Teresa Langston
Murrells Inlet,SC
Summary
I am looking to obtain a position with a reputable company where I can cultivate my diverse knowledge, experiences, and background in a healthcare setting. I have more than 25 years’ experience in the medical and dental profession. I am highly-motivated with a desire to take on new challenges. I have a strong work ethic, adaptability, and exceptional interpersonal skills. I adept at working effectively unsupervised and quickly mastering new skills. I am a dependable professional with a track record of success in the credentialing field, I seeks opportunities to improve processes and workflows for team benefit. I am conscientious, hardworking and excels at multitasking in fast-paced environments.
Overview
16
16
years of professional experience
Work History
Senior Credentialing Support Analyst/Leadership Team
GUARDIAN Life Insurance Company
Spokane, WA
09.2018 - Current
- Responsible for conducting pre-delegation and annual file audits for all delegated provider entities according to NCQA guidelines and prepare reports of findings for Credentialing Committee to review
- Perform final steps in QA credentialing/re-credentialing process to ensure accuracy and completeness of provider file before presenting to Credentialing Committee for approval
- Distribute all supporting documentation to Credentialing Committee members daily for any unclean files, monthly monitoring files, and delegated audits
- Prepare Agenda and Roster to email to Committee Members for Credentialing Committee Meeting
- Oversee Credentialing Committee Meeting, transcribe committee minutes and update committee roster to reflect Committee Members decisions of provider’s file
- Prepares Letters for Request of Additional Information from Providers with Adverse Actions
- Process and manage the Credentialing Appeals Committee meetings, meeting minutes, approval/ denial letters and NPDB reporting
- Review Recredentialing DHMO and PPO Provider files for Quality-of-Care issues and report to Credentialing Committee Members
- Assist with termination of providers in NCQA
- Produce and maintain Credentialing Training Manual according to information received
- Review existing departmental policies and procedures annually and work with management to make updates as needed
- Assist management with training needs within the department
- Review, maintain, and provide guidance on credentialing policies, procedures, NCQA standards and regulatory requirements
- Mange the development and implementation of the credentialing process
- Interview new credentialing team candidates
- Troubleshoot credentialing team inquiries and issues
- Responsible for performing auditing of the credentialing files Primary Source Verification prior to presenting them to the Credentialing Committee for consideration
- Responsible for initial training of staff as well as ongoing training as deemed necessary
- Maintain one day turnaround on Initial and Recredentialing files
- Maintain the Quality Assurance Spreadsheet used to track each credentialing file audited
- Manage and process audit requests or inquiries
- Work with team to discuss workflow changes
- Perform special projects as assigned.
Clinical Services Liaison/Credentialing Special
Coastal Healthcare Resources, Inc (Anesthesiologist and CRNA)
Florence, SC
08.2017 - 08.2018
- Developed and implemented policies and procedures to ensure all credentialing processes were completed in accordance with relevant regulations, policies, and standards; implement processes for provides to obtain privileges at hospitals facilities in a timely manner; resolve and correct issues/errors with third party payers; tracked Anesthesiologist and CRNA’s expired data; Follow up on Credentialing status with payers and hospitals; Knowledge of CAQH guidelines; Stay updated on policies and procedures for NCQA and JACHO; Q/A Patient charts for accuracy; Monthly data tracking of patient’s procedures; All other duties as requested
- This was a nation wide practice.
Senior Credentialing Analyst, Team Leader
Lexington Medical Center
West Columbia, SC
08.2008 - 08.2017
- Developed and implemented systems and procedures to ensure all credentialing processes were completed in accordance with relevant regulation, policies, and standards
- Investigates, analyzes and/or corrects any third payer issues including and not limited to appropriate provider and/or group set-up errors
- Develop, analyze and trend reports related to Credentialing processes
- Facilitates and coordinates third party payer audits for delegated credentialing
- Work with accounting to ensure Medicaid, Medicare and Commercial Payer’s EFT applications are completed for provider/group enrollment
- Knowledgeable of credentialing trends across industry through publications, attending state educational workshops, and conferences
- Initiates and coordinates the acquisition and receipt of all credentialing documents from new and existing providers and groups
- Utilizes all available resources (on-line websites, software) to aid in the background checks and license verifications of all provider applications
- Responsible for conducting pre-delegation and annual file audits for all delegated provider entities according to NCQA guidelines and prepares report of findings for review by Credentialing Committee
- Coordinates the processing, distribution and management of all credentialing and accreditation documents for affected providers to applicable health plans
- Notify all delegated payers of new providers and recredentialing providers
- Assist with delegated audits
- Communicates with all applicable internal areas on status and completion of credentialing with applicable payers
- Maintains a comprehensive credentialing database, ensuring data integrity of provider information
- Administers and coordinates provider licensing, ensuring receipt within regulation parameters and payer requirements
- Develops and maintains strong relationships with team members and outside agencies to ensure harmonious relationships
- Communicates requested information to payers in a timely and professional manner
- Maintains and ensures strict confidentiality of files and databases
- Performs miscellaneous job-related duties as assigned.
Education
Interdisciplinary Studies -
University of South Carolina
01.1980
Skills
- Initial and Recredentialing Experience
- Dental Quality Assurance
- Oversee Committee Credentialing meetings
- Think outside the box
- Knowledge of NCQA guidelines
- Knowledge of Payer credentialing standard
- Knowledge of PSV
- Ability to embrace change
- High level of productivity
- Strong interpersonal skills
- Strong oral communication skills
- Strong written communication skills
- Analytical skills
- Problem-solving skills
- Dedication to teamwork
- Willingness to go the extra mile
- Audit Support
- Workflow Analysis
Salary
Salary upon request
References
References upon request
Timeline
Senior Credentialing Support Analyst/Leadership Team
GUARDIAN Life Insurance Company
09.2018 - Current
Clinical Services Liaison/Credentialing Special
Coastal Healthcare Resources, Inc (Anesthesiologist and CRNA)
08.2017 - 08.2018
Senior Credentialing Analyst, Team Leader
Lexington Medical Center
08.2008 - 08.2017
Interdisciplinary Studies -
University of South Carolina
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