Linette Gadwah
Fairdale,KY
Summary
Years of processing Enrollment Applications, Credentialing Analysis, Contract Negotiator for managed care insurances companies and credentialing/re-credentialing medical staff privileges for Physicians, Advanced Nurse Practitioners, Fellows, Residents Physician Assistants and other Allied Health professionals. Coordinated and scheduled new staff onboarding, with experience in supporting HR recruitment and training new employees. Experience in enforcing regulatory compliance, policies and regulations with both Federal and State laws as well as associated regional applicable regulations. Expert-level proficiency in electronic online credentialing and enrollment application system, applications combined with years of industry success. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
22
22
years of professional experience
Work History
Provider Enrollment Coordniator
Synergy Health Partners Remote
Louisville, KY
11.2021 - Current
- Responsible for completion and follow-up of physicians and physician groups for medical staff privileges and payer enrollment applications including Medicare, Medicaid and top commercial payers for multiple states
- Process changes and terminations from departments and practices timely
- Investigate provider claim holds, and submit request to release hold once confirmation of payer set up is received
- Maintain integrity of physician and practice information in physician enrollment database and outside credentialing databases
- Responsible for credentialing and re-credentialing for all internal providers with IPA's, medical groups, and health plans on ongoing basis
- Maintains copies of licensure, certificates, and other documents necessary for enrollment process, and conducts verification of all data, ensuring accuracy and timely entry of information
- Work with health plans to complete rosters, provider documents, audits, and respond to internal inquiries
- Adheres to deadlines and enrollment schedules by tracking files through all stages
- Communicates with providers, payers, MSOs, CVOs via email, phone, and mail
- Ensures interpretation and compliance with appropriate credentialing regulations
- Administers credentialing and enrollment functions and analyzes workflow with accuracy and attention to detail
- Receive, review, analyze and process onboarding requests, provider enrollment and re-enrollments, and updates to provider information for Delegated, Non-Delegated and Government credentialing
- Provide timely feedback on incomplete data/documents utilizing automated checklists and reports, identifying and escalating critical issues to ensure efficiency and timeliness
- Log, troubleshoot and track enrollment, credentialing, contractual, fee schedule and demographic payer issues
- Participate in conference calls or face-to-face meetings with payers with focus on detail- oriented tracking of payer issues.
Manager Care Contract Manager
BrightSpring Healthcare Remote
Louisville, Kentucky
02.2021 - 08.2021
- Responsible for identifying and solidifying managed care and other commercial product contract opportunities across business lines
- Worked with local Executive Director leadership on rate negotiations specific to each branch
- Identified opportunities within payer plans, communicating value proposition of business line within plan products and demographic markets both to payers, leadership and operations
- Worked with leadership to create processes to support contract deliverables
- Articulated and worked with Information Technology billing support to facilitate necessary report or data to facilitate contract award and compliance
- Obtained final approval and sign off through Vice President Contracting and Contract work flow
- Researched and articulated regulatory requirements, deliverables as pertain to Medicare and Medicaid across multi-state operations and execute on requests to drive operation growth
- Worked with lines of business leadership to stay on top of and drive changing payer landscape
- Maintained fully executed contracts and other pertinent contract documents in share drive and system databases
- Maintained tracking system for new and revised agreements
- Coordinates and communicates contractual information to appropriate departments
- Prepared, updated and maintained files and database for all assigned provider contracts
- Reviewed provider contract negotiations, including FFS, capitation models, and pay for performance models is preferred
- Ensured contract loads are accurate and validates system calculations for loaded contracts
- Managed contract administration maintenance of internal reference guides, directories and databases of payer participation, billing and compliance requirements and fee schedules
- Developed and maintains strong relationships with key stakeholders in community, with payers in both commercial and government sectors
- Maintained close working relationship with contract and credentialing staff among payer sources
- Acted as liaison between entities and departments and payers regarding contract implementation, ongoing contract compliance, payer operational and contract compliance issues and contract negotiations
- Reviewed payer provider directories and provided information to support payers in appropriately including participating providers and services in provider directories for enrollees.
- Onboarded new employees with training and new hire documentation
- Trained personnel in equipment maintenance and enforced participation in exercises focused on developing key skills
Credentialing Analyst
BolderHealthcare Solutions Remote
Louisville, KY
06.2018 - 11.2020
- Responsible for completion and follow-up of physicians and physician groups for medical staff privileges and payer enrollment applications including Medicare, Medicaid and top commercial payers for multiple states
- Collected and analyzed applicant's applications and required attachments for initial privileging appointments and re-appointments to Medical Staff according to hospital, medical association functions of surgical centers and hospitals risk management
- Monitored and updated each physician and corresponding physician groups with the National Plan & Provider Enumeration System, (NPPES), as per Federal requirements
- Enrolled, monitored, and updated Council For Affordable Quality Healthcare, (CAQH), for each physician, and physician groups
- Distributed, and educated all pertinent staff members on medical insurance plan participation and non-participation
- Updated current on all Federal and State mandates in regard to health insurance plans, with thorough understanding of medical insurance carrier contracts with practice
- Coordinated and scheduled new staff training and orientation sessions
- Assisted in coordinating and processing background checks and pre-hire drug screenings
- Reported anticipated credentialing delays to management and collaborated to develop solutions
- Collected and processed verification, criminal background, and accreditation data to verify completeness and accuracy
- Multi-tasked and prioritized workload resulting in timely submitting and processing of provider applications
- Research insurance issues and effectively communicate with billing staff progress of approved provider numbers
- Developed and maintained strong relationships with clinic and hospital staff to obtain necessary credentialing documents required to complete and submit accurate applications
- Collected and maintained files in relation to credentialing of network providers including current provider licenses, DEA certificates, malpractice insurance, board certifications, and other pertinent forms need for enrollment
- Routinely reviewed and updated provider files and rosters including, but not limited to individual/group CAQH profiles, payer databases, NPI/NPPES, PECOS, and any others
- Maintained relationships with external managed care organization and clients as required
- Provided education and training to providers/producers and/or internal customers on credentialing policy and procedures
- Works collaboratively with network staff (local and regional) in issue/problem identification and resolution
- Provided coaching/mentoring to peers and co-workers
- Created and managed action plans for assigned projects relative to special network initiatives, workflow or quality improvements
- Determined potential for adverse business risk, including good investigation skills
- Provided ongoing support to department members in completing research and analysis to resolve complex issues raised by providers/producers and other internal/external customers.
Credentialing Analyst
Aetna Healthcare
Louisville, Kentucky
08.2016 - 05.2018
- Reviewed, analyzed, evaluates, validated provider/producer information against business/credentialing requirements and maintains information in Credentialing data bases
- Supported extensive research and analysis of sensitive provider/producer issues; addresses data integrity issues
- Participated in development of credentialing processes and workflows
- Identifies improvement opportunities and recommends enhancements and workable solutions
- Provided telephonic education to providers/producers on credentialing policies and procedures
- Review/credentialing verification items for CPC, QNXT, EPDB, EPC, CAQH, CARDS, Netbus, and CMS
- Provided ongoing support to department members in completing research and analysis to resolve complex issues raised by providers/producers and other internal/external customers
- Responded to network or provider/producer inquiries, including contracting and credentialing policy, procedures, credentialing status
- Performed data entry and systems maintenance as needed; align data across systems
- Trained staff how to liaise between billing department, provider representatives, and physicians
- Trained all staff on use of Corporate Credentialing software systems, Navinet, and Outlook, on "best practice" for utilizing internet for medical insurance carriers.
- Conducted primary source verifications such as background checks and board certifications
- Obtained NPI numbers for providers and facilities and updated existing profiles
- Enrolled providers and Medicaid, Medicare and private insurance plans
- Conducted periodic compliance audits and reviews to identify areas of improvement
- Confirmed data and licensing information through investigations and notified violators of required changes to bring operations into compliance
- Investigated locations to confirm license data, conducted background checked and assessed premises for compliance with licensing requirements
Compliance Officer/Credentialing Coordinator
First Urology, PSC
Louisville, Kentucky
02.2016 - 07.2016
- Initiated and maintained credentialing/re-credentialing and payer enrollments processes for physicians and allied health providers in compliance with Federal, State Programs, and Facility requirements
- Organized, executed, and delivered all chart audit requests from various medical insurance carriers, workers compensation carriers, and attorneys
- Conducted internal chart audits to ensure compliance policies are adhered to by clinical staff
- Conducted monthly peer reviews with physician/partner responsible for issues of compliance
- Managed over negative findings from peer review with physician of record and any assisting clinical staff
- Credentialed all current and incoming physicians with various medical insurance carriers
- Trained all staff on state and federal compliance policy and procedures
- Reported anticipated credentialing delays to management and collaborated to develop solutions
- Coordinated and processed background checks and pre-hire drug screenings for medical staff
- Verified primary source competences, medical practitioners and/or allied health professional's education, residency, internships, fellowships, additional formal training, relevant board certifications, health care affiliations, work history, military experiences, professional references, licensure and certifications, DEA certificates, malpractice coverage, run background checks, reported quality summaries, including both Focused Ongoing OPPE's
- Acted as liaison between medical centers and hospitals, managed care contractors
- Conducted facility and managed care delegated credentialing audits and performs internal file audits
- Maintained managed care validations, supports compliance utilization management, claims, and credentialing to address pending claims and oversight audit processes
- Researched and monitored changes to laws and regulations, both Federal and State laws as well as associated regional applicable regulations
- Maintained working knowledge of HIPAA, HHS and FWA, trains all employees on management, compliance regulations and practices privacy protocols in accordance with company policies
- Provided HIPAA Orientation, breach investigation and continued education for organization, reported to HHS
- Supported operations of privacy services in developing, coordinating and supporting privacy related functions and activities, implementing of privacy policies, procedures and best practice
- Reviewed candidate credentials to verify compliance with program requirements and state and federal standards
- Coordinated and scheduled new staff training and orientation sessions
- Collected and processed verification, criminal background, and accreditation data to verify completeness and accuracy
- Coordinated and scheduled medical staff educational training and orientation sessions.
- Conducted primary source verifications such as background checks and board certifications
- Obtained NPI numbers for providers and facilities and updated existing profiles
- Enrolled providers and Medicaid, Medicare and private insurance plans
- Collected and analyzed information to monitor compliance outcomes and identify and address trends of non-compliant behavior
- Developed and implemented onboarding and orientation programs for new employees
Medical Staff Coordinator
Norton Healthcare
Louisville, Kentucky
09.2011 - 01.2016
- Coordinated and performs all aspects of credentialing, including appointment, reappointment, privileging, and proctoring practitioners
- Collected and analyzes applicant's applications and required attachments for initial privileging appointments and re-appointments to Medical Staff according to hospital, medical associations functions of hospitals risk management
- Verified primary source competences, medical practitioners and/or allied health professional's education, residency, internships, fellowships, additional formal training, relevant board certifications, health care affiliations, work history, military experiences, professional references, licensure and certifications, DEA certificates, malpractice coverage, ran background checks, report quality summaries, including both Focused Ongoing OPPE's and privileges applicant is requesting
- Coordinated site specific credentialing processes and privileging processes, meets regulatory compliance for medical staff, orientation program and educational requirements for new medical and allied health staff appointees, and serves as liaison of hospital services to medical staff
- Provided administrative support for medical staff leadership
- Assisted with monthly medical staff committee meetings, drafting agendas, taking and drafting minutes as need basis; follow up as required resolve committee decision issues to ensure compliance with Medical Staff Bylaws, Rules and Regulations, and applicable policies and procedures with quality patient care
- Maintained confidential credential files and electronic medical staff database
- Exhibited high degree of responsibility for confidential matters
- Monitored medical services to assess quality of care and appropriate allocation of resources
- Developed and maintained computerized record management systems to store and process data such as personnel activities and information.
House Mother, Stay, Home Mother
Louisville, Kentucky
01.2009 - 09.2011
Network Administrator/Credentialing and Enrollment
Spine Surgery, PSC
Louisville, Kentucky
01.2002 - 01.2009
- Acted as Credentialing Analysis and Contract Negotiator with contracted insurance companies and practice's claim management process for pay-for-performance fees and performance measures
- Served as liaison with Medical Staff Departments/Hospital Divisions and outside agencies (e.g)
- Initiated and maintained all credentialing/re-credentialing activities with contracted /non- contracted insurances companies, along with multi-hospital privileging for physicians, nurse practitioners, fellows, residents and surgical assistance
Advocated for practice quality assurance by updating staff on new policies and regulations mandated by insurance companies and hospital bylaws and policies applicable to state and federal laws requirements and regulations - Primary source verifications for State Medical Boards, National Practitioner Data Bank, Board Certification agencies, Drug Enforcement Agency, malpractice insurance carriers and multi Managed Care agencies
- Reviewed candidate credentials to verify compliance with program requirements and state and federal standards
- Collected and processed verification, criminal background, and accreditation data to verify completeness and accuracy
- Reported anticipated credentialing delays to management and collaborated to develop solutions
- Coordinated and processed background checks and pre-hire drug screenings
- Coordinated and scheduled medical staff training and orientation sessions
- Identified effective recruiting strategies to deliver qualified candidates for hiring consideration.
- Demonstrated strong analytical, troubleshooting and problem-solving skills
- Improved overall user experience through support, training, troubleshooting, improvements and communication of system changes
- Documented support procedures, processes and solutions in centralized systems, enabling user self-service
- Developed and maintained courteous and effective working relationships
- Participated in team projects, demonstrating ability to work collaboratively and effectively
Medical Art Illustrator
01.2007 - 01.2008
- Orthopedic Patten/surgical procedural instructional manual
Kentucky Secretary
Kentucky Medical Association Staff Services
, KY
01.2004 - 01.2006
Education
JCTC
Louisville, KYSkills
- Proficient with MCO payers, hospital departmental policies, procedures, guidelines, accreditation and regulatory standards for managed care organizations
- Proficient in Medical Staff Bylaws, Procedure Rules and Regulation Standards, Joint Commission Standards, CMS Guidelines, Federal Regulations, MCO validation
- Primary verification with certification and educational boards, AMBA/AOA, State licensure/DEA, Certification Boards, The Work Number and other regulatory or accreditation bodies
- Medical staff data systems in MD Staff, EMR, iSalus, SharePoint, Trizetto, Payspan, QNEX, CAPS, CAQH, OutLook, Office Cloud, Skype, WebEx, Office 365, Salesforce, Echo and various other internet applications related to provider enrollments and credentialing procedures
- Verity/Credential Stream, Raintree, eVips/Vistar, Teams, Microsoft Windows applications, Sharepoint, Teams, Skype
- Knowledge and experience of provider paper and electronic applications, analyze and maintaining demographics data and rosters in electronic system programs
Timeline
Provider Enrollment Coordniator
Synergy Health Partners Remote
11.2021 - Current
Manager Care Contract Manager
BrightSpring Healthcare Remote
02.2021 - 08.2021
Credentialing Analyst
BolderHealthcare Solutions Remote
06.2018 - 11.2020
Credentialing Analyst
Aetna Healthcare
08.2016 - 05.2018
Compliance Officer/Credentialing Coordinator
First Urology, PSC
02.2016 - 07.2016
Medical Staff Coordinator
Norton Healthcare
09.2011 - 01.2016
House Mother, Stay, Home Mother
01.2009 - 09.2011
Medical Art Illustrator
01.2007 - 01.2008
Kentucky Secretary
Kentucky Medical Association Staff Services
01.2004 - 01.2006
Network Administrator/Credentialing and Enrollment
Spine Surgery, PSC
01.2002 - 01.2009
JCTC
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