Experience

South Country Health Alliance

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Credentialing Supervisor

  • Jul 2016 - Present

  *Manage the credentialing process by reviewing, processing and maintaining credentialing applications as well as electronic and paper files in accordance with NCQA Standards and Guidelines for Accreditation of Health Plans, Centers for Medicaid and Medicare Services (CMS), Department of Human Services (DHS) and Minnesota Department of Health (MDH) statutes and regulations. *Lead the development and ongoing monitoring of Quality Assurance metrics to ensure compliance with NCQA, CMS, and DHS credentialing standards and SCHA performance standards; this includes conducting internal quality audits and maintaining the Credentialing Performance Dashboard. *Maintain accuracy and completeness of practitioner credentialing files and SCHA’s credentialing database to ensure efficient report generation. *Coordinate the timely and accurate completion and submission of credentialing reports, including delegates’ reports, as requested in order that applicable boards and committees are fully informed of network activity. *Provide appropriate credentialing communication to practitioners, practitioner credentialing offices, and internal SCHA departments, as required for credentialing activities.*Collaborate with manager and/or Medical Director regarding credentialing and re-credentialing applications that require additional investigation due to concerns related to professional criteria.*Assist the Director of Quality with the development and implementation of the Credentialing Plan, credentialing policies and procedures, and departmental process improvements.*Support the Regulatory Audit Manager with oversight of delegated credentialing activities.*Provide supervision, mentoring, training, and coaching of credentialing staff .*Perform other duties as assigned within the scope, responsibility and requirements of the job. Show less

• Credentialing Coordinator

  • Jul 2007 - Present

  *Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility to provide quality healthcare to South Country members.*Conducts thorough background investigation, research and primary source verification of all components of a provider's application file.*Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.*Assists with managed care delegated credentialing audits; conducts internal file audits.*Utilizes the Intellisoft/Intellicred 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 Physicians, Allied and Mental Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (NCQA, CMS, federal and state), as well as South Country policies and procedures, and delegated contracts.*Oversees the work allocation and accuracy, training, enforcement of internal procedures and controls, and problem resolution, and motivates employees to achieve peak productivity and performance.*Performs miscellaneous job-related duties accordingly. Show less