Credentialing Coordinator Resume Samples

Description :

1. Coordinates and administers the credentialing and privileging processes for over 150 medical providers, ensuring compliance with NCQA and CMS standards.
2. Monitors credentialing, recredentialing, and ongoing monitoring processes to ensure adherence to regulatory requirements and organizational policies.
3. Facilitates timely reviews and approvals by senior management, streamlining the credentialing workflow.
4. Evaluates and verifies physician credentials, including medical experience, licensure, and professional references.
5. Collaborates with medical staff and healthcare practitioners to complete the privileging process, ensuring all documentation is accurate and complete.
6. Maintains accurate records and databases to track credentialing activities and compliance status.
7. Provides training and support to staff on credentialing policies and procedures, enhancing team efficiency.

Experience

2-5 Years

Level

Executive

Education

B.S. in HA

Description :

1. Conduct thorough audits of physician applications for initial credentialing and re-credentialing, verifying licensure, board certifications, and compliance with regulatory requirements.
2. Prepare and present credentialing recommendations to the Credentialing Committee, ensuring informed decision-making.
3. Monitor and manage physicians on probation with tailored compliance plans to ensure adherence to probationary terms.
4. Track and report on physician licensures, lawsuits, and disciplinary actions, maintaining up-to-date records for compliance reviews.
5. Communicate adverse actions to the Credentialing Committee Chair, providing detailed explanations and recommended next steps.
6. Managed provider credentialing processes to ensure compliance with regulatory standards.
7. Oversee provider organizations' delegated entities, ensuring compliance with NCQA and CMS guidelines through regular audits.

Experience

2-5 Years

Level

Senior

Education

B.S. Health Admin.

Description :

1. Facilitates the preparation and processing of credentialing applications, ensuring thorough evaluation of applicant qualifications.
2. Compiles and organizes credentialing files for review, meeting strict deadlines for committee presentations.
3. Reviews privilege change requests for compliance with established policies and medical bylaws.
4. Coordinates credentialing audits with internal and external stakeholders to ensure adherence to standards.
5. Maintains accurate records and documentation in credentialing databases, ensuring data integrity.
6. Communicates effectively with healthcare providers to gather necessary documentation and address inquiries.
7. Implements process improvements to enhance the overall efficiency of the credentialing department.

Experience

10+ Years

Level

Senior

Education

B.S. in HA

Description :

1. Executed comprehensive provider credentialing and re-credentialing for diverse healthcare groups managed by the MSO.
2. Established and maintained effective relationships with healthcare providers, ensuring timely primary source verification and documentation.
3. Conducted ongoing monitoring and preparation for credentialing committee meetings, ensuring compliance with regulatory standards.
4. Provided administrative support and maintained professional relationships across all organizational levels.
5. Managed multiple projects simultaneously in a high-demand environment, ensuring timely completion.
6. Oversaw accurate data entry for provider demographics, billing information, and credentialing updates.
7. Utilized Microsoft and Cactus Credentialing software to enhance operational workflows.

Experience

2-5 Years

Level

Senior

Education

BSHA

Description :

1. Conducted primary source verification of licenses, certifications, and education.
2. Research, verify, and analyze applications and credentials files to ensure compliance and accuracy.
3. Resolve credentialing issues by obtaining necessary documentation and reporting findings to management.
4. Maintain adherence to regulatory requirements outlined in governance documents and policies.
5. Stay informed on legal issues and regulatory changes affecting credentialing practices.
6. Ensured timely re-credentialing and renewal of provider credentials.
7. Ensure confidentiality of sensitive information related to medical staff performance and peer review processes.

Experience

7-10 Years

Level

Consultant

Education

B.S. in HA

Description :

1. Lead and manage the credentialing and re-credentialing processes for healthcare providers, ensuring compliance with all regulatory requirements.
2. Oversee the initial appointment and reappointment of Medical Staff and Allied Health Professionals, ensuring adherence to established bylaws and policies.
3. Interpret and apply accreditation standards, developing comprehensive knowledge of relevant statutes and laws.
4. Resolved discrepancies in provider credentials through thorough investigation.
5. Collaborate with the Credentialing Manager to enhance departmental efficiency and effectiveness.
6. Monitor and report on credentialing metrics to ensure continuous improvement.
7. Act as a subject matter expert in credentialing practices, providing guidance to team members and stakeholders.

Experience

7-10 Years

Level

Management

Education

B.S. Health Admin.

Description :

1. Credential and re-credential providers for Physician Hospital Organizations, verifying licenses, education, and affiliations.
2. Maintain provider information in MSO database, conduct audits, and provide analytical reports to senior management.
3. Serve as a liaison between physicians and Managed Care Organizations, delivering detailed reporting statistics.
4. Prepare documentation for Credentialing Committee meetings, including audit checklists and status updates.
5. Manage physician resignation and leave of absence reports for senior management and Managed Care Organizations.
6. Function as a liaison for initial managed care credentialing applicants, ensuring a smooth onboarding process.
7. Assist the compliance coordinator in the renewal process for provider credentials, ensuring timely re-evaluations.

Experience

0-2 Years

Level

Entry Level

Education

B.S. Health Admin.

Description :

1. Managed comprehensive credentialing processes, ensuring compliance with state and federal regulations.
2. Developed and maintained organized credential files to support efficient audits and reviews.
3. Conducted thorough background investigations and primary source verifications for healthcare providers.
4. Collaborated with healthcare facilities to facilitate the credentialing process, including documentation and application completion.
5. Reviewed and verified applications for accuracy prior to submission to regulatory bodies.
6. Enhanced productivity by delegating tasks effectively among team members in the credentialing department.
7. Addressed and resolved issues regarding provider enrollment with various government payers.

Experience

2-5 Years

Level

Executive

Education

BSHA

Description :

1. Oversee the credentialing process for all healthcare providers, ensuring compliance with state and federal regulations.
2. Streamline recredentialing efforts with hospitals and insurance companies, maintaining accurate records.
3. Update and verify physician Curriculum Vitae to ensure current and complete documentation.
4. Coordinate Continuing Medical Education (CME) for physicians, including scheduling and travel arrangements.
5. Manage recertification of licenses and training courses, ensuring timely completion before expiration.
6. Assist in preparing legal documents related to credentialing and maintain financial records for payroll and accounts payable.
7. Develop and implement process improvements to enhance operational efficiency in credentialing workflows.

Experience

2-5 Years

Level

Executive

Education

B.S. in HA

Description :

1. Facilitated peer review processes as part of credentialing.
2. Maintained knowledge of industry trends and best practices in credentialing.
3. Communicates with hospitals, payers, and providers to obtain and provide information for effective credentialing or enrollment.
4. Manages tasks on the athena E.H.R Enrollment Services Dashboard, ensuring timely responses and content maintenance.
5. Collaborates with the Business Office to resolve claim issues within athenaNet related to taxonomy, NPI, and enrollment.
6. Administers health plan portals for access to eligibility, claims, referrals, and prior authorizations.
7. Supported the development of training materials for credentialing staff.

Experience

2-5 Years

Level

Junior

Education

B.S. in HA

Description :

1. Managed the credentialing and re-credentialing process for over 80 healthcare providers, ensuring compliance with internal policies and external regulations.
2. Conducted thorough primary source verifications and maintained accurate records in the credentialing database.
3. Collaborated with various departments to facilitate timely credentialing of new physicians and allied health professionals.
4. Processed high volumes of privilege requests, ensuring adherence to medical staff bylaws.
5. Reviewed applications for completeness and followed up on outstanding information to expedite credentialing timelines.
6. Maintained data integrity standards while entering and updating practitioner information in the credentialing system.
7. Provided exceptional support to non-responsive practitioners, assisting them in gathering necessary documentation for credentialing.

Experience

5-7 Years

Level

Executive

Education

B.S. in HA

Description :

1. Coordinates and oversees the review of practitioner applications, ensuring compliance with eligibility requirements.
2. Conducts comprehensive background investigations and primary source verifications for all application components.
3. Identifies and resolves discrepancies, ensuring thorough follow-up on outstanding issues.
4. Prepares credentialing files for Medical Staff Committee review, ensuring timely completion.
5. Processes privilege requests in alignment with clinical criteria and regulatory standards.
6. Responds to provider inquiries and collaborates with internal and external stakeholders on credentialing matters.
7. Assists with credentialing audits and maintains compliance with managed care standards.

Experience

5-7 Years

Level

Executive

Education

B.S. Health Admin.