Credentialing Specialist
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Objective: To secure a challenging position as a Credentialing Specialist or similar position in the healthcare industry that will utilize my skills and experience and offers opportunity for growth and advancement.
Strengths: Excellent communication skills, polished telephone etiquette, professional appearance, knowledge of HIPPA, Joint Commission and NCQA requirements, multi task and prioritize accordingly to meet objectives.
Career Skills: Initial credentialing and recredentialing of physicians and mid-level practitioners, CAQH, Cactus software, MS Office and Office Management.
Work Experience:
April 2010 - present
Parallon Business Solutions
Houston, Texas
Credentialing Specialist for HCA entities
Maintains high quality, timely and accurate credentialing processes of medical professionals per CPC policy and procedure, assists in the credentialing process by entering and scanning information into credentialing system (Cactus) for initial, updated and add on applications, acts as liaison with MSO by ensuring compliance and delivery of required information to clients in a timely manner, processes and maintains credentialing and recredentialing in accordance with CPC policy and procedure, Joint Commission standards and State and Federal Regulatory regulations, including but not limited to the following verifications:
National Practitioner Data Bank, Sanctions for Medicare/Medicaid exemption, DEA Verification Licensure, Board Certification, Professional School, Residency/ Fellowship and peer recommendations, ensures that all credentials files are current and complete pursuant to expiration date of medical licenses, board certification, professional-liability insurance coverage. Monitors collection of all information received, follows up on missing items and/or incomplete forms per CPC policy and procedure, submits, follows up on requests for verifications as needed, identifies and evaluates potential red flags and works in collaboration with practitioner to document the issue and physician response. Advises Manager and/or Director of questionable information received and any issues identified during the processes, submits closed files for audit/final review and secure missing items as identified by audit/final review prior to releasing file to the appropriate entity MSO. Maintains all credentials files ensuring that all correspondence in the credentialing and reappointment process is accurately entered in Cactus database and is in compliance with HCA policy and procedure, Federal and State regulatory and accrediting agencies as required. Performs other duties and works on special projects as requested.
April 2009 – January 2010
WellPoint (UniCare)
Houston, Texas
Credentialing Specialist, Managed Care
Performed credentialing and recredentialing of UniCare network providers, nursing homes and skilled nursing facilities within established time frames and in accordance with Company policies, state and federal laws and NCQA, received applications, entered provider information into database, contacted providers for additional supporting documents or clarification, monitored collection of items and entered into database, accessed CAQH to monitor provider updates, performed credentials primary source verifications, requested NPDB and AMA reports, reviewed report to determine if provider met criteria, identified files with issues and sanctions to be reviewed by the Medical Director, prepared files and materials for monthly Committee meetings, contacted Network Services and requested Access Needs Waiver or Business Needs Waiver, monitored and contacted non-responders for missing items, maintained database of delegated providers by entering initials, recreds, updates and terminations into database, performed on site audits of delegation groups to ensure NCQA compliance, assisted with special projects and recredentialing for other regions as needed.
March 2008 – April 2009
Crdentia (Staffing Agency)
Houston, Texas
Credentialing Specialist
Credentialed nurses, allied health employees and physicians to work in area hospitals, ensured candidates received application material and instructions in a timely manner, provided orientation material required from various hospitals, set up applicant for computerized testing, performed Fit testing on candidat...
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