Barbara Hood
Brandywine,MD
Summary
Credentialing professional with proven track record in managing credentialing operations and ensuring compliance. Valued for strong collaborative skills and achieving results through efficient processes. Known for adaptability and reliability in dynamic environments, with expertise in documentation and regulatory standards.
Overview
19
19
years of professional experience
Work History
Credentialing Specialist
George Washington Medial Faculty Associates Inc.
06.2023 - Current
- Perform day-to-day credentialing and re-credentialing activities for providers within the Credentialing Department
- Performs payor enrollment and maintenance with payors on a regular basis
- Utilize the CAQH database to retrieve and analyze practitioner applications and supporting documentation for completeness according to accreditation and regulatory standards
- Inform practitioner and MFA department contacts of the application status, and resolve pending issues, including the collection of additional information
- Ensure compliance with accreditation and regulatory standards by processing initial and reappointment applications for eligible practitioners
- Compile, evaluate, and present practitioner files for committee review to ensure compliance with accreditation and regulatory standards
- Complete practitioners' enrollment applications into DC Medicaid, Maryland Medicaid, Virginia Medicaid, Medicare, and Tricare
- Ensure the provider numbers for the governmental payors are loaded in the billing system to ensure the timely release of claims to the payors
- Complete the revalidation/re-enrollment application into DC Medicaid, Maryland Medicaid, Virginia Medicaid, and Medicare for each practitioner every five years
- Update the medical/professional licenses that are about to expire with DC Medicaid, Maryland Medicaid, and Virginia Medicaid
- Work with the billing department to make sure rejections for credentialing-related reasons are addressed in a timely fashion and the charges are resubmitted for payment
- Identify, investigate, and report any discrepancies/adverse information obtained from practitioner applications, primary source verifications, or other sources
- Perform primary source verifications of licensure, board certification, DEA/CDS certification, education/training, Medicare/Medicaid sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB queries
- Prepare documentation and participate in on-site audits from delegated credentialing entities to ensure compliance with accreditation and regulatory standards
- Perform ongoing monitoring and evaluate practitioner sanctions, complaints, and adverse actions to ensure compliance with accreditation and regulatory standards
- Meet or exceed individual productivity metrics, quality, and timeliness standards as defined by department guidelines and current workload
- Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
- Managed multiple priorities effectively, resulting in the on-time completion of credentialing tasks for numerous providers simultaneously.
- Conducted audits of provider files, ensuring all necessary documents were up-to-date and compliant with regulatory requirements.
- Prepared records for site visits and file audits.
- Improved turnaround time for credentialing applications by implementing an efficient online system.
- Reduced errors in credentialing files by conducting thorough reviews and consistently maintaining attention to detail.
Credentialing Coordinator
Signify Health
07.2022 - 03.2023
- Established and maintained a system for timely processing of credentialing/re-credentialing files in accordance with NCQA policies
- Maintained up to date credentialing database
- Reviewed and process credentialing and re-credentialing files
- Maintained copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers
- Assembled all verified information and prepares files for presentation to Credentialing Committee
- Assisted with ongoing monitoring of contracted providers
- Reviewed all background screenings and record results
- Utilized MD Staff credentialing database, optimizing efficiency, and performs query, report and document generation
- Monitored initial, re-credentialing and expirable process
- Verified providers' requirements for approval to work in specific states and plans
- Provided administrative support to Director of Medical Staff Services and Credentialing Manager.
Credentialing Coordinator
CareFirst Community Health Plan of District of Columbia
06.2019 - 07.2022
- Organized and reviewing credentialing and re-credentialing applications for District of Columbia Medicaid Health Plan
- Performed verifications of education, training, experience, and certifications for providers
- Requested state criminal history background checks and drug screening
- Organized and submits 'credentialing' documentation for review and approval
- Maintained provider data in computer database (CAQH)
- Maintained a weekly report of all credentialing activities
- Processed providers credentialing applications via District of Columbia guidelines
- Sent providers welcome letters, denial letters via email
- Created and maintained candidate files in compliance with company and client policies
- Followed all Standard Operating Policies (SOP) in a professional timely manner, providing functional expertise on an ongoing basis
- Ensured correct credentialing forms are sent to the candidate/employee either via email or regular mail.
Credentialing Specialist II
Health Net Federal Services
10.2006 - 06.2019
- Monitored critical credentialing activities/processes and update management of issues Ensure compliance with company standards, NCQA or URAC, State and Federal policies and regulations
- Developed reports on credentialing activities and recommend improvements to ensure goals are met
- Ensured credentialing database remains current and accurate
- Reviewed and update credentialing program descriptions, policies and procedures
- Research benchmark and industry standards
- Analyzed, developed, implemented and monitored quality initiatives to achieve healthy outcomes for assigned projects
- Worked closely with applicable networks to determine accuracy and appropriateness of the credentialing status and procedures
- Assisted with Credentialing Committee activities, as necessary to comply with NCQA requirements
- Verifies and maintains all network, individual and/or facility/ancillary providers' information
- Monitors disciplinary actions, and follows up accordingly
- Corresponds with licensing board, hospitals, certification agencies, training programs and medical groups to resolve any issues
- Assisted in preparation of file reports and binders for monthly Credentialing Committee meetings, including pre-and post-Committee functions
- Corresponded with licensing board, hospitals, certification agencies, training programs and medical groups, practitioners, office staff, provider network administrators, contracting and management to resolve issues.
Skills
- New employee orientation
- Time Management
- HIPAA Compliance
- Credential verification
- Background checks
- Applicant qualification
- Provider enrollment
- Microsoft office
- License verifications
- MDStaff
- Qgenda
- SAM
- OIG
- Medicaid/Medicare enrollment
- Training and mentoring
- New hire onboarding
Timeline
Credentialing Specialist
George Washington Medial Faculty Associates Inc.
06.2023 - Current
Credentialing Coordinator
Signify Health
07.2022 - 03.2023
Credentialing Coordinator
CareFirst Community Health Plan of District of Columbia
06.2019 - 07.2022
Credentialing Specialist II
Health Net Federal Services
10.2006 - 06.2019
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