LaSonja Martin-James
Glenn Heights
Summary
Credentialing Coordinator with expertise in managing credentialing processes for healthcare professionals. Proficient in NCQA standards and Medicare/Medicaid regulations, ensuring compliance and accuracy in provider databases. Proven track record of enhancing efficiency in credentialing workflows and maintaining high compliance rates. Strong communication and problem-solving skills facilitate adaptability in dynamic work environments.
Overview
19
19
years of professional experience
Work History
Credentialing Coordinator(Contractor)
Dean Health Plan/Medica
06.2023 - Current
- Managed end-to-end provider credentialing process, ensuring adherence to industry standards.
- Coordinated timely processing of reappointment applications per NCQA requirements.
- Executed PSV on all applications to verify accuracy and compliance.
- Ran daily reports from Echo for updated credentialing data.
- Followed up with non-responsive practitioners to secure necessary information.
- Mailed out recredentialing and organization applications promptly.
- Assisted in auditing processes to ensure compliance and accuracy.
- Oversaw special projects while meeting monthly production goals and tight deadlines.
Credentialing Coordinator (Contract Role)
Hardenberg Medical Staff Service
04.2022 - Current
- Company Overview: Medical Services Professional Independent Contractor - Nationwide
- Perform a range of duties within the medical staff departments for acute care and teaching hospitals of various sizes across the United States, in Credentialing Coordinator roles.
- Responsibilities included processing of applications for appointment and reappointment, CME weekly and monthly meetings.
- As CVO Specialist accountable for sending, receiving, and processing primary source verification for initial and reappointment and they relate to clinical privileging and payor enrollment.
- Additionally, responsible for ensuring physicians, clinicians, and other providers are credentialed, appointed, and privileged with health plans, hospital medical staff's, other patient care facilities, physician organizations and other network arrangements such as a clinical integrated network ('CIN') and accountable care organization ('ACO').
- Through numerous entry points throughout the system, responsible for establishing and then leading/managing the standards, governance, process-flows.
- Lastly, accountable for maintaining up-to-date data for each physician, clinician, and provider in the database and online system, including data and reports used for payer roster management.
- This includes initial credentialing and re-credentialing as required by regulatory bodies, either every two years, three years, or other date spans as required.
- Demographic data is to be gathered and stored in a standardized manner, including proof of timely renewal of licenses and certifications.
- Medical Services Professional Independent Contractor - Nationwide
Credentialing Contractor/Payor Enrollment
TeamMedGlobal
Dallas
12.2022 - 05.2023
- Updated provider CAQH, Re-attests provider information every 120 days in CAQH
- Manage the completion and submission of provider enrollment applications with Medicare and Medicaid with the commercial and government program.
- Ensuring the site and providers at that location are set up correctly for billing purposes.
- Work on Special project
- Follow up with non-responsive practitioners and assist with obtaining Credentialing information.
Credentialing Contractor (Contract Role)
Pyramid Consulting
Dallas
09.2022 - 03.2023
- Completion of the standardized credentialing applications and provider forms for initial and reappointment cycles
- Process required primary source verifications for providers according to NCQA standards.
- Research, review, and articulate missing/missed components to complete state-specific credentialing requirements.
- License Coordinator- submit license to different states for Medical Doctor, work with FCVS-FSMB to ensure application in process.
Credentialing Coordinator (Contract Role)
Radgov Inc.
York Town
04.2022 - 09.2022
- Responsible for credentialing and recredentialing, application provider joining WellSpan Hospital Network
- Processes initial provider, initial credentialing and recredentialing
- Obtain provider references.
- Creates, assembles and prepares application packet for providers to complete, reappointment applications for WellSpan Health entities and submits applications to payers.
- Completes primary source verifying provider credentials per established policies and procedures.
- Enters provider credentials and application requirements into Cactus, CAQH
- Initiates mandated queries, both federal and state, for all initial applicants and those due for recredentialing with the National Practitioner Data Bank
- Re-attests provider information every 120 days in CAQH
- Runs reports and complete Medicare and Medicaid revalidations for WellSpan Medical Group (WSMG) & Hospital Based providers.
- Follows up, receives and documents confirmations on all initial enrollment status and changes for health plan providers with which WellSpan participates.
- Runs expiring provider credentials reports, notifies practices and updates Cactus accordingly.
- Assists with helping resolve claim issues by contacting applicable provider reps.
- Change letters.
- Creates and submits letters to update payers, Cactus, CAQH, NPI and other stakeholders of any changes and terms to provider data per 25 payer requirements.
Credentialing Coordinator- hospital credentialing (Contract Role)
Matrix Medical Network
Scottdale
07.2021 - 02.2022
- Responsible for credentialing and recredentialing Matrix Medical Network (Matrix) practitioners
- Perform the initial credentialing and recredentialing functions for employed and contracted Matrix practitioners, which may include collaborating physicians and Locum Tenens.
- Review practitioner applications for completion and accuracy and ensure appropriate follow up; monitor and report on the credentialing progress of each practitioner
- Maintain timely and accurate data entry and periodically revise practitioner data in the Matrix credentialing database; maintain practitioner paper and electronic data files for Matrix practitioners
- Ensure employed practitioners are enrolled under the Matrix professional liability insurance plan; monitor and report progress on each practitioner
- Respond to all practitioner, client health plan and internal inquiries in a timely manner within one business day
- Monitor expiring licensure, board and professional certifications and other expirable documents with practitioners within the prescribed Matrix timeframes as outlined in the policies and procedures, assisting practitioners with timely renewal as appropriate and escalating to manager and field management as appropriate
- Conduct sanctions and compliance monitoring and alert Manager of any undisclosed negative findings immediately
- Adhere to Matrix policies and procedures including timely delivery of completed work and use of resources
Credentialing Coordinator (Contract Role)
Robert Half
San Diego
12.2020 - 05.2021
- As Credentialing Coordinator ensure all necessary paperwork is timely and accurate completion of the standardized credentialing applications and provider forms for initial and reappointment cycles
- Contact and assist providers with the information needed to complete the credentialing process
- Process required primary source verifications and sanctions for providers according to NCQA standards.
- Prepare and organize credentialing files
- Obtain proper signatures from providers when necessary
- Research, review, and articulate missing/missed components to complete state-specific credentialing requirements.
- Communicate continually with physician offices following up on outstanding information
- Prepare file for Medical director signature
- Clerical support including data entry, filing, copying, scanning, faxing, etc. is required
Credentialing Coordinator
Methodist
Dallas
11.2017 - 11.2020
- Responsible for processing applications for providers that are going through the initial and re-credentialing process.
- Meets credentialing/re-credentialing deadlines
- Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality
- Strong ability to multi-task and work independently
- Maintains and tracks professional license renewals
- Coordinates and processes all application for reappointment on a timely manner as required by TDI and NCQA
- Prepare files for annual audits by Manage Care Plans
- Tracks and maintains all License, DEA, Malpractice Insurance, and Board Certification expiration dates
- Follow up with non-responsive practitioners and assist with obtaining credentialing packets and other documentation
- Enter and update practitioner information in the credentialing database maintaining data(MD-Staff)
- Run Reports from MD-Staff
- Scan documentation of approved membership/privileges and privilege letters and ensure timely notification is sent to practitioners
- Ensuring the site and providers at that location are set up correctly for billing purposes.
- Manage the completion and submission of provider enrollment applications with Medicare and Medicaid
- Follow up with Medicare and Medicaid application
- Work on Special project
- Analyzes physician enrollment, re-enrollment, and dis-enrollment data to determine timely completion in line with contract terms.
- Supports the Provider Relations Director, Credentialing Management, Quality Management and Regulatory Compliance with requested data reporting
- Responsible for facilitating monthly Credentialing Committee meetings
Credentialing Coordinator
Blue Cross - BCSTX
Dallas
03.2006 - 09.2017
- Responsible for processing applications for providers that are going through the credentialing and recredentialing process.
- Verify license using TX State Medical Board
- Verify to see if a provider is Board Certified
- Request site visit for all PCP providers (primary care providers). Credential NM, OK, IL providers
- Verify provider's hospital privileges
- Review file for completes
- Verify hospital privileges
- Verify education
- Credential NM, OK, IL providers
- Make sure all providers meet NCQA, URAC, and TDI standards Quality Co-workers' files
- Pull reports daily
- Ensures follow-up with providers when applications are incomplete by collaborating with the network contracting and provider relations departments
Education
Associate Certificate - Associate Certificate Business
National Education Center
Dallas, TX12-1991
High School Diploma -
Varnado High
Varnado, La05-1990
Skills
- Primary source verification and credentialing management
- Regulatory compliance and NCQA standards
- Provider enrollment and re-credentialing processes
- Healthcare administration
- Problem solving and time management
- Effective communication skills
- Credentialing software proficiency
- Data entry and background checks
- Facility and solo practitioner credentialing
- License verifications
Timeline
Credentialing Coordinator(Contractor)
Dean Health Plan/Medica
06.2023 - Current
Credentialing Contractor/Payor Enrollment
TeamMedGlobal
12.2022 - 05.2023
Credentialing Contractor (Contract Role)
Pyramid Consulting
09.2022 - 03.2023
Credentialing Coordinator (Contract Role)
Hardenberg Medical Staff Service
04.2022 - Current
Credentialing Coordinator (Contract Role)
Radgov Inc.
04.2022 - 09.2022
Credentialing Coordinator- hospital credentialing (Contract Role)
Matrix Medical Network
07.2021 - 02.2022
Credentialing Coordinator (Contract Role)
Robert Half
12.2020 - 05.2021
Credentialing Coordinator
Methodist
11.2017 - 11.2020
Credentialing Coordinator
Blue Cross - BCSTX
03.2006 - 09.2017
Associate Certificate - Associate Certificate Business
National Education Center
High School Diploma -
Varnado High
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