Simone Wilson-Adeleke

Leading the credentialing team to ensure the timely and accurate credentialing and recredentialing of providers as per company, regulatory, and client requirements. Establishing and maintaining relationships with the heads of other departments, insurance company contacts, and outside vendors to foster teamwork and the achievement of common goals.

Key Contributions:

• Submission of Dental provider licensing with multiple states
• CMS Medicaid enrollments
• Implementing new credentialing & e-prescribing software systems
• Implemented new policies and practices
• Contracting with new insurance companies
• Worked on acquisitions and transitioning of acquired dental practices
• Obtain and maintain relationships with upper-level executives at multiple insurance companies
• Integrated with the Revenue Cycle team to combat and reduce insurance company denials
• Implementing new /updated departmental processes

Accountabilities:

Credentialing

• Prepared, submitted and tracked provider Dental license applications with multiple state boards.
• Implemented delegation processes with 10 insurance companies.
• Decreased credentialing onboarding turnaround times by two weeks.
• Optimized operational processes using analytics tools to address provider-specific metrics.
• Works with various departments to ensure a smooth transition of providers when on-boarding, for new contracts and during acquisitions.
• Credentialing verification processes
• knowledge of CAQH Payer credentialing processes.
• Knowledge of related accreditation and certification requirements.

Quality Assurance & Compliance

• Analyze and implement process improvements to enhance efficiency of credentialing.
• Conduct on-going evaluations and audits of data integrity.
• Serve as primary resource to employees with regards to issues, interpretation and application of organization and department policies and procedures.
• Create, implement, document and audit policies and procedures.

Engagement

• Worked closely with organizational leadership and board of directors to guide operational strategy.
• Established departmental performance goals and provided feedback for underperforming areas.
• Leveraged professional networks and industry knowledge to strengthen payer relationships.
• Drafted and distributed reports to assist board members with critical business decisions.
• Remained composed and highly professional in fast-paced and constantly changing environment, effectively handling challenging situations and difficult individuals to achieve objectives.
• Conducted meetings with staff to discuss production progress and to attain enrollment objectives.
• Ability to lead and manage others, strong interpersonal, project management and mentoring skills.

Directs all activities associated with a full agenda of a Credentialing department's day-to-day production regimen. Manages overall staff administration, including Permanent or Temporary employee staffing models, recruiting, performance management, and salary administration.

Key Contributions:

• Led and oversaw the work for collecting and maintaining all data and information to support credentialing providers as well as the payer enrollment process
• Ensure departmental goals, quality expectations, and deadlines are met
• Requiring intimate knowledge of credentialing industry standards and best practice processes, as well as the ability to guide team members in the direction of compliance
• Collaborate with all levels of personnel, providing internal leadership to drive productivity, quality, and the accomplishment of department and company goals
• Develop, manage, and monitor processes and procedures that support the credentialing, re-credentialing, expirable, data management, and delegated credentialing contract processes
• Researched, negotiated, and implemented credentialing online database
• Oversaw payer enrollment of 100 providers to 46 insurance carriers across 108 insurance plans
• Oversees all credentialing functions, including application management and primary source verification
• Ensures compliance with the appropriate accrediting and regulatory agencies
• Supervises credentialing staff in the day-to-day management of the overall CVO credentialing process and database management

Accountabilities:

Credentialing

• Track license and certification expirations for all providers to ensure timely renewals
• Ensures practice addresses are current with dental plans, agencies, and other entities
• Preparation of annual group professional liability renewal for providers
• Audit dental plan directories for current and accurate provider information
• Maintain strict compliance with State, Federal, and other regulations, (e.g, OSHA, Joint Commission, Dental
• Board, HIPAA, ADA, DOL, Employee Handbook)
• Oversees provider enrollment of the 21st Century Cures Act registration with the State of New Jersey for participating Providers

Quality Assurance

• Oversight of application process, deadline management and volume monitoring.
• Assist with the Quality Check process and compliance tracking.
• Review audit findings to confirm quality standards are met.
• Collaborate with department leadership to identify areas of concern.
• Assist with process improvement and best practice protocol development.

Engagement

• Collaborate with Operations Team, Dental Directors, Dental owners and other departments to ensure providers’ needs are met.
• Proficiently interact with all levels of personnel.
• Monitor for provider engagement and satisfaction.
• Manage outside vendor relationship that supports payer enrollment and credentialing.
• Respond to claim denials, escalations and manage resolution.

Direct support and leadership in establishing quality improvement initiatives. Execute quality checks, analysis, and review of audit findings. Systemize workflow processes for onboarding and credentialing procedures, saving three days on the application process.

• Used advanced software to prepare documents, reports, and presentations.
• Reviewed business operations and obligations to help organization function at acceptable level.
• Detected and corrected mistakes early on and implemented systems to avoid recurring issues.
• Partnered with auditors to track errors and add contributions to maintain accuracy.
• Co-Chair of the Policies and Procedure Committee.
• Introduced new methods, practices, and systems to reduce turnaround time.
• Created and enforced department policies, procedures and standards to establish productivity and quality.
• Implemented process improvement to shape organizational culture, optimize procedures for higher efficiency and help company evolve and grow.
• Prepared detailed reports for management to clarify existing trends, review admissions, patient rating data and support shrink minimization and safety awareness.
• Performed statistical analyses to gather data for operational and forecast team needs.
• Develop and manage the credentialing process for contracted staff members, volunteer services, student & intern programs, and CDL contracted staff drivers across seven locations throughout the state of NY.
• Develop quality and compliance educational bulletins and newsletters.
• Managed the credentialing of multiple provider types.
• Medicare and Medicaid provider enrollment and recertification.
• Recruited, onboarded and trained intern and extern staff.
• Setup, tracked, and maintained all employee fingerprint clearance within the NYS health commerce system.
• Co-Chair of the Emergency Preparedness Committee.
• Conducts hazardous vulnerability analysis.
• Coordinate and maintain the emergency preparedness program.
• Assist in the development of Quality and HIPPA training materials.
• Automation of audit tool library.
• Administrative oversight of automated Exclusion Checking and tracking of federal files, including OMIG, F-OIG, SAM/EPLS, OFAC, and most individual state files.

Communicated effectively with internal/external providers and departmental leaders. Certified compliance with regulatory agencies by completing internal file audits and corrective action plans. Oversaw four direct reports and delegated tasks

Key Contributions:

• Bolstered efficiency by 30% through the implementation of credentialing processes
• Successfully re-credentialed the entire medical staff over three months
• Executed initial, reappointment, and verification process for all medical, allied health, and other health professional staff
• Developed and Implemented workflow of credentialing processes expediting 30% more clinical privileges to be processed
• Managed four direct reports within the department, delegating tasks accordingly
• Ensured compliance with regulatory agencies by conducted internal file audits and implementing corrective action as needed
• Addressed inquiries from multiple healthcare organizations
• Communicated with internal and external providers and departmental leaders daily.

• Delivered exemplary customer service to customers calling in for assistance
• Processed customer service transactions to include refunds, store credits, and other service issues in accordance to company policy
• Effectively resolved customer challenges to include following up to ensure remediation.

• Supported four senior executives in the organization and management of office systems and processes
• Coordinated efficient and productive meetings with global attendees, remote location arrangements, and multiple presenters
• Regulated complex academic and clinical calendar management
• Facilitated presentations, documentation, and materials for the Executive Director
• Key Contribution: Instrumental in recruiting & credentialing new nurses for hospital staff and the development of a nursing database of 44 nurses which saved the company on the need to purchase credentialing and scheduling software.

• Expertly managed all medical records in an electronic system
• Organized credentialed files for over 300 medical staff members
• Handled the processing of payroll, invoices, and meetings
• Key Contribution: Generated $150K in revenue through expert teamwork on the 2007 education bid, which permitted a contract with the State of New York Board of Education
• Reduced HR tasks by 25% by taking over HR responsibilities, including interviews and evaluations.