Credentialing Specialist Resume Example

Responsible for activities associated with credentialing and recredentialing of physicians and providers. Process provider applications including receipt, reviewing and loading data into the tracking system. Review provider Interest Forms and CAQH applications to ensure all internal, state, accrediting and regulatory standards are being met. Send out "In Process" or "Incomplete letters" to providers within the 30 day timeframe as well as ensure all providers are credentialed within the required 120 days. Maintain provider information in online credentialing databases, systems and excel spreadsheets. Oversee primary source verification activities with all delegated entities and ensure all PSV verifications(licensure, board certifications, education, training, hospital affiliations etc) are being completed within compliance of Maryland State Law and NCQA standards. Review credentialing reports once received from CVO. Run Clean File Report for all providers with no adverse actions to submit to the Chief Medical Officer for review and approval. Pull all files with adverse actions, build file documentation and prepare files for credentialing committee review. Manage agenda and take the minutes for the Provider Advisory and Credentialing Committee (PACC). Ensure that Robert's Rule of Order is being followed in the credentialing committee meetings. Assist with NCQA audit by ensuring all 21 credentialing elements are being met. Train interns on the credentialing process to assist the credentialing department.

Responsible for all aspects of credentialing operations. Developed a written credentialing process and stored on a shared drive for viewing. Communicate with project managers and physician recruiter regarding criteria for credentialing with various positions at Medical Treatment Facilities with the Department of Defense and US Coastal Guard. Review Task Order Proposal Requests to analyze credentialing requirements for various Army and Naval Hospitals and Medical Centers. Primary Source Verify all required credentials (CV, licenses, education,employment history,BLS,NPI etc) and verify all site specific forms are completed and signed by provider. Communicate with site regarding establishing a start date for provider once security check is clear. Review NPDB for any reports as well as review any explanation letter from the provider regarding any reports found. Produce a weekly status report on credentialing files for both new hires and current employees. Advise supervisor on any issues concerning credentialing operations. Recommended procedural changes by bringing all credentialing in house (even with joint bids) to ensure compliance and consistency. Review Health Form for immunizations (MMR, HepB, Varicella, PPD, and Flu Shot). Run criminal background check using a 3rd party vendor to screen applicants before security clearance is denied to minimize a delay in the hiring process. Verify privileges held for physicians at previous employers. Monitor expiring credentials (licenses,BLS, immunizations etc) sending notices out to providers as well as their assigned project manager. Run report for expiring credentials at 30 and 90days. Conduct Market Salary Research for all positions both privileged and non privileged.

Responsible for the credentialing as part of the appointment process at the medical center, including full-time, part-time, independent, dependent practitioners and other allied health professionals. Responsible for the enrollment of new employees into the VetPro system (electronic credentialing program/system). Coordinates the collection of information and documents used to primary source verify credentials. Ensure all applications submitted are complete and accurate. Manage the credentialing and privileging for health care providers. Assist practitioners and other health professionals with entering their information in the system. Responsible for verifying references, education, verify supplemental attestation questions have been answered, employment history, licenses, certifications and registrations by national or professional organizations including DEA and CDS. Verify NPI numbers, screen through HIPDB and LEIE. Ensures all applicants are credentialed in a timely manner. Act as a resource for credentialing responding to outside inquires. Monitors licenses and certifications daily. Produce 30 and 45 day reports of expiring licenses and certifications. Assist employees who request to view confidential information contained in their credentialing and privileging folder.Use government purchase cards to order verifications create purchase orders and reconcile purchases on a timely basis. Transfer files and grant shared access to VAs requesting access. Keep track of deadlines including grace periods for licenses and certifications. Conduct final appointments after researching, analyzing, and validating all data and info required. Responsible for the Without Compensation Program (WOC). Ensure all applications and paperwork is complete with student and service ensure correct signatures are on the WOC Appointment Requests. Ensure identification documents and investigation paperwork are included in student's file. Tracks incomplete applications as well as unsigned applications. Type and create welcome packets. Explain process to applicants as well as services. Interact with recruiters to monitor number of applicants and paperwork. Inform Protection and Support and Police and Security of employee's/student's who appointments are expiring. Assist with HR functions.

Timely and accurately entered data of all providers' demographic information including tracking of applications and contracts in system. Performed reviews and analysis of incoming documents to determine completeness of applications and contractual documents. Completed primary source verifications based on the requirements of each provider's state and professional level. Conducted verifications including license; licensing board, federal, state and professional sanctions, general risk/liability assessment, malpractice coverage, malpractice history, clinical hours, education and experience, professional and board certifications. Provided status reports on providers. Maintained compliance with HIPAA, URAC, NCQA Credentialing Standards, and Federal and State Guidelines. Sent correspondence to field reps, providers, and all others needed to obtain information/documents needed to complete the credentialing process. Managed credentialing and privileging functions. Developed monitoring and tracking strategies for reports. Responsible for reporting changes and updates to CVO Director. Ensured accuracy of TINs, service addresses, office hours etc. Trained temporary staff as well as conducted refreshers for current employees on the credentialing process.

Maintained Compliance with HIPAA, NCQA Credentialing Standards, and Federal and State Guidelines. Processed and tracked the status of credentialing applications and updated and maintained the credentialing database in accordance with internal policies and procedures. Collected and maintained files in relation to the credentialing and re credentialing of network practitioners including applications (CAQH),DEA, CDS, licenses, malpractice insurance, education, hospital privileges, current physician license, board certifications, and other pertinent forms. Prepared documents for credentialing committee review. Responded and resolved inquires from practitioners regarding status of application, communicated with hospitals, malpractice insurance companies, licensing boards, office managers and practitioners via email, phone, and fax. Produced detailed credentialing reports (demographics, board certified, type of provider)

Maintained employees personnel files in compliance with applicable legal requirements. Explained provisions of employee benefits and services programs; interpreted and analyzed regulations, policies and procedures. Assisted in the hiring process by coordinating job postings on websites (CareerBuilder, Indeed, Monster), reviewed resumes, performed telephone interviews and reference checks. Classification of all positions. Coordinated health, life and disability insurance enrollments. Reviewed worker's compensation claims, conducted investigations and reviewed medical for completion. Conducted research on various federal programs and grants pertaining to the childcare sector. Recruited childcare professionals by attending job fairs and local community colleges. Handled all human resource functions for both the Westland, Michigan and Boston, Massachusetts offices.

Responsible for the administrative duties required in the credentialing verification process and assisted in the general clerical functions of the department. Maintained compliance with HIPAA, NCQA credentialing standards, and federal and state guidelines. Reviewed practitioner's applications for appropriate documentation required and completeness for the credentialing and re credentialing process and sending correspondence for missing information/documents. Responsible for scanning documents into system. Responsible for the data entry of all practitioner's information into system. Verified legitimacy of practitioners Information (education, licensing, certification, etc). Responsible for contacting practitioners to update information absent from CAQH Application. Acted as a resource to inform practitioners of their status in the credentialing process.. Ensured all information entered into the system was accurate and up to date. Responsible for credentialing and privileging.