ASTRID CARL
New York,NY
Summary
Transformative, dynamic, and analytical professional and leader with a proven record of providing leadership, oversight, evaluation, and direction to several departments. With thorough knowledge of the fundamentals of hospital and health plan operations, business, and human resources administration principles. Advanced understanding of TJC, DNV, CAQH, and NCQA guidelines, as well as industry standards for credentialing best practices, managed care contracting, and provider (hospital, physician, ancillary, etc.) reimbursement. In-depth knowledge of credentialing/enrollment regulations and best practices. With proven competence in the following areas: Subject Matter expert in Hospital, Health Center, Health Plan, and Payer Credentialing. Managed Care Contracting, Compliance, Project Management, Data Analysis, Physician and Provider Network Management. Revenue Cycle, Operations/Quality Management, Auditing, Post-Doctoral Training Programs. Affiliations and Contracts, Performance Improvement, Risk Management. In-depth knowledge of Medicaid/Medicare/NYSD and Managed Care Plan Regulations. CMS, AAAHC, Article 28, Article 31, CAQH Proview, URAC, HICE, FQHC, FTCA, IPRO, HRSA, OASAS, CARF, and COMPA.
Overview
20
20
years of professional experience
Work History
CONSULTANT – OPERATIONS (Per Diem)
AVALANCHE HOME CARE INC.
02.2025 - Current
- Work closely with the Corporate Executive Director of Patient Services, the COO, and other executives to drive operational services, enhance customer satisfaction, and support the company’s growth objectives.
- Operational leadership: Develop and implement operational strategies that align with the company’s goals and objectives.
- Team Management: Ensure that all team members are aligned with the company’s mission and values.
- Process Improvement: Identify and execute process improvements to enhance operational efficiency and reduce costs.
- Customer Satisfaction: Ensure that all operational activities contribute to a positive customer experience.
- Strategic Planning: Work with the executive team and pursue new business opportunities that align with the company’s capabilities.
- Credentialing: Support and enhance the efficiency of the credentialing functions of the organization, including delegated, initial, and ongoing.
- Resolve day-to-day questions and blockers for the team, and address priority issues as needed.
DIRECTOR – CREDENTIALING/PAYER ENROLLMENT OPERATIONS
BROWNSVILLE MULTIFAMILY HEALTH AND WELLNESS CENTERS
01.2024 - Current
- Oversee all aspects of Provider Credentialing and Payer Enrollment for 14 health, wellness, and urgent care centers (1,200 +), ensuring compliance with all regulatory standards and accrediting bodies.
- Develop and implement credentialing strategies, policies, and procedures to enhance compliance, improve data integrity, and optimize operational efficiency.
- Oversee credentialing and re-credentialing processes to ensure compliance with federal and state regulations, as well as standards set by accrediting bodies such as NCQA, The Joint Commission, and URAC.
- Direct day-to-day operations, including processing applications, conducting primary source verification, and managing provider enrollment with Medicaid, Medicare, and commercial health plans.
- Play a crucial role in the Payer Strategy team and work collaboratively with Finance, Operations, Compliance, Revenue Cycle Management, and physician and dental practices, ensuring all providers are credentialed and enrolled with participating health plans. This includes collaboration with the Finance Department to establish payer contracting.
- Lead internal quality audits of credentialing files and processes, and serve as the primary liaison for external audits and accreditation reviews.
- Oversee the use of credentialing software and databases, managing data integrity, and leading the implementation of new tools and systems to enhance workflows. Ensure that the entire team is fully trained and able to work independently to the level of their role.
- Work directly with plans to foster a strong partnership and maximize efficiencies related to all credentialing and enrollment processes. This includes staying updated on payer requirements and ensuring regulatory compliance.
- Prepare and present reports on credentialing activity, performance metrics, and compliance readiness to senior leadership.
- Support delegated credentialing, including initial and ongoing assessments. Coordinate and prepare management reports.
- Recommend hiring, salary actions, performance appraisals, promotion, termination, and perform orientation/training to facilitate the professional growth and development of assigned staff.
- Maintain and report to leadership on team performance using metrics and KPIs, while continually looking for ways to improve efficiencies.
- Provide monthly payer roster assessments to ensure accurate and up-to-date listings within payer networks.
- Monitor the effectiveness of team activities to ensure productivity is maximized within regulatory guidelines and assure continuing compliance.
- Oversee the CAQH Database and payer portals: Monitor and update the CAQH database and payer portals, ensuring accuracy and compliance with NCQA requirements.
DIRECTOR – REVENUE CYCLE AND MANAGED CARE
START TREATMENT AND RECOVERY SERVICES
01.2023 - 01.2024
- Responsible for all billing activities for a complex system of 10 clinical sites, grants, and research programs of the Substance Use Treatment Programs at START.
- Managed the setup and maintenance of EDI/EFT accounts to ensure payment accuracy.
- Directed and oversaw all policies, objectives, and initiatives of the organization’s revenue cycle activities to optimize the patient financial interaction along the care continuum.
- Responsible for finalizing, executing, and communicating revenue-generating solutions involving managed care contracts, both professional and facilities.
- Developed performance metrics by which effectiveness, efficiencies, responsiveness, and productivity are measured; ensured compliance with all applicable external regulations as well as departmental and institutional policies and procedures; and oversaw the revenue department, including staff, teams, compliance, revenue analysis, and strategic planning.
- Prepared monthly, quarterly, and fiscal year billing reports; monitored managed care contractual agreements and reimbursement trends; investigated billing problems and formulated and implemented solutions.
- Provided quality care services and mediated disputes for initial managed care and provider contract negotiations, as well as assessing and evaluating performance data, identifying specific revenue enhancement opportunities, and renegotiating contracts to improve financial outcomes.
DIRECTOR – PAYER ENROLLMENT/REVENUE CYCLE (REMOTE, CONTRACTED)
ONE BROOKLYN HEALTH SYSTEM
01.2021 - 01.2022
- Responsible for the successful implementation and optimization of key revenue cycle systems and revenue cycle operations for the hospital health system.
- Oversaw revenue cycle operations team with responsibilities for quality assurance, training, reporting, process improvement, vendor management, and project management. Responsible for Contract Management, Contract Modeling, and Treks eligibility and insurance verification processing for the Health System, as well as state regulatory reporting, electronic data interchange, vendor support services, centralized Clarity reporting, and centralized EPIC revenue cycle systems maintenance.
- Participated with the VP in the contract negotiation process, including contract templates for all provider contracts, negotiation of reimbursement methodology and financial terms for OBHS financial goals and objectives.
- Led and participated in various revenue cycle initiatives to maximize reimbursement and cost containment. Represented One Brooklyn Health System at task forces and committees. Leveraged committee involvement to support the organization’s program and progress in achieving organization-wide results.
- Oversaw, supervised, and coordinated activities with the offshore team responsible for credentialing and licensing, through re-credentialing processes, and ensuring compliance with regulatory guidelines and accreditation standards.
- Extracted from multiple data resources, analytics, and reporting to provide recommendations for process improvements and troubleshooting strategies. Perform Revenue Cycle audits, including contract templates for all provider contracts, negotiation of reimbursement methodology and financial terms for OBHS financial goals and objectives.
- In collaboration with company legal, financial, and compliance teams, developed and submitted claims. Ensured that templates for all provider contracts were updated and modified as required for specific contract negotiations.
- Reviewed, created, and submitted claims. Directed the administrative interface with Medical Staff Leaders and Medical Staff organization and hospital administration, and Athena and other databases.
- Monitored the effectiveness of team activities to ensure productivity is maximized within regulatory guidelines and assure continuing compliance.
DIRECTOR – MEDICAL STAFF AFFAIRS
MOUNT SINAI SOUTH NASSAU
01.2015 - 01.2020
- Responsible for the oversight and coordination of all functions and activities of the Medical Staff Office administration department, credentialing (over 2,000 practitioners), strategic planning, oversight of budgets, staffing, short- and long-range planning, program development, policy, and procedures.
- Developed of the provider network strategy, provider contracting, provider relations, and operations to support provider service, network development, provider education, and product and market expansions. Ensured compliance with local, state, and federal regulation and regulatory agencies, offering efficiency in services and delivery of optimal customer service.
- Directed all aspects of the licensing and credentialing functions of appointments and reappointments, expirables (license, DEA, malpractice), privileges (disaster, temporary, modifications), and payer enrollment. Assisted in implementing and maintaining audit activities necessary for the continuous quality improvement program.
- Ensured credentials and privileges of all members of the medical and professional staff were in conformance with the hospital staff bylaws, rules and regulations, hospital policy and procedure, NY State regulations, Joint Commission, and CMS standards.
- Coordinated and maintained Medical Staff Office governance documents such as medical staff bylaws, rules and regulations, and other documents (organization and functions manual, credentials policy, etc.) and policies and procedures of the Medical Staff Office. Assured that there was a review of existing policies and governance documents regularly and recommended changes to the Medical Executive Committee/Medical Board as appropriate.
- Worked with other hospital personnel to ensure that practitioners practiced within the scope of their privileges. Interpreted, developed, and implemented practices of all systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies, e.g., CMS, TJC, NCQA, and URAC.
- Maintained computer systems and applications, including relational databases (Crimson, Tableau, and Premier) to perform analysis and generate reports on physician performance, e.g., core measures and other meaningful quality data review, performance improvement metrics (Focused and Ongoing Professional Practice Evaluations). Received, analyzed, and evaluated reported findings, submitted corrective action, drafted findings, conclusions, and made recommendations to support the management of the status and progress of inspections.
- Directed the administrative interface with Medical Staff Leaders and Medical Staff organization and hospital administration, and governing body, and hospital departments to assure and enhance effective relationships.
- Responsible for compliance with delegated Managed Care credentialing contracts, audits, policies, and procedures. Performed periodic analysis of the provider network from a cost, coverage, and growth perspective.
- Responsible for the administration and coordination of credentialing workflows, ensuring quality assurance and continuous operational performance by the hospital, while overseeing credentialing workflows, ensuring quality assurance, and continuous operational performance.
SENIOR ASSOCIATE DIRECTOR HOSPITALS – CREDENTIALING/MANAGED CARE
NORTH BRONX HEALTHCARE NETWORK/HEALTH AND HOSPITAL CORPORATION
01.2006 - 01.2015
- Responsible for the operational oversight of a two-network Department of Credentialing/Payer Credentialing (over 1,800 practitioners).
- Reviewed, designed, and implemented processes surrounding admissions, pricing, billing, third-party payer relationships, compliance, collections, and other financial analyses to ensure that clinical revenue is effective and properly utilized.
- Oversaw Managed Care and Provider Network contract negotiations and maintenance. Building and maintaining strong relationships with health plan partners and other industry stakeholders to develop brand recognition for the Company.
- Created and updated documentation on processes and workflows. Lead Joint Operation Committees (JOC) of National Facility/Ancillary provider groups, driving the meetings in the discussion of issues and changes, specifically highlighting strategic opportunities.
- Performed root cause analysis to identify opportunities for claims processing process improvements and/or automation, and implemented new procedures. Oversaw the updating and maintenance of providers’ CAQH, PECOS, and payer credentialing portals.
- Oversaw facility and provider credentialing and re-credentialing (340 practitioners), ensuring provider enrollment was executed promptly. Determined if clinical staff were meeting regulatory guidelines, objectives, and goals, and monitored and coordinated the credentialing review processes. Timely monitored and audited payer/contractual performances on a quarterly and yearly basis.
- An affiliate of Albert Einstein College of Medicine of Yeshiva University
Education
M.B.A. - Healthcare Administration and Finance
Wagner College
Staten Island, New YorkB.A. - History/Chemistry
York College, City University of New York
Skills
- Strong process improvement skills with experience implementing credentialing technology and workflow automation Ability to manage both direct and indirect remote and offshore employees, ensuring internal controls were followed Proactively worked with operations leadership on effectiveness to ensure compliance
- Comprehensive knowledge and experience with: ACCME, COMPA, CPME, HRSA, ADS, IRB, ACStip, ACGME web ADS, ERAS, NRMP surveys and national reports, and RRC Health and Hospitals Annex Reporting, HCAHPS, Press Ganey, and HEDIS/QARR PCMH (patient-centered medical home), ACO (accountable care organization) Delivery System Reform Incentive Payment Program (DSRIP) HRSA Electronic Workbook and grants Experience with CAQH Proview database, NPI, NPPES websites, and maintaining EDI, EFT, and ERA processes Meaningful Use measures
- Microsoft Office Suite: Access, Excel, Outlook, PowerPoint, MS Project, Visio Microsoft 365, ChatGPT Morrisey MSO for Windows, Visual Cactus, Web-based Cactus (SYMPLR), ECHO, Crimson Midas Seeker Midas Care Management IntelliSoft Credentialing Managing, HealthStream – Credential Stream (Verity) Meeting Pro, Budget System, Allscripts, Epic, 10e11, eCW, Siemens (Executive View/Analytical Tool), OPTIMUM and ORSOS HR-PeopleSoft and Lawson Performance Yard Tableau Athena Net Microsoft TEAMS, Smart Sheets, SharePoint, and Premier
- LEAN Methodology – Green and Bronze Belt Certified Apply Lean Six Sigma improvement methodologies to optimize workflows Certified Medicaid/Marketplace Assessor Notary Public Member of the Greater New York Hospital Association, American College of Healthcare Executives, and the National Association of Medical Staff Services Actively participating in a CPCS procession program
- Proficiency in credentialing standards for facilities, hospitals, and health plans, medical terminology, and business management
Timeline
CONSULTANT – OPERATIONS (Per Diem)
AVALANCHE HOME CARE INC.
02.2025 - Current
DIRECTOR – CREDENTIALING/PAYER ENROLLMENT OPERATIONS
BROWNSVILLE MULTIFAMILY HEALTH AND WELLNESS CENTERS
01.2024 - Current
DIRECTOR – REVENUE CYCLE AND MANAGED CARE
START TREATMENT AND RECOVERY SERVICES
01.2023 - 01.2024
DIRECTOR – PAYER ENROLLMENT/REVENUE CYCLE (REMOTE, CONTRACTED)
ONE BROOKLYN HEALTH SYSTEM
01.2021 - 01.2022
DIRECTOR – MEDICAL STAFF AFFAIRS
MOUNT SINAI SOUTH NASSAU
01.2015 - 01.2020
SENIOR ASSOCIATE DIRECTOR HOSPITALS – CREDENTIALING/MANAGED CARE
NORTH BRONX HEALTHCARE NETWORK/HEALTH AND HOSPITAL CORPORATION
01.2006 - 01.2015
B.A. - History/Chemistry
York College, City University of New York
M.B.A. - Healthcare Administration and Finance
Wagner College