Paresh Doshi Email & Phone Number

Mclean, Virginia, Us

Newark, Nj, Us

Newark, Nj, Us

• Accountable for oversight and monitoring compliance with NCQA, CMS and other Regulatory standards as applicable. This includes communication with stakeholders and assistance with interpretation and implementation of any needed updates to the enterprise Quality Improve program to meet plan compliance.• Develop training materials and conduct training sessions for employees on NCQA and Regulatory requirements to encourage a proactive approach to Healthcare Compliance. • Support departments within the organization as the subject matter expert for NCQA and Regulatory compliance by reviewing new programs and initiatives to ensure compliance with accreditation standards and regulatory requirements.• Function as the subject matter expert for Quality compliance including preparing and maintaining the Quality Improvement Program Description, Quality Improvement Program work plan, Quality Program Evaluation and to ensure that all accreditation standards, regulatory requirements and business needs are met.• Accountable to identify key accreditation, regulation and licensing issues and define areas for improvement including development of policies and procedures, documentation and reports.• Accountable for monitoring and reporting compliance status with the NCQA Standards to management and various workgroups and committees and provide subject matter expertise to develop corrective action plans.ACCOMPLISHMENTS• Coordinated a successful NCQA Interim and Renewal submission for the enterprise in 2014.• Coordinated a successful NCQA First Survey submission for the enterprise in 2015

Newark, Nj, Us

ACCOMPLISHMENTS•Developed a comprehensive Credentialing and Re-credentialing training manual that focused on NCQA, New Jersey Department of Banking and Insurance and CMS standards.•Developed Health Insurance Portability and Accountability Act (HIPAA) training manuals that focused on HIPAA requirements including Caller Verification Process, Personal Representative Process, and documentation of Un-authorized Disclosures to ensure compliance with ARRA and HITECH requirements.•Developed training manuals for regulatory training focusing on State and Federal Healthcare Mandates.•Streamlined the dissemination process of Personal Representatives to Horizon Delegates and Vendors.•Developed a Utilization Management crosswalk that encompassed standards from NCQA UM9 and Chapter 13 of the CMS Managed Medicare Manual.•Developed comprehensive auditing and monitoring tools.

Newark, Nj, Us

• Conduct research and root cause analysis for the department with the goal of recommending and implementing new processes and solutions to problems, which resolve issues and improve operational performance. • Streamlined error capturing and reporting process by designing an Access Database to assist management in reducing systemic errors. • Implement new business, products or contracts on the system through review of system files and testing of benefits. • Implement State and Federal Mandates on National, Large, Small Group and Consumer accounts to make these accounts fully compliant and thereby meeting enterprise compliance goals.

Newark, Nj, Us

• Monitor New Jersey State Board of Medical Examiners, Medicare and Medicaid Sanctions of network providers. Coordinate with in-house legal counsel to present sanctioned medical providers and facilities to the Credentialing Sub-committee and facilitate their removal from the network. • Coordinate appeal hearings with in-house Medical Directors and external Medical Consultants. • Process Voluntary and In-voluntary terminations of medical professionals and facilities from the network. • Oversee the Credentialing and application process of professional medical providers affiliated with delegated facilities and vendors. • Oversee the Compliance Criteria of the Credentialing Department in my role as the Compliance Coordinator. • Conduct on site audits of delegated vendors and facilities to ensue that the Compliance criteria’s are met.

Newark, Nj, Us

• Oversee the credentialing and application process of new medical providers, including creating of paperwork file, updating credentialing checklist, and follow-up with provider offices for missing information. • Responsible for the credentialing of providers by assuring required documentation on practice, practitioners and site are complete and accurate before submission to the Credentialing Sub-committee. Primary contact for the Credentials Verification Organization (CVO). • Interact with state agencies and occasionally NCQA to stay current on licensing and full credentialing requirements to maintain accreditation.• Incorporate CVO data or credential verification data into provider paperwork file and /or provider database; quality review for completion; submit application for approval or further investigation when needed. Compile credentialing information to be used by the Credentialing Committee or Peer Review Subcommittee at monthly meetings and provide additional staff support to Committee as needed.• Organize and maintain provider database to provide timely access to accurate, current network status and to allow for meaningful analysis of network size, scope, geographical needs, etc by way of RFP’s. • Act as a liaison between Professional Relations, Marketing and Claims departments for production or update of provider directories and resolving discrepancies/errors in the data used to produce the directories.

Newark, Nj, Us

Advised participating professional medical providers of member benefits and determined claim status. Adjudicated claims according to HCFA guidelines.

Master Of Business Administration (M.B.A.), Business Administration And Health Care Administration

Bachelor’S Degree, Business Administration