Summary
Overview
Work History
Education
Skills
Accomplishments
Certification
Social Platform
Languages
Timeline
Generic

LOURDES ESPADA

Summary

Resourceful, hands on manager with 20 years of healthcare experience. Expert in state and federal regulatory requirements and NCQA accreditation standards for credentialing/recredentialing programs. Creates effective programs and consistently meets deadlines to support organizational objectives. Excellent at building relationships, negotiating conflict, developing people, managing projects and forging solid relationships with internal and external partners to achieve results in both private practice and corporate settings.

Administrative professional skilled in optimizing office workflows and managing diverse administrative tasks. Proven ability to support higher management through effective scheduling and coordination. Strong focus on team collaboration and adaptability to changing organizational needs, ensuring seamless operations and goal achievement.

Overview

24
24
years of professional experience
1
1
Certification

Work History

Accreditation and Delegation Administrator

Yale New Haven Health System
12.2016 - Current
  • Responsible for maintaining the Accreditation on National Committee on Quality Assurance
  • Oversight of payer delegation agreements (13)
  • Responsible for writing and implementing all NEMG internal credentialing policies, procedures
  • Initial Credentialing applications over 1300 practitioners and prepare for the Credentials Committee approval to ensure adherence to NCQA standards; to remain compliant and continue to remain accredited
  • Responsible for maintenance of payer delegation agreements; ensuring they are consistent and current, and with performing timely payer reporting and external audits
  • Establish and maintains and manages delegated credentialing agreements with all commercial payers
  • Responsible for initiating and continuing communication with payers to pursue delegated credentialing arrangements whenever possible
  • Reviews delegation agreements and considers and negotiates terms to achieve consistency across all agreements & Initiates review of agreements with Legal

Credentialing Manager

HealthyCT (HCT), Inc.
02.2013 - Current
  • Developed, implemented and continuously improve HCT's credentialing program, policies and procedures for this new health insurance CO-OP (Consumer Operated and Oriented Plan)
  • Manage the internal, CVO and delegated credentialing and recredentialing processes for a network of 12,000+ practitioners and organizational providers; ensure compliance with state and federal regulatory requirements and NCQA accreditation standards
  • Participates in site visit preparation for accrediting agency NCQA
  • Communicates new state, federal and accrediting requirements to appropriate staff
  • Responsible for the presentation of applications to the Chief Medical Officer and Credentialing Committee
  • Insure that all decisions are reflected in the database and providers are advised accordingly
  • Oversees committee meetings, including invitation and agendas; convey and set up of committee meetings; manages the completion and distribution of signed meeting minutes
  • Monitors OIG sanctions and state regulatory action reports related to credentialed providers
  • Serves as primary CVO contact and Subject Matter Expert (SME) for all internal and external (applicant and vendor) inquiries; resolves questions and/or obtain missing information or required documentation
  • Develops and nurtures key internal and external relationships to support process efficiency and accuracy; works with partners to identify barriers and implement improvements for timely application processing
  • Supports the Chief Medical Officer and Credentialing Committee; organizes meetings, prepares applicant files, identifies and escalates issues to them and/or HCT Legal or executives as appropriate; follows up on issues, enforces the appeal process
  • Supports the Delegation Oversight Committee: conducts oversight review, pre-assessments and annual audits of contracted delegates, creates/presents accurate reports and executes corrective action plans
  • Serves on internal project teams; liaison to network management, sales, other staff and HCT leaders
  • Consults with IT to update practitioner and provider information in internal databases and systems; maintains HCT access to required systems (i.e
  • CAQH, NPDB, CVO etc.)
  • Audits online provider directory to ensure member access to current, accurate information

Credentialing Manager

Onward Healthcare, Inc.
01.2012 - 02.2013
  • Managed approximately 500 traveling clinical professionals and 250 vendors; responsibilities ranged from applicant screening, hiring, supervision and reimbursement to apartment acquisition and logistics
  • Responsible for drug, background and employment screenings for staffing professionals
  • Managed issue resolution and monitored weekly productivity, conducted annual performance evaluations and periodic counseling sessions
  • Conducted weekly audits of personnel files to ensure compliance with The Joint Commission and appropriate state and federal standards
  • Assisted Director of QM with compliance training for new company employees, internal/external audit activities and personnel issues
  • Provided direct management and support to the Compliance Coordinators; provided status of current compliance issues and identified steps for resolution
  • Instituted a credentialing process for physicians and allied professionals

Credentialing Manager

Health Net, Inc.
04.2004 - 04.2011
  • Ultimately managed 14 FTEs and a $700K budget for one of the largest credentialing organizations in the northeast; supported a network of 64,000 providers
  • Ensured maximum efficiency and accuracy via staff development and performance management, effective work distribution, and implementation of policies and processes to address issues and meet goals
  • Coordinated department events designed to motivate employees; fully leveraged Spot Awards program
  • Served as content expert for credentialing on regional and national committees and boards
  • Collaborated with Provider Network to identify/resolve barriers to timely application processing
  • Implemented best business practice initiatives related to settlement of national class action litigation brought by physicians against the managed care industry
  • Filed and obtained regulatory approval of quarterly NY HPN filings; filed NPDB Integrity filings; created a tracking mechanism for New York provisional credentialing, Implemented New Jersey special needs tracking to meet Medicaid requirements
  • Worked with Legal to manage, resolve and close (with reduced or no sanctions) various regulatory corrective action plans and filings
  • Provided compliance oversight of delegated provider groups, prepared and submitted compliance reports to HNI's Delegation Oversight Committee
  • Developed/Implemented policies and procedures consistent with NCQA, CMS and state regulations
  • Facilitated a work force reduction plan and maintained 100% compliance with credentialing standards
  • Supported the wind down of Health Net business and transition of membership to United Healthcare, including the successful tracking/transfer of 80,000 accurate credentialing files to UHC

Administrative Director of Medical Services

St. Christopher's, Inc. dba Children's Health Services
10.2000 - 11.2003
  • Supported the reconstruction of five not-for-profit medical facilities operating under a $1 million budget and providing comprehensive care to all age groups, with 2,500 patient visits in the first three years
  • Implemented all governmental regulations and agency policies; assisted with annual regulatory quality audits
  • Processed credentialing applications, applied for staff physician hospital privileges and scheduled continuing education for physician staff
  • Scheduled staff coverage for all five medical facilities
  • Negotiated and executed HMO and managed care contracts
  • Indirectly supervised 20 FTE
  • Supervised billing staff and cash receipt postings, accounts receivable and accounts payable functions; facilitated subcontract for third party billing due to HIPAA enforcement
  • Prepared daily, monthly and annual statistical reports related to patient encounters
  • Coordinated fundraising events and community outreach, including blood drives, managed care enrollment and annual family day

Education

Associate of Health & Administration -

Ashworth College
01.2022

Skills

  • Analytical Problem Solving
  • Communication
  • Team Building
  • Flexibility/Adaptability

Accomplishments

  • Successfully managed compliance and accreditation processes by effectively implementing and maintaining regulatory standards during client audits. Led internal audits, identified gaps, and implemented corrective actions to ensure adherence to industry regulations. Developed and enforced comprehensive compliance framework, facilitated team training; and maintained through documentation to support audit readiness. Coordinated with clients to align organizational practices with regulatory requirements, ensuring successful outcomes in external audits and continuous improvement.

Certification

Certified Provider Credentialing Specialist (CPCS), 2016

Social Platform

Facebook, Founder of Accreditation and Managed care group, 2021, Over 300 members have joined in to network and provide support with NCQA, Payer Enrollment questions.

Languages

Spanish
Professional Working

Timeline

Accreditation and Delegation Administrator

Yale New Haven Health System
12.2016 - Current

Credentialing Manager

HealthyCT (HCT), Inc.
02.2013 - Current

Credentialing Manager

Onward Healthcare, Inc.
01.2012 - 02.2013

Credentialing Manager

Health Net, Inc.
04.2004 - 04.2011

Administrative Director of Medical Services

St. Christopher's, Inc. dba Children's Health Services
10.2000 - 11.2003

Associate of Health & Administration -

Ashworth College

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LOURDES ESPADA