Sheena Jones

Assisted in resolving provider issues and maintaining provider tracking databases. Supported network management department by contributing to root cause analysis and developing reports related to provider contract configuration accuracy and issue resolution.

• Responsible for the Delegation email inbox, which includes responding to Delegates, we currently have 81 and all Health Partner Reps in a timely manner.
• Research and answer any questions from the above to the best of my ability.
• Assist my fellow co-workers who are assigned Delegated Entities with any questions they have from their roster assignments or questions they receive from the delegation inbox.
• Complete termination rosters for delegation, Ohio Market specific to ensure that we stay in compliance within the 5 day SLA.
• Any other duties as assigned.

• Responsible for accurate and timely processing of provider additions, terminations, and changes to meet regulatory requirements.
• Assure that data entry activities are accurate, timely, and compliant with state and regulatory standards.
• Respond to calls and emails from internal/external customers.
• Continuously monitor all work queues to ensure Turn Around Times (TAT) are being met.
• Actively participate in HPLC meetings as appropriate.
• Assist with performance evaluations, hiring, and disciplinary action.
• Maintain time sheets for non-exempt employees.
• Supervise staff for quality review, performance feedback, disciplinary issues, and merit/bonus appraisal review.
• Tracking and reporting of staff production and quality; review in monthly 1:1s.
• Provide mentoring, training, and ongoing education regarding optimal performance and Standards of Excellence.
• Perform any other job-related duties as requested.

• Ensure delegated credentialing activities are compliant with NCQA, and all state and federal regulations.
• Act as liaison between CareSource and delegates as it pertains to credentialing.
• Responsible for initiating contact with proposed new delegate and work with HP and/or internal departments to ensure all requirements for audits, contracting and state approval are met, perform oversight for entities delegated for credentialing activities in all states which CareSource operates.
• Conduct pre-delegation and annual assessments for ongoing delegation oversight and submit with appropriate reporting to state as required prior to submission timeline.
• Assist HP with all new Delegation contracting.
• Present pre-delegation and annual review results for delegated entities to the Credentialing Committee for review and approval/denial, create and maintain electronic binders (folders) that include pre-delegation and annual reviews, monthly roster receipts, quarterly reports, contractual documents, etc.

• Accurately load provider information into Facets and Cactus.
• Ensure that all providers are credentialed and contracted prior to loading.
• Monitor and answer emails promptly.
• Communicate with Delegated entities outside of CareSource.
• Monitor and complete large monthly rosters.
• Research and resolve issues for delegates and Health Partner Representatives.
• Complete Tasks within a timely manner, meeting our SLA requirements.
• Assist in escalated issues for Delegates and providers.

• Clinical- Room patients, obtain vitals-blood pressure, pulse and temperature, weight and height, obtain laboratory testing as needed and ordered by physician.
• Assist physician with minor in-office surgical procedures, able to set up sterile surgical area, sterilize equipment.
• Obtain brief reason for visit, review current medications, update patient's information at visit and any documentation of what was done at visit through EMR.
• Kept medical supplies in sufficient stock by monitoring levels and submitting replenishment orders before depleted.
• Assisted with routine checks and diagnostic testing by collecting and processing specimens.
• Prepared and administered medications to alleviate patient symptoms.
• Verified appropriate lab couriers picked up collected lab specimens.