Credentialing Coordinator, Team Lead, 01/2014 to 10/2014
MCNA Dental Plans Fort Lauderdale, FL
  • Responsible for performing the credentialing and re-credentialing functions in accordance with the Plan's policies and procedures to ensure compliance with all regulatory agencies requirements.
  • Interfacing with physicians and office staff and other interdepartmental staff to effectuate completion of files.
  • Responsible for credentialing all providers in network.
Insurance Agent, 07/2013 to 12/2013
Sentinel Casualty Insurance Pembroke Pines, FL
  • Develop and implement sales plan and manage all phases of the sales cycle- from prospecting to close and follow-up support.
  • Represent a full line of insurance and financial products, serving as a trusted advisor to businesses and individuals.
Comptroller, 01/2009 to 05/2013
National Armory LLC Pompano Beach, FL
  • Responsible for overseeing the day-to-day operations of the business; responsibilities include but are not limited to human resource issues, accounting, scheduling, compensation and benefits.
  • Handled human resource issues including maintaining human resource files, maintaining employee complaints and reviews, maintaining proper payroll records.
  • Responsible for daily cash flow operations, recording of daily deposits, tracking credits and debits in QuickBooks Accounting Software, reconciling daily, monthly, quarterly, and annual accounting reports.
General Manager, 01/2002 to 01/2009
National Law Enforcement Distributors, Inc Davie, FL
  • Responsible for overseeing the day-to-day operations of the retail business; ensuring that the sales floor staff is scheduled for proper coverage; tracking the daily sales and entering the credits and debits into the accounting ledger; negotiating the pricing for new products; overseeing the implementation of a computerized point of sale; maintaining relationships with vendors and law enforcement agencies.
Managed Care Lead Analyst, 01/2001 to 01/2002
PhyAmerica Physician Services, Inc Ft. Lauderdale, FL
  • Responsible for overseeing analysis, preparation and reporting on medical service contracts and utilization data; preparing and explaining managed care comparison reports; creation and maintenance of managed care database; importing and exporting of data into and out of Microsoft Access databases.
Credentialing Supervisor, 01/1999 to 01/2001
Coordinated Care Solutions, Inc Coral Springs, FL
  • Responsible for ensuring the accuracy and completeness of facility, ancillary, and physician files abiding by NCQA guidelines, allowing payers to delegate CCS for credentialing.
  • Prepares and submits to management monthly reports of credentialing activities.
  • Creates and updates company's Policies and Procedures in accordance with NCQA, JCAHO, and URAC guidelines.
  • Supervises the Credentialing Coordinators, Clerks, and Temporary Staff.
  • Major duties include but are not limited to: tracking receipt of credentialing and/or recredentialing applications through recording of requests made and receipt of applications.
  • Identifying and requesting needed information and clarification for the credentialing and/or recredentialing process verbally and in writing.
  • Identification and tracking of files for providers failing to comply with the credentialing and/or recredentialing process.
  • Ensure that the records in the SweetQ database are accurate and complete.
  • Organize and present credentialing/recredentialing files for review at Credentialing Committee meetings.
  • Ensures files are processed in accordance with regulatory requirements (e.g.
  • NCQA, JCAHO, URAC).
  • Monitor and follow-up as required ensuring timely processing.
  • Prepare reports for management summarizing credentialing activities.
Credentialing Coordinator,
  • Ensures accuracy and completeness of facility, ancillary, and physician files in accordance with NCQA, JCAHO & URAC accreditation, individual state standards, company policies and procedures and other outside auditors.
  • Major duties and responsibilities include but are not limited to: initiating the credentialing process through data entry in the SweetQ database; requesting primary source verification from appropriate sources.
  • Accomplishments.
  • Upgraded SweetQ database to current edition.
  • Acquired proper verification tools to ensure compliance with regulatory agency standards.
  • Revised and created proper policies and procedures to ensure compliance with regulatory agencies and contracted insurance companies.
  • Computerized form completion for credentialing meetings via downloads into Microsoft Access.
  • Implementation of new internal credentialing forms and credentialing applications for facilities, ancillary providers, allied health providers, and physicians.
Credentialing Specialist, 01/1997 to 01/1999
Foundation Health Sunrise, FL
  • Responsible for performing the credentialing and recredentialing functions in accordance with the Plan's policies and procedures to ensure compliance with all regulatory agencies requirements.
  • Interfacing with physicians and office staff and other interdepartmental staff to effectuate completion of files.
  • Responsible for credentialing all providers in network.
Secretary I,
  • Shared secretary between two departments responsible for the maintenance of the departmental logs, maintaining of agendas, preparing purchase orders, generating and circulating interdepartmental correspondence, receiving and directing incoming calls, assisting in the coordination of the workflow between departments.
  • Accomplishments.
  • Instrumental in creating duo-departmental log for documenting workflow.
  • Key team member for updating policies and procedures and attachments for roadmaps during the AHCA and NCQA Accreditation audits.
  • Critical in assisting with the creation of the Delegation Agreement.
  • Instrumental in generating reports utilizing SweetQ data.
  • Expanded the use of technology in daily credentialing functions.
  • Moonlighted in the claims department to assist in processing claims.
  • Moonlighted in Data Management department to correct and enter data in the AMISYS database.
New Accounts Clerk, 01/1993 to 01/1996
Investacorp, Inc Miami Lakes, FL
  • Responsible for the posting of various trading documents into the clearing firm's data files as well as the firm's in house database; provide strong support for approximately 400 stockbrokers.
  • Service included but was not limited to the following: establishment and maintenance of new accounts (i.e.
  • trading accounts, retirement accounts and specialty accounts), liaison between clearing firms and brokers.
Stock Broker Assistant,
  • Responsible for maintaining client files, typing and mailing correspondence, answering client phone calls, opening client accounts, dictation, back-up to the trade desk, assisting accounting department with verification of daily trade blotters, shipping and insuring of securities received.
Insurance Licensing Coordinator,
  • Responsible for updating registered representative's insurance files, appointing the various representatives with different insurance companies, distributing commissions, liaison between insurance representatives and the insurance companies and verifying the licensure status with the respective states.
  • Responsible for maintaining continuing education files for president of company and in house insurance representatives.
  • Accomplishments.
  • Instrumental in creating commission pay out spreadsheet for insurance commissions.
  • Instrumental in maintaining records detailing requirements for insurance licensure in each state.
Education
High School Diploma: 1992
American Senior High School -
Human Resources, Current
Broward College -
Pre-Law, 1993
Syracuse University -
Affiliations
Former Member, Legal Assisting Society of Broward Community College
Languages
English: excellent communication skills - written and verbal Spanish & French: fair understanding and communication skills
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